Every finding on record at Lomond Peak Nursing and Rehabilitation

Based on interview and record review, the facility did not ensure each resident received and the facility provided food that accommodated the resident allergies. Specifically, for 1 out of 27 sampled residents, a resident was served food that contained an allergen resulting in the resident being administered an epinephrine injection. This non-compliance resulted in a HARM deficiency. Resident identifier: 52.Findings included:Resident 52 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Helicobacter Pylori, atrial fibrillation, chronic kidney disease, neuromuscular dysfunction of bladder, retention of urine, exocrine pancreatic insufficiency, cardiac arrhythmia, hypertensive retinopathy, hypertension, cardiac pacemaker, cardiomyopathy, thrombophilia, epilepsy, osteoporosis, and heart failure.On 8/10/26 at 10:37 AM, an interview was conducted with resident 52. Resident 52 stated that she was allergic to all nuts and was served foods with nuts in it. Resident 52 stated that she believed that the kitchen still served food items with nuts in them. Resident 52 stated that she had to have an Epinephrine (EpiPen) injection multiple times since admission. Resident 52 stated that the last EpiPen injection was after she consumed some carrot cake that contained walnuts. Resident 52 stated that she no longer ate any desserts because the facility did not eliminate nuts from the food served. Resident 52 stated that she also took Benadryl daily as a preventative measure in case any food items had nuts. Resident 52's dashboard on the electronic medical record listed the following allergies: Benazepril, Erythromycin, Lisinopril, sulfADIAZINE, Tetracycline, traMADol, Coconut, Nuts, and Peanuts. On 10/24/23, resident 52's physician ordered EpiPen 2-Pak Injection Solution Auto-injector 0.3 milligram/milliliter (MG/0.3ML) (Epinephrine (Anaphylaxis), Inject 1 application intramuscularly as needed for nut allergy. On 4/4/24, resident 52's physician ordered Benadryl Allergy Oral Tablet 25 milligrams (Diphenhydramine Hydrochloridel), Give 1 tablet by mouth one time a day for allergies. Resident 52's May 2026 Medication Administration Record documented that the EpiPen was administered on 5/22/26 at 2:44 PM. On 1/27/26, resident 52's Nutritional Assessment documented that the resident had a nut allergy. Resident 52's Progress notes revealed the following: a. On 10/7/25 at 8:38 AM, the Health Status Note documented, A resident has received a prescription for a new medication, but the accompanying allergy list did not align with our existing records. In response, the DON [Director of Nursing] and the ADON [Assistant Director of Nursing] engaged with the resident to clarify which allergies should be incorporated into her profile. The stated allergies included benazepril, coconut, erythromycin base, honey, lisinopril, morphine, peanuts, nuts, sulfa, tetracycline, tramadol, and Tylenol. During the discussion, the resident confirmed that she is not allergic to honey, morphine, or Tylenol. Furthermore, she indicated that while tramadol is not an allergy, it should be avoided due to her history of seizures. The DON will update the allergy list in the resident's profile accordingly. b. On 6/12/26 at 12:11 PM, the Health Status Note documented, The resident returned from the hospital on the previous day. During review of the hospital discharge documentation, nursing staff identified several allergies and medication sensitivities listed that were not currently reflected in the facility's medical record. The listed allergies included honey, lisinopril, morphine, tramadol, acetaminophen, and cephalexin. Nursing staff reviewed the listed allergies with the resident to verify accuracy. During the discussion, the resident reported that tramadol is not an allergy but rather a medication she is unable to take due to a history of seizures associated with its use. The resident further confirmed that she should not receive lisinopril and identified this as a valid medication allergy/intolerance. The resident denied having allergies to honey, morphine, acetaminophen, and cephalexin, stating that she has tolerated these substances/medications without allergic reactions. The discrepancies between the hospital documentation and the resident's reported history were reviewed and documented. The provider was notified of the allergy reconciliation. The resident's medical record was updated accordingly to ensure the most accurate allergy and medication intolerance information is available for ongoing care and medication management. On 8/12/26 at 10:18 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that resident assessments for likes/dislikes and allergies were completed by himself and updated monthly if changes were identified. The DM stated that information was communicated to kitchen staff through the meal tray cards. The DM stated that resident 52 had food allergies to all nuts. The DM stated at first it was just nuts then resident 52 included coconut. The DM stated that he removed all nuts from the kitchen and did not purchase nuts anymore. The DM stated that they still had food items that contained nuts such as peanut butter. The DM stated that he tried to make the menu nut free, and had been doing that for a couple of months. The DM stated that as another added safety measure he went through the meal tickets daily to verify that the alerts for allergies were present. The DM stated that resident 52's meal ticket documented allergies to coconut, peanut butter, and any nuts. The DM stated that a couple of months ago they served carrot cake that contained nuts and resident 52 was accidentally served that food item. The DM stated this was what prompted them to change the meals to be nut free. The DM stated that resident 52 reported eating the carrot cake and having a reaction to the food item. The DM stated that he spoke with resident 52 after the incident and reassured her that they would not order anymore of the carrot cake, which was the only item that had nuts. The DM stated that he provided an inservice on the topic to the kitchen staff that covered allergies in general and paying attention to meal tickets. The DM stated that he emphasized that to the staff that if they get it wrong they put the resident at risk. The DM stated that they still needed to pay attention to any food item that contained nuts, such as peanut butter. The DM stated that if staff used utensils and equipment in the kitchen that came into contact with nuts, they needed to use separate items. The DM stated that prior to resident 52 being served the carrot cake the allergy was listed on the meal ticket. The DM stated that he now verified ingredients in food items such as sauces to ensure none contained nuts. On 8/12/26 at 10:38 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 52 was allergic to coconut, and all nuts. The DON stated that information was communicated to staff on the meal ticket, the resident facesheet, and kitchen staff were aware. The DON confirmed that resident 52 had an order for an EpiPen. The DON stated that in May 2026 resident 52 was served and ate a piece of carrot cake that had nuts in it. The DON stated that afterwards resident 52 felt like the cake had nuts in it and informed the Certified Nursing Assistant (CNA) who informed the nurse. The DON stated that the nurse administered the EpiPen and then notified the physician. The DON stated that the practice was to enter a progress note of the incident. The DON confirmed that the nursing staff did not document the incident in a progress note. The DON stated that resident 52 should not have been served the carrot cake with nuts. The DON stated that they conducted a staff inservice afterwards about recognizing allergies with kitchen checks and CNA double checks.

Based on interview and record review, the facility did not obtain laboratory services only when ordered by a physician. Specifically, for 3 out of 27 sampled residents, the facility did not have a physician order for laboratory tests that were obtained. Resident identifiers: 8, 52, and 62.Findings included:1. Resident 8 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, palpitations, chronic pain, heart failure, cerebral infarction, peripheral vascular disease, type 2 diabetes mellitus, asthma, chronic kidney disease, hyperlipidemia, and hypertension. Resident 8's laboratory results were reviewed. The following test results were identified as not having a physician order:a. On 2/16/26, Immunoglobulin A (IgA antibody protein), Tissue Transglutaminase IgA, Amylase, Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Lipase, Thyroid Stimulating Hormone (TSH) b. On 2/24/26, Hemoglobin A1C c. On 5/29/26, Urinalysis (UA) d. On 6/16/26, low-density lipoprotein (LDL), lipid panel e. On 6/26/26, CBC, CMP, UA f. On 7/27/26, UA with Culture and Sensitivity g. On 8/4/26, Hemoglobin A1C.On 8/11/26 at 1:15 PM, an email from the Regional Nurse Consultant (RNC) stated that all the above listed test results had a verbal order that was not entered into resident 8's electronic medical record. No documentation was provided of a signed verbal order from the physician for the tests that were obtained. 2. Resident 52 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Helicobacter Pylori, atrial fibrillation, chronic kidney disease, neuromuscular dysfunction of bladder, retention of urine, exocrine pancreatic insufficiency, cardiac arrhythmia, hypertensive retinopathy, hypertension, cardiac pacemaker, cardiomyopathy, thrombophilia, epilepsy, osteoporosis, and heart failure.Resident 52's laboratory results were reviewed. The following test results were identified as not having a physician order:a. On 5/7/26, TSHb. On 8/7/26, Urine CultureOn 8/11/26 at 1:55 PM, an email from the RNC stated that the above listed test results had a verbal order that was not entered into resident 52's electronic medical record. No documentation was provided of a signed verbal order from the physician for the tests that were obtained. 3. Resident 62 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included, type 2 diabetes mellitus, asthma, atrial fibrillation, hypertension, hyperlipidemia, paranoid schizophrenia, generalized anxiety disorder, insomnia, and cataracts.Resident 62's laboratory results were reviewed. On 1/13/26 and on 4/9/26, a Hemoglobin A1C was obtained without a physician order.On 8/11/26 at 4:50 PM, an email from the RNC stated that the Hemoglobin A1C tests had a verbal order that was not entered into resident 62's electronic medical record. No documentation was provided of a signed verbal order from the physician for the tests that were obtained. On 8/13/26 at 8:01 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that nurses should enter a verbal order into the resident's electronic medical record and the physician would then electronically sign the order. The DON stated that if staff obtained a verbal order but did not enter it into the electronic medical record then it was never signed by the physician.

Based on observation and interview, the facility failed to store and prepare food under sanitary conditions to prevent cross-contamination and ensure proper food rotation. Specifically, food items were not labeled, and food items were not stored appropriately.Findings included:On 8/10/26 at 8:27 AM, an initial observation of the kitchen environment was conducted and revealed the following:a. Walk-In Refrigerator: A box of tomatoes located on the bottom shelf was uncovered and undated. A tote containing a plastic bag of chicken was stored directly above this box of tomatoes. b. Dry Storage: An opened box of flour tortillas and four boxes of [NAME] Round Top Bread lacked a received date on the outside of the packaging. c. Freezer: A box of packaged sliced strawberries had no received date and was placed under a box of lasagna. An unmarked and undated package of raw meat in a blue transparent plastic wrapper was stored beside a box of strawberries. A box of raw ground beef patties with no received date was stored on a shelf directly above a transparent package of waffles. A box of raw chicken breast tenders was stored directly above boxes of pound cake. A box of raw seafood was stored directly above boxes of Boston cream pie. A box of tilapia, dated 7/13, was stored directly above a box of strawberries. On 8/12/26 at 1:01 PM, a follow-up observation of the kitchen environment was conducted and revealed ongoing cross-contamination risks: a. Walk-In Refrigerator: A box of fresh lettuce and a box of oranges were stored directly underneath a container of deli meat. b. Walk-In Freezer: A box of sausage was placed directly above boxes of pound cake and blueberry muffins. A box of bratwurst was stored directly above boxes of Boston cream pie. A box of raw fish was stored directly above a box of mixed vegetables. A box of raw ground beef was stored directly above a box of apple pie. On 8/12/26 at 2:28 PM, an interview with the Dietary Manager (DM) was conducted. The DM stated that when the food was delivered, items would be dated with the received date. The DM stated that he would store the food by, first in first out. The DM stated that he knew what needed to be used first by the received date. The DM stated that every box must have a received date written on the outside of the box, that included dry storage, refrigerated, and frozen items. The DM stated that the way he stored items in the refrigerator and freezer included all meats including raw chicken should always be placed on the bottom and separated from the fruits and vegetables. The DM stated that meat should not be stored above fruits and vegetables or desserts. The DM stated that he stored his food grouped together on separate sections of the refrigerator.

Based on observation, interview, and record review, the facility did not ensure that a resident who self-administered medications was evaluated and determined by the Interdisciplinary Team as safe and clinically appropriate for self administration. Specifically, for 1 out of 27 sampled residents, the facility did not evaluate a resident for the ability to safely self administer medications and multiple medications were located at bedside. Resident identifier: 62.Findings included:Resident 62 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included, type 2 diabetes mellitus, asthma, atrial fibrillation, hypertension, paranoid schizophrenia, generalized anxiety disorder, insomnia and cataracts. On 8/10/26 at 2:36 PM, an observation was made of resident 62's room. Resident 62 had on his bedside table a metered dose inhaler, Clotrimazole cream, a red pill in a blister package, and a bottle that appeared to be nasal spray. Resident 62's physician orders revealed the following:a. Azelastine-Fluticasone Nasal Suspension 137-50 micrograms/actuation (MCG/ACT),one spray in both nostrils every 12 hours as needed for congestion. The order was initiated on 3/26/26. b. Saline Spray Nasal Solution, one spray in both nostrils every 4 hours as needed for nasal congestion/nasal dryness. The order was initiated on 1/31/26. c. Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 MCG/ACT, two puffs inhaled orally two times a day related to asthma. Rinse and spit after use. The order was initiated on 12/11/25. Resident 62's medical record\ was reviewed and no documentation was found for a self administration of medication assessment.On 8/11/26 at 3:15 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that some residents self administered inhalers and management conducted an assessment to see if they were able to do that on their own. LPN 1 stated that if the resident was allowed to self administer medications the assessment would be in evaluations, orders, or the care plan. On 8/11/26 at 3:24 PM, an observation of resident 62's bedside table was made with LPN 1. LPN 1 identified a bottle of saline nasal spray, a bottle of eye itch relief drop, a fluticasone nasal spray bottle, and an inhaler for Budesonide-Formoterol at the bedside. On 8/11/26 3:28 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that some residents self administered medication. The DON stated that those residents were assessed for self administration and had to demonstrate how to administer the medication safely. The DON stated that the assessment ensured that the resident could appropriately use the medication and covered the frequency of use for that medication. The DON stated that the self administration of medication assessment was conducted at least quarterly and as needed if there was a change in condition. The DON confirmed that resident 62 did not have an assessment to determine if he was able to safely administer his medications that were located at the bedside.

Based on interview and record review, the facility failed to ensure it was free from mental and emotional abuse. Specifically, for 1 out of 27 sampled residents, two staff members hid in the resident's darkened room, whispered his name to cause distress, and recorded the incident on a cell phone to distribute among nine co-workers; none of the staff members reported the abuse. Resident identifier: 9.Findings included:Resident 9 was admitted to the facility on [DATE] with diagnoses which included paraplegia, post-traumatic stress disorder, depression, panic disorder, and mild cognitive impairment of uncertain or unknown etiology. On [DATE] at 5:24 PM, the facility reported to the State Agency the following; On [DATE] at 4:29 PM, Resident reported to staff this afternoon during cares that a couple of CNA's [Certified Nursing Assistants] were hiding under his table and making noise at night and saying his name but not identifying themselves. When asked if he felt threatened or afraid the resident did state it does cause distress and he felt terrorized. The nurse reported this to management to be investigated as possible mental/emotional abuse. A review of resident 9's progress notes revealed the following;On [DATE] at 10:44 AM, an Event Note Template stated, .Event Description: While nurse was performing cares with this resident, he made a comment about a past incident where a group of CNA's played a prank inside of his room. Nurse encouraged resident to share details of what happened, as she could sense that it seemed to have bothered him. Resident described an incident that occurred in the evening roughly about 2 months ago. Resident states that he was in bed for the evening, when he heard voices coming from under his table near his bed, calling out his name and making nonsensical statements. Resident states that at first he felt unsure of what the voices where [sic] and why he was hearing them. Resident states he felt terrorized at first. After the voices continued and he heard giggling, he then realized it was CNA's hiding under his table messing with him and he began to banter back and forth with them. Risk Factors and Root Cause Identification: Resident suffers from paraplegia, neuromuscular dysfunction of bladder, chronic respiratory failure, chronic pain, weakness, PTSD [Post Traumatic Stress Disorder], depression, anxiety d/o [disorder] , panic d/o and mood disorder. Resident is wheelchair/ bedridden, making him fully dependent on stafffor [sic] most all cares. On the evening of the incident, resident was constricted to his bed d/t [due to] his comorbidities, making the incident more frustrating to him because he was unable to stand up from bed and look under his table on his own.Preventative Measures in Place Prior to Incident: Resident has not had an incident of this nature in the past. Staff are educated about resident right's [sic] and the professional work expectations of [name redacted] upon hire. Staff are re-educated yearly throughout the year, via staff meetings and online Relias training.New Interventions: This incident was reported to the abuse coordinator, who initiated an investigation for mental/ emotional abuse. MD [Medical Doctor], APS [Adult Protective Services] and OPD [Police Department] were notified of the incident. Abuse coordinator interviewed staff members about their knowledge of the incident. Upon interviewing staff, it was identified that 3 staff members partook in the incident, and one of them recorded the audio on their phone. This audio recording was then shared in a text thread amongst several staff members. Every staff member who was in the text thread was instructed to meet with the administrator, where they each received a final written warning for failure to report that the audio was being shared in a text thread. Two of the three CNA's who were identified as initiating the incident in resident'sroom, [sic] have ended their employment with [name redacted] at various times over the last couple months. The third CNA identified has been terminated from employment with [ name redacted] due to this incident. Staff and resident's [sic] were interviewed to ensure that no other resident has felt victimized by the CNA's identified and to ensure that all staff understand what is considered abuse and who to report it to. Since the date of initial investigation, this resident has recanted the statement that he was upset over the incident. He has verbalized that he feels the CNA's were just being kids and horsing around. Although the resident recanted his initial statement of feeling terrorized, IDT [Interdisciplinary Team] still support the final write ups and termination of an employee due to recording audio in the room and sharing it via text thread, and no staff members reporting the shared thread. This resident was educated to please report any incident's [sic] with staff to a nurse or nurse management as soon as possible in the future, so the issue can be remedied as soon as possible.On [DATE] at 11:04 AM, an interview was conducted with resident 9. Resident 9 stated that when the incident was happening, It was horrifying. Resident 9 stated that he has Central Nervous System problems and his senses were amplified by 30%, when it was happening it was dark, he could not see what was going on, he was bedridden, and unable to get up. Resident 9 stated that he liked the way the facility handled the situation and he continued to feel safe in the facility. Resident 9 stated that when he learned that one of the staff members that was involved was terminated, he requested for them to be re-employed. Resident 9 stated that he had to provide a signed written statement requesting the staff member to return to the facility. On [DATE] at 11:04 AM, an interview was conducted with the Administrator (ADM). The ADM stated that when he learned of the incident he immediately started an investigation. The ADM stated the incident happened about two months prior to resident 9 bringing it to the staff's attention. The ADM stated that ten CNAs and one nurse were involved and a video was produced during the incident. The ADM stated that two of the CNAs produced the video and was shared with nine other staff members. The ADM stated that he did view the video, the screen was dark, and only voices were heard. The ADM stated that he heard the resident's name being said a few times in a whispered tone. The ADM stated that he heard resident 9 asking, who was there, in a concerned tone. The ADM stated as the video continued resident 9 began bantering with the other voices. The ADM stated that the two CNAs who produced the video, one of them had already ended their employment and the other CNA's employment was terminated. The ADM stated that the remaining involved staff members were given abuse training and were given a final warning write up, for not reporting the abuse when knowing about it. The ADM stated that he unverified allegations of abuse due to resident 9 recanting his initial statement when he learned it involved a staff member that he really liked and he did not want her in trouble. The ADM stated that resident 9 requested the terminated staff member be re-hired to the facility. The ADM stated that he did re-hire the staff member after resident 9 provided a signed written statement asking for her to return to the facility.

Based on record review and interview, the facility failed to ensure that necessary pharmaceutical services were provided to meet the needs of each resident. Specifically, for 1 out of 27 sampled residents, the facility failed to safely procure, track, and administer a prescribed phosphate binder medication (sevelamer), resulting in missing 107 consecutive doses over a 36-day period. Resident identifier: 7.Findings Included:Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included delusional disorders, peripheral vascular disease, end stage renal disease, and metabolic encephalopathy. A review of Resident 7's progress notes revealed the following;a. On 4/28/26 at 5:05 PM, The resident's Sevelamer is currently on hold. The dialysis center notified the facility that delivery may take approximately 5-7 days. MD [Medical Doctor] was notified of the temporary interruption, reviewed the situation, and gave approval for the medication to remain on hold until the supply arrives.b. On 5/7/26 at 10:07 AM, Contacted [name redacted] Pharmacy regarding resident Sevelamer medication.Medication [sic] hasn't been sent out to facility because [name redacted] has not enrolled resident in mail order.Dialysis [sic] center was contacted today but was closed.Will [sic] contact Dialysis center tomorrow to ask them to enroll resident.c. On 5/29/26 at 12:38 PM, The NP [Nurse Practitioner] from the resident's dialysis center was contacted regarding the resident's Sevelamer prescription. The dialysis center NP reported that the medication is expected to arrive within the next week. It was determined that there had been a delay in dispensing the medication because the prescription was missing the required provider signature and therefore could not be processed by the pharmacy until the dialysis center completed the necessary documentation. The resident's house MD was notified of the update regarding the medication delay and anticipated delivery timeframe. No new orders were received at this time.A review of resident 7's medication administration record revealed 4/26/26, starting at noon's medication administration, sevelamer was marked as being held and continued to be on hold until 6/1/26, at noon's medication administration.On 8/13/26 at 1:39 PM, an interview was conducted with the Administrator (ADM), Regional Nurse Consultant (RNC), Director of Nursing (DON), and Assistant Director of Nursing (ADON) 1 regarding resident 7's missing sevelamer medication. The RNC stated that resident 7 went without his prescribed sevelamer from the end of April 2026 until approximately May 2026, which equated to about five to six weeks without the medication. The RNC stated that the facility was unable to obtain the sevelamer because the dialysis center was responsible for sending it. The RNC stated that she did not know why the facility's contracted pharmacy could not supply the medication but hypothesized it was due to an agreement with the dialysis center. ADON 1 stated that the dialysis center normally provided sevelamer refills. ADON 1 stated that when she reached out to the dialysis center, she was informed that the medication came from a specialty pharmacy and would take five to seven days to deliver. ADON 1 stated that when the medication failed to arrive, she contacted the specialty pharmacy and learned that resident 7 was not enrolled in their mail-order program. ADON 1 stated that she attempted to enroll the resident but was told only the dialysis center could set up the account. ADON 1 stated that the facility had to wait for the dialysis center to complete the setup. ADON 1 stated that she contacted the facility's primary pharmacy, but was told they did not carry sevelamer because it was classified as a hospice medication.The RNC stated that the kidney specialist prescribed the medication, and the house Doctor followed the specialist's orders for administration of medication. When orders were placed into the facility's system, they defaulted to the facility's primary pharmacy. Regarding responsibility for accurate prescriber information, the RNC explained that the receiving nurse entered the order, and the DON or ADON completed an entry audit to verify the information. The RNC stated that while waiting for the medication to arrive, staff strongly suggested that resident 7 remain compliant with his diet and limit his soda intake, per the dialysis center communications. The RNC stated that routine labs were tracked and performed at the dialysis center. The RNC stated that the facility did not have routine labs ordered during that time period resident 7 was without the sevelamer. The RNC stated that the dialysis nurse was diligent about calling with concerns, but the facility had not received any calls or notifications regarding resident 7's lab values.The DON stated that going without sevelamer could cause increased phosphorus and noted that brittle bones were the main potential outcome.The RNC stated that monitoring the resident's condition was a group effort and that the dialysis center was aware the resident was not receiving his sevelamer. The RNC stated that the facility observed no issues with the resident during this timeframe, and the resident did not report any complaints. When asked where this monitoring was documented, the RNC stated that the facility only documented negative outcomes and did not chart when a resident was at baseline. The RNC stated that communication occurred regularly between the facility and the dialysis center, providing opportunities to flag issues, but nothing notable or concerning arose during that time frame.The ADM stated that the facility would have purchased the sevelamer at cost for the resident if they had known that was an option. However, the ADM stated they were not given the opportunity to make that choice because they could not obtain the correct information from the dialysis center.

Based on interview and record review, the facility did not obtain laboratory services to meet the needs of its residents. Specifically, for 2 out of 27 sampled residents, the facility did not obtain laboratory tests when ordered by the physician. Resident identifiers: 8 and 62. Findings included:1. Resident 8 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, palpitations, chronic pain, heart failure, cerebral infarction, peripheral vascular disease, type 2 diabetes mellitus, asthma, chronic kidney disease, hyperlipidemia, and hypertension. On 1/20/26, resident 8 had a physician order for a Comprehensive Metabolic Panel (CMP) and a Lipid panel. No documentation could be found in resident 8's medical record for the results of the laboratory orders. On 8/11/26 at 2:19 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that they needed to contact the cardiologist to determine if the lab was drawn at the appointment. The RNC stated that if the laboratory order was entered into the facility electronic medical record then the nurse should obtain that order unless otherwise specified within the order. On 8/11/26 at 2:36 PM, an email from the RNC stated, .updating you on resident [8] for labs ordered at Cardiology appointment in January. [Name of Facility] nurses should have drawn those labs here at the facility. 2. Resident 62 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included, type 2 diabetes mellitus, asthma, atrial fibrillation, hypertension, hyperlipidemia, paranoid schizophrenia, generalized anxiety disorder, insomnia and cataracts. On 1/20/26, resident 62 had a physician order for Routine labs: Draw CBC [Complete Blood Count], CMP, lipid panel, and A1C [Hemoglobin A1C] q [every] 6 months July and January. A1C q 3 months No documentation could be found in resident 62's medical record for the results of the laboratory orders for July 2026. On 8/11/26 at 4:50 PM, an email from the RNC stated, July routine labs- CBC, CMP, Lipid panel- Not obtained.

Based on interview and record review, the facility did not maintain medical records for each resident that were complete, accurately documented, and readily accessible. Specifically, for 2 out of 27 sampled residents, a resident's shower/bathing assistance was not documented in the medical record and a resident's Civil Commitment order was not in the resident's medical record. Resident identifiers: 6 and 15.Findings included:1. Resident 6 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder, hypertension, hypokalemia, generalized anxiety disorder, edema and neuropathy. On 8/10/26 at 9:21 AM, an interview was conducted with resident 6. Resident 6 stated that she was scheduled for showers 3 times a week but sometimes did not get them. Resident 6's Certified Nursing Assistant (CNA) bathing task for the last 30 days was reviewed. The task documented two instances when resident 6 had a 5 day lapse since the last shower was provided on 7/27/26 and 8/10/26. On 8/11/26 at 11:46 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 6 was fully dependent upon staff and they did all the bathing tasks and washing. CNA 1 stated resident 6's bathing schedule was Monday/Wednesday/Saturday in the morning. CNA 1 stated that resident 6 rarely refused showers. CNA 1 stated that if a resident refused a shower they asked 3 times and then had the resident and nurse sign the shower refusal form. It should be noted that no shower refusal forms were found for resident 6 in the past 30 days. On 8/11/26 at 1:23 PM, an interview was conducted with the Administrator (ADM) and CNA 1. The ADM stated that if a resident refused a shower it should be documented in the electronic medical record and on a shower refusal form. The ADM stated that CNA 1 completed the shower on Saturday 8/8/26, and could verify this. CNA 1 stated that she gave resident 6 a shower on 8/8/26, and she felt confident that she gave her a shower on 7/25/26. CNA 1 stated that resident 6 had never refused a shower for her. CNA 1 stated that she forgot to document the shower completion in the electronic medical records for both dates identified. 2. Resident 15 was admitted to the facility on [DATE] with diagnoses which included disorganized schizophrenia, dysthymic disorder, generalized anxiety disorder, hypertension, hypothyroidism, anemia, chronic kidney disease, and chronic pain. On 8/10/26 at 9:01 AM, an interview was conducted with resident 15. Resident 15 stated that she received mental health services for schizophrenia and she did not like her psychotropic medication. Resident 15 stated that she did not want the monthly antipsychotic shot and she did not think she should have it. Resident 15's had a physician order for Abilify Intramuscular injection 400 milligrams every 28 days initiated on 2/18/26. On 5/15/26 at 1:30 PM, resident 15's Social Service Note documented, I want to get off my civil commitment . Talked about the civil commitment being a subject she can take up with her assigned therapist when he visits again. On 6/30/25, resident 15's Level II Pre-admission Screening and Resident Review documented, She has a long history of psychiatric treatment dating back over 25 years, including multiple inpatient hospitalizations in [states omitted]. Her treatment history reflects chronic mental illness including psychosis, depression, and anxiety. She is currently under a civil commitment through [behavioral health name omitted] and is connected with a therapist and a psychiatric nurse practitioner for medication management and therapy. No documentation could be found in resident 15's medical record of the civil commitment order. On 8/11/26 at 11:51 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 15's commitment order should be in the resident medical records. The DON confirmed that resident 15's medical records did not contain a copy of the Civil Commitment Order. On 8/11/26 at 1:04 PM, an email from the Regional Nurse Consultant (RNC) documented, The administrator reached out to [behavioral health name omitted] and requested documentation of commitment for resident [15]. We received the attached form, which we will upload into her chart.

Based on observation, interview, and record review it was determined, for 2 out of 26 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, two high fall-risk residents did not have interventions put in place after falls and interventions were repeated. One of these examples was cited as harm. Resident identifiers: 39 and 43.Findings included: HARM 1. Resident 43 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, mild cognitive impairment, and ataxia. On 10/6/25 at 2:59 PM, an interview was conducted with resident 43. Resident 43 stated that he had fallen a few times at the facility and had gotten hurt. Resident 43 stated that he had gone to the hospital a few times for lacerations. Resident 43's medical record was reviewed 10/6/25 through 10/9/25. An admission Minimum Data Set (MDS) dated [DATE] documented resident 43 as supervision or touching assistance with transfers, toileting, and bed mobility. A care plan dated 1/21/25 and revised on 7/23/25 revealed, [resident 43] is at risk for falls r/t [related to] impaired gait and balance, Parkinson disease, moderate impaired cognition, ataxia, chronic pain, osteoarthritis, degenerative disk [sic] disease, neurogenic claudication, use of medications that increase risk for falls, impaired vision, impaired hearing, and reoccurring falls.Resident 43's progress notes were reviewed and revealed the following: a. On 1/24/25 at 6:12 PM, resident had unwitnessed fall in his bathroom. resident states he was trying to walk out of the bathroom and his feet wouldn't move. resident fell forward hitting his right eyebrow on a shelf. resident noted with a deep cut to the area. MD [medical doctor] notified. neuros [neurological] initiated. LN [licensed nurse] cleansed w/ [with] NS [normal saline] and applied steri strips. Care plan intervention for this fall: Educated resident to ask for staff assistance in the bathroom when he finishes toileting. b. On 2/3/25 at 11:09 PM, Residents roommate came to the nurses station stating that resident was on the floor. Resident found lying on floor next to bathroom door. He couldn't describe how he had fallen. No injuries sustained. Assisted to wc [wheelchair]. Neuro checks and vs [vital signs] started. MD and management notified. Reminded resident to use call light for assistance and encouraged to drink water. Call light within reach. Checked on often by staff. Care plan interventions for this fall: The resident has been educated to use his wheelchair for nocturnal restroom visits. c. On 3/3/25 at 10:44 PM, Resident observed on the floor sitting by the bathroom door. Resident states 'he fell when walking to the bathroom'. No injuries noted.Care plan intervention for this fall: Moved resident closer to nurses station to be able to do more frequent rounds. d. On 3/17/25 at 10:53 AM, was called down to resident room by house keeping who stated that resident had fallen upon arrival resident was up walking with his walker to the restroom he was asked to stop so a head to toe assessment could be done small skin tear above his right eye was noted and some bruising to his forehead neuros were started at that time and resident was allowed to cont [continue] to the restroom when asked resident stated that he tripped when housekeeping was asked she stated that he tripped over his shoes (that were in thewalk [sic] way) and fell face first on the floor she asked him to stay put but he got up and cont to the restroom administration and Md. notified attempted to call his sister [name redacted] but both numbers were out of service. Care plan intervention for this fall: The resident has been educated to ensure that shoes are kept out of the walkway. e. On 3/26/25 at 1:50 AM, Resident is on alert charting for an unwitnessed fall that happened at 1905 [7:05 PM] on 03/25/2025. Resident was in the shower room when he tripped and fell forward. Resident stated he did not hit is [sic] head. Residents vitals were WNL [within normal limits]. Neuro checks were started and physician was notified.Care plan intervention for this fall: Resident was educated to ask for staff assistance when undressing in the shower room. f. On 4/2/25 at 4:55 AM, During routine rounds, (CNAs) [certified nurse assistant] discovered the resident seated on the floor with his feet extended. Upon inquiry, the resident expressed that he was attempting to get out of bed to reach the bathroom but lacked adequate support, resulting in his fall from the edge of the bed. Care plan intervention for this fall: Resident will work with physical therapy on balance and strengthening, g. On 4/2/25 at 5:35 AM, On 4/2, at approximately 0520 [5:20 AM] the nursing staff was conducting routine neuro checks following a previous fall involving the resident. During this procedure, the nurse discovered the resident on the floor. The resident reported that he attempted to rise from his walker when he began to experience increased weakness in his right leg and knee, which caused him to fall backward and strike his head against the dresser.Care plan intervention for this fall: The facility will provide the resident with floor to ceiling positioning bar to assist with transferring in and out of bed. h. On 4/8/25 at 1:05 AM, Resident had an unwitnessed fall at around 0025 [12:25 AM] while trying to go to the bathroom. Resident tripped over his shoes and fell on his bum. Resident stated he did not hit is head and was not in any pain.Care plan intervention for this fall: The resident has been educated to keep his shoes under the bed when he is not wearing them. i. On 5/8/25 at 3:41 AM, Staff was sitting at nurses station when there was a loud crash. Resident was found lying prone with walker in front of him. Denies hitting head. No injuries found with assessment. Assisted to sitting position on bed. Neuro checks and vital signs started with no changes from baseline assessment. Reminded resident to use call light for assistance if feeling unsteady. Fluids encouraged. Call light within reach.Care plan intervention for this fall: Resident has been educated to ask for staff assistance to the bathroom when he is feeling drowsy in the middle of the night. It should be noted that this intervention was used on 1/24/25. j. On 5/16/25 at 5:54 PM, Resident was found by staff sitting on the floor of his room. He stated he fell trying to go to the bathroom.Care plan interventions for this fall: Reeducate resident to ask for staff assistance. It should be noted that this intervention was used on 1/24/25 and 5/8/25. k. On 5/22/25 at 10:53 PM, CNA came to nurses station stating that resident had fallen in the shower. Resident found sitting on floor in shower room. No injuries noted. Denied hitting head. Helped to get dressed. Resident alert and oriented. Able to use wheelchair and came out to the nurses station where Neuro checks and vital signs were started. Resident stated that he was trying to put underwear on and slipped on the wet floor. MD and management notified.Care plan intervention for this fall: The resident was educated to allow staff to help him get dressed in the shower room. l. On 6/15/25 at 6:17 PM, Resident had a witnessed fall. Got out of wheelchair to move a walker, when he went to sit back into his wheelchair he misjudged where the chair was and fell. [NAME] [sic] pain. No visible injuries.There was no updated intervention added to the care plan. m. On 7/3/25 at 6:42 AM, The resident had a witnessed fall. The nurse was entering the room when the resident attempted to sit in their power wheelchair when they missed and fell on their buttocks. The resident did not hit their head or sustain any injuries related to the fall.There was no updated intervention added to the care plan. n. On 7/6/25 at 12:47 PM, was called down to resident room he was sitting in the middle of the restroom floor next to a small puddle of water and the sink a head to toe assessment was done and resident was asst [assisted] up x [times] 1 and asst with walking x 2 to his recliner neuros started when asked what happened he stated he went to the restroom to urinate when he was done and leaving he lost his balance and reached out and grabbed the sink taking the sink with him when he fell when asked if there were objects or water on the floor before he fell he said no when asked why he did not take his walker or call for help he stated he did not think he needed help pt [patient] education done on the importance of using his walker any time he wants to ambulate and if he is feeling weak he needs to call for help resident states understanding Md. and management notified of fall.Care plan intervention for this fall: The resident was re-educated to ask for staff assistance. It should be noted this intervention was used on 1/24/25, 5/8/25, and 5/16/25. o. On 7/10/25 at 7:25 PM, I was administering medication to another resident when it was reported that the resident had a witnessed fall in the shower room. The CNA was able to help the resident back into the shower chair, and he was not injured, nor did he hit his head.Care plan intervention for this fall: Educate staff members to position the resident's wheelchair close to the grab bar in the shower for extra support when standing up. p. On 8/14/25 at 9:00 AM, Resident had an unwitnessed fall in his bathroom. Resident stated that he was trying to use the toilet and fell but he does not remember what happened to cause him to fall. There was a laceration located at the back of his head, due to concern of head trauma 911 was called. Care plan intervention for this fall: The facility installed an extra grab bar next to the toilet to provide the resident with enhanced support during restroom use. q. On 8/23/25 at 6:22 PM, At 1555 [3:55 PM] Nurse was notified by resident's room mate that the resident had fallen. Nurse found resident on the bathroom floor lying on his right side. Resident stated that he lost his balance and fell.Care plan intervention for this fall: The resident has been educated to leave the bathroom lights on when exiting to ensure adequate lighting for him to safely return to his chair. r. On 9/6/25 at 4:58 PM, The resident's roommate reported to the nursing station that the resident had experienced a fall in his room. The nurse promptly intervened and discovered the resident on the floor in a seated position. An assessment of the environment indicated no obstacles present, adequate lighting, and no moisture on the floor. Notably, the resident's walker was not in sight. The resident did not engage the call light prior to the incident and indicated that he was attempting to pull up his pants when he lost his balance and fell.Care plan intervention for this fall: Risk vs [versus] benefit discussion. s. On 9/6/25 at 8:01 PM, CNA called nurse to residents bathroom where resident was found on the floor sitting on his bottom with 4 wheeled walker next to him; CNA states she was in the room and heard the resident fall; no call light was used; no socks or shoes on; light was on inbathroom [sic] and there was no clutter or wet floors;States [sic] he stumbled backward while washing his hands; denies hitting head and states he landed on his bottom. Care plan intervention for this fall: Educated to use assistive device when going to the bathroom. It should be noted that on 2/3/25 resident 43 was educated to use his wheelchair for nocturnal restroom visits. t. On 9/27/25 at 11:31 PM, resident on alert charting for unwitnessed fall in his bathroom. resident did not request help to the restroom and fell as he was trying to sit on the toilet. resident landed between the toilet and the wall, denied pain at the time. neuros and vitals started, MD notified. attempted to call and notify sister, left voicemail as she did not answer. resident assessment normal at the time of the fall and resident denied pain at the time, later complained of pain to his left pinkie as he stated he tried to catch himself with that hand. treated with ibuprofen, resident stated it was effective. vitals and neuros WNL, will continue to monitor.Care plan intervention for this fall: IDT [interdisciplinary team] held a meeting with resident to identify barriers to why he does not ask for help while in the bathroom. On 10/8/25 at 10:00 AM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated that resident 43 was unsteady, had balance issues, and was a fall risk. The CNA Coordinator stated that resident 43 had fallen in the shower. The CNA Coordinator stated that resident 43 had gotten injured when he fell down in his bathroom and had to get staples to the back of his head when he hit the toilet. On 10/8/25 at 10:23 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 43 had trouble transferring and did not have good balance. CNA 2 stated that resident 43 should always have assistance with transferring and needed help in and out of the bathroom. On 10/8/25 at 11:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that resident 43 was a fall risk. LPN 2 stated that resident 43 had been injured by his falls. LPN 2 stated that resident 43 had received staples in his head from a fall in August 2025. On 10/9/25 at 8:18 AM, an interview was conducted with the Administrator (ADM). The ADM stated that he had had a discussion with resident 43 about his falls. The ADM stated that resident 43 had gotten a laceration above his eye and on the back of his head that had required hospital visits. On 10/9/25 at 10:06 AM, an interview was conducted with the Director of Nursing (DON), the Director of Clinical Services (DCS), and the ADM. The DCS stated that for the falls that occurred on 6/15/25 and 7/3/25, nurses did not open a risk management plan and interventions were not implemented because the administration did not know about the falls. The DON stated that resident 43 fell a lot in the bathroom and they had a meeting with resident 43 about it. The ADM stated they were thinking about getting a sign to put in the bathroom to remind the resident to call for assistance. 2. Resident 39 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included, unspecified dementia, insomnia, generalized muscle weakness, and repeated falls. Resident 39's medical record was reviewed 10/6/25 through 10/9/25. On 10/7/25 at 1:26 PM, resident 39 was observed to be laying in bed. The bed was pushed up against the wall and there was no fall mat observed in the room or next to the bed. A Quarterly MDS dated [DATE] documented resident 39 was a partial/moderate assist with transfers, toileting, and bed mobility. A Brief Interview for Mental Status (BIMS) dated 12/20/24 revealed that resident 39 had a score of 4. A score of 0-7 indicated severe cognitive impairment. A care plan dated 12/22/23 and revised on 7/6/25 revealed, The resident is at risk for falls r/t: dementia, terminal diagnosis of CHF [congestive heart failure], unsteady gait and balance, hx [history] of falls, use of medications that increase risk for falls, respiratory failure, chronic hypoxia, SOB [shortness of breath], use of oxygen, episodes of incontinence, reoccurring falls, and pain.Resident 39's progress notes revealed the following: a. On 1/8/25 at 10:32 AM, The CNA was checking on the resident after her bathroom door alarm went on. The nurse intervened and found the resident in a supine position. Care plan intervention for this fall: Staff provided the resident with longer oxygen tubing so she could safely reach the bathroom. b. On 1/11/25 at 11:30 AM, CNA alerted nurse that pt had fallen in restroom, pt ambulating without assistance, and fallen attempting to transfer to toilet, bed alarm, door alarm, in place at this time, pt has had frequency r/t current UTI [urinary tract infection], CNA was alerted by alarms and went in to assist to pt's needs and pt was sitting on floor next to pt's toilet, pt stated that they missed the toilet when trying to sit down and fell down on their buttock. Care plan intervention for this fall: Staff received re-education on the importance of offering routine toileting, especially considering the resident's increased frequency related to her UTI. c. On 1/28/25 at 10:04 AM, was called down to resident room resident was sitting on the toilet she was wearing fuzzy socks and no shoes the floor in the restroom had some water spots on the floor CNA was asked what happened she reported that she arrive resident was sitting on the floor getting herself up CNA tried to get her to stay were she was but she refused and cont to get up and sit on the toilet at that time a head to toe assessment was done no injuries noted neuros [neurological] started resident was educated on the importance of using hercall [sic] light or to verbally ask for help and to wait for the help Management, Md and [family member] have been notified of the fall.Care plan intervention for this fall: The staff was re-educated on the importance of ensuring that residents wear appropriate footwear, especially socks with grips. d. On 4/9/25 at 5:18 AM, Resident had an unwitnessed fall in her bathroom around 0312 [3:12 AM]. Resident was very confused and did not know if she had hit her head or how she had fallen. Resident was placed back into bed with pressure alarm functioning correctly. It should be noted that hospice initiated Depakote for increased agitation and this intervention was not placed on the care plan. e. On 4/11/25 at 12:45 PM, Resident was found on the floor in a side lying position. She states she went to get out of bed and tripped. There was a significant amount of oxygen tubing lying on her room floor that may have caused her to trip. The tubing was organized and put in an appropriate spot. Resident states she is not in any pain or feels she sustained an injury from the fall. Care plan intervention for this fall: Staff has received education on the proper management of the resident's oxygen tubing, ensuring it is wrapped and stored safely when she is in her room. It should be noted that on 1/8/25 an intervention for longer oxygen tubing was implemented. f. On 4/23/25 at 5:40 PM, Resident had a witnessed fall. Resident's chair alarm went off and CNA checked on her. Found her on the floor in the TV [television] common area. Vitals were done. Neuro assessment was done. Resident stated she was trying to get into a chair. After reviewing camera footage it was determined that resident did not hit her head.Care plan intervention for this fall: Staff have been educated to offer the resident to sit in the recliner in the common area before dinner. g. On 5/6/25 at 3:42 PM, was called into the common area resident was sitting on the floor with her back to the chair head to toe assessment was done no injuries noted resident denies c/o [complaining of] pain or discomfort reviewed video of common area resident was attempting to transfer herselffrom [sic] w/c [wheelchair] to chair she sat down on the edge of the chair and slid into the floor she did not hit her head after assessment she was asst x one into her w/c.Care plan intervention for this fall: Staff has been educated to ask the resident to sit in the recliner after lunch if she does not want to lie in bed. h. On 5/25/25 at 7:58 PM, The resident sustained a fall while attempting to self-transfer. The CNA witnessed the incident, during which the resident slipped from her chair and landed on her buttocks. The CNA promptly alerted the nurse, who intervened immediately.Subsequently, the resident was assisted into a recliner to watch television, and monitoring will continue as part of her care plan.Care plan intervention for this fall: Staff have been instructed to offer the resident the option to sit in the recliner until she feels ready for bed to help mitigate future incidents. It should be noted that after the fall on 4/3/25 staff were educated to offer the resident to sit in the recliner in the common area before dinner. i. On 6/7/25 at 11:52 AM, resident was sitting in common area in front of the nurses station she attempted to stand and slid out of her chair onto the floor head to toe assessment done no injuries noted she denies c/o [complained of] increased or abnormal pain she did not hit her head Md and management notified.Care plan intervention for this fall: Staff members have been educated to offer the resident the option to sit in the recliner or lie down between meals to enhance her comfort. j. On 6/16/25 at 4:14 PM, called down to resident room resident was laying on the floor on the far side of her nightstand with her w/c on top of her a head to toe assessment was done no injures were noted she was asst up x 1 and toileted.Care plan interventions for this fall: To further enhance safety, the facility will provide a fall mat to be placed next to her bed. It should be noted, upon observation resident 39 did not have a fall mat at bedside. k. On 7/19/25 at 5:09 PM, resident alarm went off upon arrival to room resident was standing and turning to sit in her w/c she missed her w/c and slid down onto the floor she did not hit her head she landed on her buttocks. Care plan intervention for this fall: Re-educated staff on additional call light system and how to recognize and answer it promptly. l. On 9/1/25 at 7:36 PM, Nurse was called to lounge area to assess resident that had fallen; resident was found on floor next to chair, lying on back; witness states resident stood up and lost balance falling backward over arm of armchair; resident landed on buttock and then backof [sic] head hit the floor; resident stated she was getting up to get into her wheelchair and lost her balance.Care plan intervention for this fall: staff education was reinforced to ensure the call light/alarm system remains operational at full volume and not on vibrate. It should be noted on 7/19/25 staff were re-educated on the call light system. m. On 9/7/25 at 12:35 PM, At 1130 [11:30 AM] resident attempted to stand up from wheelchair in the hallway near the nurses station. The wheelchair moved form [sic] behind the resident and the resident lost her balance and fell onto the ground, landing on her right side and hitting the right side of her face on the ground. Resident was promptly assessed and moved from ground to wheelchair .Care plan intervention for this fall: Staff members have been instructed to encourage the resident to utilize the recliner before meals to minimize the risk of falling, as the recliner provides a more stable surface upon rising from a seated position. It should be noted this intervention was used on 4/23/25, 5/6/25, 5/25/25, and 6/7/25. n. On 9/12/25 at 11:13 PM, Resident has an unwittnessed [sic] fall around 1745 [5:45 PM] in her room. Resident was unable to express if she had hit her head or not. Neuro checks started.Care plan intervention for this fall: All new staff members received education regarding the proper recognition of the resident's additional call light system. Furthermore, our competency checklist for new hires will be updated to reflect this change.It should be noted that placing resident 39 in the recliner was used as an intervention on 4/23/25, 5/6/25, 5/2/25, 6/7/25, and 9/7/25. Staff education on the call light system was used as an intervention on 7/19/25, 9/1/25, and 9/12/25.On 10/8/25 at 9:54 AM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated that resident 39 was a fall risk and required a lot of transfer assistance. The CNA Coordinator stated that resident 39 had a pressure sensor alarm that would buzz at the nurse's station whenever resident 39 got up out of bed or a chair. The CNA Coordinator stated that current fall interventions for residents were written on a white board in the administration office. The CNA Coordinator stated that the sensor alarm was the only intervention that she knew of for resident 39. On 10/8/25 at 10:36 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 39 liked to stand up and if her alarm went off staff needed to respond quickly. CNA 1 stated that resident 39 was a fall risk and was kept in the common area as often as possible. CNA 1 stated that resident 39 was confused with dementia.On 10/8/25 at 10:54 AM, an interview was conducted with LPN 2. LPN 2 stated that resident 39 was a fall risk and was on a pressure alarm. LPN 2 stated the alarm was portable and could be kept in her pocket or on the medication cart in order for a nurse to hear it. LPN 2 stated that interventions for falls were found in the care plan and management kept those updated. LPN 2 stated that resident 39 cognitively could not use a call light to call for assistance.On 10/9/25 at 8:02 AM, an interview was conducted with the DON and the DCS. The DCS stated that resident 39 was forgetful and staff were trained to routinely check on residents to prevent falls, remove clutter, and to encourage residents to wear proper footwear. The DCS stated that resident 39 was a fall risk and should have a fall mat in her room. On 10/9/25 at 8:04 AM, an interview was conducted with the ADM. The ADM stated that resident 39 was a fall risk. The ADM stated that there was an alarm system in place to help alert staff. The ADM stated that newer staff had to be re-educated regarding care for resident 39 as staff would get her up and leave her in a wheelchair and that was why the recliner was used as an intervention multiple times. The ADM stated he was unsure why the fall mat was removed or if it was causing falls for resident 39.

Based on observation, interview, and record review, it was determined that the facility did not provide or obtain laboratory services to meet the needs of its residents. If the facility provided its own laboratory services; the services must meet the applicable requirement for laboratories. Specifically, the facility glucometers were not being calibrated according to the manufacturer requirements and the control solution available was expired. Findings included:On [DATE] at approximately 3:00 PM, the 200 hall medication cart and medication storage room were observed. There were bottles of glucometer control solution in both the 200 hall medication cart and the medication storage room with an expiration date of [DATE]. There were no bottles available that were not expired.On [DATE] at 3:03 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated she did not know what the process for testing the glucometers was because the night shift tested the glucometers. On [DATE] at 11:00 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated each resident had their own glucometer and the night shift nurses tested the glucometers weekly. The ADON stated staff were trained according to the manufacturer requirements. The facility Administrator (ADM) provided the glucometer manual which revealed .Always check the expiration date-DO NOT use control solutions if they're expired.

Based on observation and interview, the facility did not provide food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, for 7 out of 26 sampled residents, residents complained of the quality and taste of the food and a test tray was not palatable. Resident identifiers: 3, 4, 6, 10, 11, 56, and 77.Findings Included: On 10/6/25 at 10:22 AM, an interview was conducted with resident 56. Resident 56 stated the food was bland and did not taste good. On 10/6/25 at 11:50 AM, an interview was conducted with resident 4. Resident 4 stated that the food did not taste good and most of the time she bought her own food to eat.On 10/6/25 at 2:34 PM, an interview was conducted with resident 10. Resident 10 stated that the food was dry and not tasty.On 10/6/25 at 3:07 PM, an interview was conducted with resident 6. Resident 6 stated the food was not edible.On 10/6/25 at 3:48 PM, an interview was conducted with resident 11. Resident 11 stated the food was lukewarm and not good and he had to buy his own snacks.On 10/7/25 at 9:32 AM, an interview was conducted with resident 3. Resident 3 stated the food was only good when they got it right. Resident 3 stated the kitchen had trouble getting the orders correct.On 10/7/25 at 10:00 AM, an interview was conducted with resident 77. Resident 77 stated the food was absolutely terrible.On 10/8/25 at 1:20 PM, a test tray was sampled. The menu was garlic roasted chicken, penne alfredo, parsley carrots, and bananas foster cake. The pasta was mushy, overcooked, and had no flavor. The chicken was dry and grisly and hard to chew. The carrots were diced and did not contain parsley. The cake had a strong artificial banana flavor and was dry in texture.On 10/9/25 at 8:48 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that he had received food complaints from residents and there was a food committee. The DM stated that he had complaints from residents about undercooked chicken and so now he was making sure that the chicken was overly cooked. The DM stated that he had been told his food was too spicy so he had stopped using seasonings in the food.

Based on observation and interview, it was determined that the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there were undated food items stored in the refrigerator and freezer, hairnets were not worn correctly; resident refrigerators' temperatures were not monitored and food was unlabeled and undated; a dietary aide touched fish, chicken, and pasta with gloved hands after touching multiple surfaces; and chicken and fish were chopped with the same knife during lunch service causing cross-contamination of foods. Findings included: On 10/6/25 at 8:11 AM, an initial tour of the kitchen was conducted. The following observations were made: a. Dietary Aide (DA) 1 was wearing a hairnet with her bangs uncovered by the hair net. b. There was undated pudding in cups in the refrigerator. c. There was covered juice in cups that were undated. d. There was an opened and undated carton of thickened orange juice. e. There was an opened and undated container of lettuce. f. There was an opened and undated bag of tater tots in the freezer.On 10/7/25 at 9:16 AM, an observation was made of the resident refrigerators. The following observations were made: a. In the 200/300 refrigerator there was no thermometer to monitor the temperature. b. There was a container with pasta that was undated. c. There was an undated bag of fruit that was mushy and leaking on the shelves. d. There was an opened and undated container of pudding. e. The shelves in the door of the 200/300 refrigerator were covered in a brown sticky substance. f. There were burritos uncovered, undated, and opened to air in the 200/300 freezer. g. There was an ice cream shake that was unlabeled and undated in the 100/400 freezer. h. There was a frozen chimichanga in the freezer with a use by date of 10/4/23. i. There was an unlabeled and undated Subway sandwich in the refrigerator that was hard to the touch. j. There was an undated and unlabeled chicken sandwich in the refrigerator that was hard to the touch.On 10/8/25 at 12:19 PM, a follow-up tour was conducted in the kitchen. The lunch tray line was observed and the following observations were made: a. At 12:20 PM, DA 1 was wearing a hairnet with her bangs uncovered. b. At 12:37 PM, DA 2 put on gloves, opened the oven door, picked up a plate and touched the middle of the plate with his gloved hand. DA 2 then touched the chicken and slid it to the side of the plate with his gloved hand. c. At 12:40 PM, DA 2 with the same gloved hands, picked up two pieces of fish and placed them on a plate. d. At 12:41 PM, DA 2 with the same gloves, picked up a plate and placed his gloved fingers in the center of the plate. DA 2 then picked up a piece of fish with the same gloved hand and placed the fish on the counter and began to cut up the fish. e. At 12:42 PM, DA 2 touched chicken as it was placed on top of pasta on the plate. DA 2 was still wearing the same gloves. f. At 12:44 PM, DA 2 slid pasta to the side of the plate with the same gloved hands and then touched the chicken as it was placed on top of the pasta. g. At 12:48 PM, DA 2 removed his gloves and donned new gloves. h. At 12:50 PM, DA 2 rested both gloved hands with the palms down on a dirty countertop. i. At 12:51 PM, DA 2 touched pasta and chicken with his gloved hands. j. At 12:52 PM, DA 2 picked up chicken and then chopped it in the same area that he had cut up fish with the same gloved hands and knife. k. At 12:54 PM, DA 2 picked up fish with his gloved hands and placed the fish on a plate. On 10/8/25 at 1:39 PM, an interview was conducted with DA 2. DA 2 stated that allergies and preferences of residents were on meal tickets. DA 2 stated that to prevent food allergies in residents he would keep a close eye on the foods, made sure he changed gloves, and used different kitchen utensils. DA 2 stated that there were two residents in the facility who have fish allergies. On 10/9/25 at 8:48 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that hairnets needed to be worn by the kitchen staff that covered the entire head. The DM stated that kitchen staff should wash their hands often. The DM stated that kitchen staff should change gloves every time they moved out of their station or if they touched things. The DM stated that he preferred if staff did not touch food with gloved hands. The DM stated that items should be dated and labeled if they were in the refrigerator or freezer. The DM stated that he was not sure of who was responsible for the resident refrigerators and that the kitchen staff was not doing it. The DM stated that he knew of two residents in the facility that had fish allergies. The DM stated there were no issues with cross contamination because the chicken and fish were cooked. On 10/9/25 at 9:11 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the night shift nurses were responsible for maintaining the resident refrigerators. The DON stated that items in the refrigerator should be dated and labeled. The DON stated that she was not aware of any residents who had fish allergies.A review of the outside food policy revealed: Policy:It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident.Policy Explanation and Compliance Guidelines:1. Family members or other visitors may bring the resident food of their choosing.2. All food items that are already prepared by the family or visitor brought in must be labeled with content and dated.a. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator.b. The prepared food must be consumed by the resident within 3 days.c. If not consumed within 3 days, food will be thrown away by facility staff.d. The facility will not be responsible for maintaining any reusable items.3. All food items brought in that are manufactured and does not require refrigeration, may be kept in the resident room inside a lock tight container that is provided by the resident.4. Foods may be reheated in a microwave and should be stirred during the reheating process and reheated to at least 165 F.5. Ensure that reheated foods are cooled enough to a palatable temperature prior to consuming to prevent burns.6. It is the responsibility of the resident and/or resident representative to maintain said container and items in the container.7. All items not maintained are subjected to being thrown away if not removed by the resident and/or resident representative.8. If any part of this policy is not followed, the facility reserves the right to protect others by not allowing food items to be brought into the facility for a resident.9. The facility staff will assist residents in accessing and consuming food that is brought in by resident and family or visitors if the resident is not able to do so on their own.

Based on observation, interview, and record review it was determined that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 5 out of 26 residents, Enhanced Barrier Precautions (EBP) were not implemented for residents, staff were observed not performing hand hygiene during medication administration, and glucose monitors were not disinfected according to manufacturer instructions. Resident identifiers: 5, 8, 39, 67, and 73.Findings included: Enhanced Barrier Precautions On 10/6/25 at 8:37 AM, an initial tour of the resident hallways was conducted. No signage indicating transmission based precautions were observed outside residents' doorways. Pink and green dots were observed on some of the resident name placards. On 10/6/25 at 8:50 AM, an interview was conducted with the Office Manager Assistant, who stated that the pink and green dots indicated residents' code status. 1. Resident 5 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease, type 2 diabetes mellitus, and hemiplegia and hemiparesis following cerebral infarction. Resident 5's medical record was reviewed on 10/6/25 through 10/9/25. On 9/19/25, EBP were ordered related to wounds for resident 5. On 10/6/25 at 10:10 AM, no signage for EBP was observed outside resident 5's room. On 10/7/25 at 1:13 PM, EBP signage was observed outside resident 5's room. 2. Resident 8 was admitted to the facility on [DATE], with diagnoses that included paraplegia, neuromuscular dysfunction of bladder, and neurogenic bowel. Resident 8's medical record was reviewed on 10/6/25 through 10/9/25. On 6/5/25, EBP were ordered related to an indwelling catheter for resident 8. On 10/6/25 at 3:52 PM, no signage for EBP was observed outside resident 8's room. On 10/7/25 at 1:13 PM, EBP signage was observed outside resident 8's room. 3. Resident 73 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included congestive heart failure, type 2 diabetes mellitus, Parkinson's disease, and chronic kidney disease. Resident 73's medical record was reviewed on 10/6/25 through 10/9/25. On 10/7/25 at 9:35 AM, it was observed that the banner located in resident 73's electronic medical records stated Special Instructions: EBP (Enhanced barrier Precautions). No physician order for EBP could be located in resident 73's medical record. On 10/8/25 at 9:01 AM, an interview was conducted with Nurse Aide (NA) 2. NA 2 stated that nursing management would communicate changes to EBP through a staff messaging app. NA 2 stated that EBP signage posted outside resident rooms was a new system. On 10/8/25 at 9:13 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that EBP signage should have been posted outside resident rooms, but frequent room changes made it difficult to update the signage. On 10/9/2025 at 12:46 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff were made aware of EBP in multiple ways, such as an EBP order in the resident's chart, EBP updates communicated through a staff messaging app, and EBP signage posted outside resident rooms. When asked why no EBP signage was observed in the hallways on 10/6/25, the DON stated that they previously used colored dots to indicate any transmission based precautions. The DON stated that they transitioned to posting EBP signage outside resident rooms because the colored dots were not as noticeable. The DON stated that previously EBP orders were posted on the banner located in a resident's electronic medical records. The DON stated that resident 73 was previously on EBP, and the electronic medical records banner had not been updated after resident 73 was no longer on EBP. Glucometer On 10/8/25 at approximately 9:00 AM, LPN 1 was observed performing medication administration for the 200 hall. LPN 1 obtained Resident 67's blood glucose using the residents personal glucometer. After LPN 1 obtained Resident 67s blood glucose, LPN 1 was observed to use an alcohol prep-pad to disinfect Resident 67's glucometer before securing it in a resealable plastic bag and placing it back into the bin next to the other residents glucometers. On 10/9/25 at 11:00 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the process for cleaning the glucometers were following the manufacturers requirements. The ADON stated the glucometer was wiped down daily with microclean wipes which had purple tops and then a 1-minute dry time. The ADON stated the glucometers were cleaned after every use. The manufacturer recommendations from the manual revealed, Cleaning and disinfecting the meter and lancing device is very important in the prevention of infectious disease. Cleaning is the removal of dust and dirt from the meter and lancing device surface so no dust or dirt gets inside. Cleaning also allows for subsequent disinfection to ensure germs and disease causing agents are destroyed on the meter and lancing device surface. The EvenCare G2 Meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. The manual provided a list of disinfecting wipes that were approved for use to clean the glucometer. Hand Hygiene On 10/8/25 at approximately 9:30 AM, LPN 2 was observed performing a medication administration for the 400 hall. LPN 2 entered resident 39's room with their meds in a small cup. LPN 2 passed Resident 39 their medications and a cup of water. LPN 2 proceeded to exit the residents room to get more water for the resident and failed to sanitize their hands prior to touching both the cups and water pitcher on the 400 hall medication cart that was used for all of the residents in that hall. On 10/8/25 at approximately 3:15 PM, an interview was conducted with LPN 2. LPN 2 stated during med pass hand hygiene should have been performed after passing medications to Resident 39 and prior to touching the cups and water pitcher on the medication cart.

Based on interview and record review, for 1 of 26 sampled residents, the facility did not provide residents the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed. Specifically, a resident was not provided written notice when she had roommate changes. Resident identifier: 77. Findings included: Resident 77 was admitted to the facility on [DATE] with diagnoses which included dementia, generalized anxiety disorder, cognitive communication deficit, hypothyroidism, fibromyalgia, major depressive disorder and post traumatic stress disorder.On 10/17/25 at 10:00 AM, an interview was conducted with resident 77. Resident 77 stated she had different roommates and her current roommate had returned from the hospital recently. Resident 77 stated her roommate was not the same since returning from the hospital. Resident 77's medical record was reviewed. There were no notifications that resident 77 had roommate changes. There were no nursing progress notes located regarding roommate changes for resident 77. On 10/9/25 at 8:41 AM, an interview was conducted with the Resident Advocate (RA). The RA stated she usually gave a 24 hours notice before the room change to the resident who was moving. The RA stated that resident 77 complained of her roommate and she was moved out and another resident moved in. The RA stated then resident 77 was having problems with the new roommate so she requested her old roommate back, so they moved the original roommate back into resident 77's room. The RA stated she did not have documentation of room moves or notification to the residents. On 10/9/25 at 10:34 AM, an interview was conducted with the Director of Clinical Services (DCS) and the Director of Nursing (DON). The DON stated resident 77's roommate was moved and then resident 77 stated she missed her roommate so they moved her back. The DON stated usually when conducting a room change, the staff looked to see if the residents were compatible, then provided a 24 hour notice of the room change, unless there was a safety concern. The DCS stated the RA should be providing both residents with a form to notify them of the room change. The DCS stated the form was signed by the resident and scanned into their medical record.

Based on interview and record review, it was determined that the facility did not ensure that any individual working in the facility as a nurse aide for more than 4 months was competent to provide nursing and nursing related services; and completed a training and competency program, or a competency evaluation program approved by the State. Specifically, a Nurse Aide (NA) was employed at the facility and worked as a NA for over 4 months without completion of a training or a competency evaluation program approved by the State.Findings included: On 10/8/25 NA 1's employee file was reviewed. NA 1 was hired on 5/7/25. NA 1 was still employed as a NA and the last shift worked was 10/3/25.On 10/8/29 at 2:08 PM, an interview was conducted with the Business Office Manager (BOM). The BOM stated that NA 1 was still employed by the facility as a NA. The BOM stated that NA 1 had not taken her test nor completed the NA program. The BOM stated that NA 1 had last worked on 10/3/25 and was now removed from the schedule. The BOM stated the Certified Nurse Assistant (CNA) Coordinator was in charge of scheduling NA's. On 10/8/25 at 2:16 PM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated that NA 1 had been in the certification program, but had not completed the program. The CNA Coordinator stated that she found out at the beginning of September 2025 that NA 1 had not completed the program. The CNA Coordinator stated that NA's should not work after 120 days until they become certified.On 10/8/25 at 2:20 PM, an interview was conducted with the Administrator (ADM). The ADM stated that NA 1 had been hired and assigned to the CNA course. The ADM stated that NA 1 was having some personal problems and did not complete the course. The ADM stated he was not sure when NA 1 last worked, but knew it was after 120 days. The ADM stated that NA 1 is off the schedule and not working until she completed the course.

Based on observation, interview and record review, for 1 of 26 sampled residents, the facility did not ensure each resident received necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, a resident with mental health diagnoses was not offered counseling services. Resident identifier: 77. Findings included: Resident 77 was admitted to the facility on [DATE] with diagnoses which included dementia, generalized anxiety disorder, cognitive communication deficit, hypothyroidism, fibromyalgia, major depressive disorder and post traumatic stress disorder. On 10/7/25 at 10:00 AM, an interview was conducted with resident 77. Resident 77 stated she was concerned because child molesters were moving into the facility and it made her feel really uncomfortable. Resident 77 stated her ex-husband molested her daughter so knowing there were residents like that in the facility brought back all her feelings. Resident 77 stated her roommate had Schizophrenia like her ex-husband and the roommate came back from the hospital about a week ago and was not the same. Resident 77 stated she goes to sleep fearing her roommate. Resident 77 stated she talked to the Resident Advocate (RA) yesterday about moving away from her roommate. Resident 77 stated her roommate moved out and another one in and that was worse so she asked for her roommate back. Resident 77 stated she did not have a therapist or talked to one but she really, really needs to. Resident 77 was observed to be on the verge of tears during the interview. Resident 77's medical record was reviewed 10/7/25 through 10/9/25.A Preadmission Screening Resident Review (PASRR) Level II dated 1/4/24 revealed resident 77 history included major depressive disorder with anxiety since her 20's. Resident 77 was abused and neglected as a child. Resident 77 had an abusive husband who sexually abused her little girl with her son as a witness. Resident 77 received mental health help for three years, which included one year at a sexual abuse treatment center. The PASRR further revealed Diagnostic Formulation: [Resident 77] has had a long history of trauma, and some history of subsequent treatment. She continues to experience depression and reactions to trauma despite the years since trauma has occurred. (However, it is also possible that she has had more recent traumatic experiences given her history of homelessness.) She has been insufficiently employed or unemployed, a reported past drug user, and is disconnected from family. She's had suicide attempts in the past and she has regular suicidal ideations for the past two years. She endorses high levels of anxiety and cannot pinpoint the origin of the anxiety. However, she does admit to having anxiety when planning for her future. She is seriously mentally ill.The PASRR continued with Recommendation for Specialized Services for mental illness treatment: Referral for mental health therapy and medication management as needed. Ongoing monitoring and assessing of her suicidal ideations due to current suicidal ideation and suicide attempts in the past. Continue to encourage [resident 77] to socialize with the other residents and engage in activities provided at the SNF [skilled nursing facility]. [Resident 77] scored a 13 on her BIMS [brief interview of mental status], but there have been concerns about her memory and prior records indicate a diagnose [sic] of dementia. Further testing for dementia would be beneficial.A care plan dated 12/27/23 and revised with no new interventions on 3/28/24 resident 77 had a Level II PASRR and is considered significantly mentally ill due to her diagnoses of Generalized anxiety disorder, depression recurrent/moderate, PTSD chronic, and dementia. The goal was Psychosocial, mental and physical needs will be met through the next review date. The interventions were Administer medications as ordered and monitor for adverse effects and notify physician as needed; Follow PASRR II plan of care:.Referal for mental health therapy and medication management as needed; Psychology consult as needed/recommended; Staff will utilize facility resources to meet the needs of the resident; and Updates will be made to PASRR and appropriate agencies notified as necessary. Another care plan regarding Trauma informed care initiated on 12/27/23 and revised on 1/24/24 revealed triggers were shouting, yelling, loud voices or anything that had the potential to move into violence. Interventions included arranging to receive services from a licensed mental health provider as indicated. There was no documentation located in the medical record regarding resident 77 was ever offered therapy or counseling services. On 10/9/25 at 8:52 AM, an interview was conducted with the RA. The RA stated she did not think that resident 77 would want counseling services. The RA stated there was a contracted Licensed Clinical Social Worker (LCSW) who reviewed the PASRR's, and the social history and psychological assessments completed by her upon admission and annually. The RA stated the LCSW then created the care plans based on that information. On 10/9/25 at 10:50 AM, an interview was conducted with the Director of Nursing (DON).The DON stated there was a therapist who came to the facility weekly to provide therapy but did not treat resident 77. The DON stated she thought therapy services were offered and resident 77 refused. The DON stated she did not document when therapy services were offered. On 10/9/25 at 1:40 PM, an interview was conducted with the Administrator and Director of Clinical Services. The Administrator stated resident 77 had never mentioned that she wanted mental health services or therapy. The Administrator stated resident 77 was very closed off when talking with new people. The Director of Clinical Services stated shortly after resident 77 was admitted , she offered therapy services but she refused. The Administrator stated he submitted the PASRR's and reviewed the recommendations. The Administrator stated resident 77 was admitted over 2 years ago and was not sure what the recommendations were but felt like every person was referred for mental health services. The Administrator stated offering mental health services should be documented in the residents medical record.

Based on observation and interview, it was determined that the facility did not ensure that all drugs and biologicals were stored and labeled in accordance with accepted professional principles, under proper temperature controls and cautionary instructions, and the expiration date when applicable. Specifically, there were expired medications stored in the facility's medication storage room available for patient use. Findings included: On 10/8/25 at 2:05 PM, an observation was made of the facility's medication storage room. The following medications were observed and available for resident use:One bottle of Naproxen tablets expired 9/25 Two bottles of Vitamin C tablets expired on 8/25 One bottle of Calcium tablets expired 7/24Multi-Symptom Day Cold/Flu medicine expired 9/24 on the box, the medication inside of it showed an expiration date of 9/22 Anti-Anxiety Relief one bottle expired 10/2/23, one bottle 6/2/24, and another bottle expired 7/24/24Fiber Therapy bottle expired 12/22/24One bottle of Fiber Powder expired 3/25Two boxes of Fiber Lax caplets expired 9/25A box containing twenty-three bottles of protein shake supplements expired on 3/1/25Ammonium Lactate expired 7/25Arginine powder, Arginaid expired 8/6/25Two bottles of Magnesium Citrate oral solution had expired on 9/13/25Inside of the medication fridges, there were three boxes of the influenza vaccines that expired on 6/29/25Inside the medication fridge there were Covid vaccines that expired on 3/29/25 On 10/9/2025 at 10:57 AM, an interview was conducted with the Director of Clinical Services (DCS) and Director of Nursing (DON). The DCS stated that the night shift nurses were supposed to go through expired medications and return them to the pharmacy. The DCS and DON stated the pharmacy came to the facility daily except Sunday.

Based on interview and record review, for 1 of 26 sampled residents, the facility did not provide or obtain radiology services to meet the needs of the residents. Specifically, a resident did not have a Magnetic Resonance Imaging (MRI) scheduled. Resident identifier: 3. Findings included: Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis, neurologic neglect, dysphagia, major depressive disorder, insomnia, and mild-protein calorie malnutrition.On 10/7/25 at 9:32 AM, an interview was conducted with resident 3. Resident 3 stated she had a subluxation to her left shoulder. Resident 3 stated she went to a doctor's appointment 3 weeks ago and needed an MRI. Resident 3 stated the MRI had not been scheduled yet.Resident 3's medical record was reviewed 10/7/25 through 10/9/25. A nursing progress note dated 9/26/25 at 1:22 PM revealed, Resident had an appointment with an orthopedic provider today regarding her left shoulder. It appears the resident has atrophy of the left shoulder but rotator cuff tendons are intact. Ortho [orthopedic] provider recommends resident obtain an MRI of the left shoulder. Orthopedist also suggests the resident get more intensive post stroke care in a neuro rehab facility. MD [Medical Director] notified.On 10/9/25 at 8:20 AM, an interview was conducted with Nursing Aide (NA) 2. NA 2 stated resident 3 told her that her shoulder was a stage 4 dislocation and she complained of shoulder pain. On 10/9/25 at 9:13 AM, an interview was conducted with the Administrator who stated the Director of Nursing (DON) had a spreadsheet for appointments to be made by the Transport Director. The DON was observed to look at the spreadsheet and unable to find the appointment on the spreadsheet. The Administrator stated there was a folder of appointments to be made in the Transport Directors desk. The Administrator was observed to look in the folder and there were no documents for resident 3's MRI. On 10/9/25 at 11:23 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated she received the referral for MRI on 9/26/25.

Based on observation, interview, and record review it was determined that, for 1 of 26 sampled residents, the facility failed to provide food that accommodated resident allergies, intolerances, and preferences. Specifically, a resident was provided food that was listed as an allergy. Resident identifier: 50.Findings included: Resident 50 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, irritable bowel syndrome, and lactose intolerance.Resident 50's medical record was reviewed on 10/6/25 through 10/9/25.On 10/06/25 at 10:16 AM, an interview was conducted with resident 50. Resident 50 stated that even though he required a lactose intolerant diet, dairy products would frequently be on his meal trays. Resident 50 stated that he and the Certified Nursing Assistants (CNA) had repeatedly spoken to the kitchen staff about his lactose intolerance, but he continued to receive dairy on his meal trays. Resident 50 stated that he was constantly on the lookout for dairy products because he would develop diarrhea if he consumed any dairy products. Resident 50 stated that he was often served ranch with his salad, and when he asked for a substitute he was told ranch was the only dressing available. On 10/6/25 at 12:20 PM, an observation and additional interview were conducted with resident 50. Resident 50 stated that he was given ranch dressing on his lunch tray, and that he gave the ranch to his roommate. Resident 50's lunch tray was observed and the side salad was covered with plastic wrap. Resident 50 stated that he planned on eating the side salad dry because no substitute was available. An observation was made of resident 50's meal ticket. Resident 50's meal ticket stated: LACTOSE INTOLERANT, NO MILK OR PRODUCTS AT ALL.On 10/6/25 at 12:30 PM, an additional interview was conducted with resident 50, who stated that when he uncovered his salad to eat it he discovered there were cheese shavings mixed in with the salad. Resident 50 stated that he had notified the staff, and CNA's would bring him a new salad from the kitchen. On 10/8/25 at 9:13 AM, an interview was conducted with CNA 2. CNA 2 stated that food allergies were listed on a resident's meal ticket. CNA 2 stated that while substitute meals were available, the substitute for ranch dressing was not always in stock. On 10/9/25 at 8:48 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that resident 50 was lactose intolerant and could not have any milk products. Additionally, the DM stated that he would not serve ranch dressing or cheese to a resident that was lactose intolerant. On 10/9/25 at 12:46 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that a resident's food allergies and preferences were located in their chart and on their meal tickets. Additionally, the DON stated that staff were expected to check a resident's meal tray before they delivered it to the resident, and that substitutes were expected to be available in the kitchen.

Based on observation, interview and record review it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the dish machine washing temperature did not reach the required temperature, cups were observed to have a white substance inside of them and a staff member was observed to touch dirty surfaces with gloves and then touched clean dishes. Resident identifier: 84. Findings include: 1. On 4/22/24 at 10:38 AM, an initial tour of the kitchen was conducted. The following observations were made: a. On 4/22/24 at 10:41 AM, an observation was made of Dietary Aide (DA) 2. DA 2 was observed to touch dirty dishes and loaded them into a dish machine basket. DA 2 was observed to push the basket into the dish machine with gloved hands. DA 2 was observed to grab the handle on the dish machine with soiled gloves and pull it down. DA 1 was observed to have gloves on and touched the handle that DA 2 had touched with soiled gloves. DA 1 was observed to touch clean dishes and put them away without changing gloves or performing hand hygiene. At 10:43 AM, DA 2 was observed to touch the dish machine handle after touching dirty dishes. DA 1 was observed to touch the same handle with a gloved hand and then was observed to touch the inside of the plate domes and plate bases when putting them away. DA 1 was observed to remove gloves and perform hand hygiene at 10:44 AM. b, At 10:46 AM, an observation of the facility dish machine was made. [Note: All temperatures were in degrees Fahrenheit.]: i. The washing temperature was 110 for wash and the rinse temperature. ii. The washing temperature was 115 and rinse temperature was 122. iii. DA 2 was observed to check the sanitizer solution and stated it was at 100 parts per million of chlorine. DA 2 was interviewed and stated the dish machine temperatures were to be 120 to 160 for the washing cycle and the rinse cycle. DA 2 stated the temperatures were checked before starting dishes after each meal. 2. On 4/22/24 at 12:54 PM, an observation was made of a meal cart in the 400 hallway. The vents on the back of the meal cart were observed to have a dried white substance dripping out of them and down the back of the meal cart. 3. On 4/24/24 at 3:04 PM, a follow-up kitchen tour was conducted. The following was observed: a. There was a white substance on the back of a meal cart after it had been cleaned by DA 2. b. There was a white substance inside cups that were stored in the clean area. c. The dish machine temperatures were the following: [All temperatures were in degrees Fahrenheit.] i. At 3:19 PM, an observation was made of DA 2 touching the handle of the dish machine. DA 1 was observed to touch the same handle with a gloved hand and then touch clean dishes and replace them with clean dishes. ii. At 3:20 PM, the washing cycle was 110 and the rinsing cycle was 120. iii. At 3:21 PM, an observation was made of DA 1 documenting temperatures from the dish machine. The temperatures documented were 139 for the washing cycle and 137 for the rinsing cycle. iv. At 3:23 PM, the washing cycle was 110 and rinsing cycle was 120. DA 1 was observed to place mugs and bowls from the dish machine to the shelves with clean dishes. v. At 3:26 PM, the washing cycle was 111 and the rinsing cycle was 125. An interview was immediately conducted with the Dietary Manger (DM). The DM stated the dish machine needed to run a few times for the temperatures to be above 120 for the washing cycle and the rinsing cycle. The DM stated he was unable to see the thermometer because it was to low, so he drew a line above the thermometer so staff could see the temperatures. The DM stated there was a water booster that was set to 150 so the temperatures were not able to be below 120. vi. At 3:30 PM, an observation was made of DA 2 touching the dish machine handle after DA 1 had touched the same handle with soiled gloves. DA 2 was observed to touch the inside of the domes and replace the domes with clean dishes without removing gloves or performing hand hygiene. vii. At 3:31 PM, the washing cycle was 116 and the rinsing cycle was over 125. An interview was conducted with DA 2. DA 2 stated if the dish machine sat unused for a few minutes, then it had to be run a few times to get the temperature above 120 for the washing and rinsing cycles. On 4/22/24 at 11:05 AM, an interview was conducted with resident 84. Resident 84 stated that the cups are dirty with a white film. Resident 84 stated that he asked the staff what the white stuff was and was told that it was hard water buildup. Resident 84 stated that he was able to wipe the white residue out of the cup with his finger. Resident 84 stated that he doesn't think the cups are being washed at a high enough temperature. Resident 84 stated that he refuses to use the cups and requested only to use Styrofoam cups. On 4/25/24 at 12:46 PM, an interview was conducted with the DM. The DM stated the white substance in the glasses was from hard water. The DM stated that the facility was looking into a water softener. The DM stated that until the facility installs a water softener, the glasses were soaked in lime-away weekly and then re-washed. The DM stated that he was aware of the white substance and tried to buy new glasses but it continues to build up quickly. The DM stated that he was not aware that DA 1 was putting clean dishes away after touching the same handle as DA 2 had touched with soiled gloves.

Based on interview, observation and record review, the facility did not ensure that 6 of 56 sample residents who displayed or is diagnosed with [REDACTED]. Specifically, residents expressing [MEDICAL CONDITION] were not treated appropriately. The findings for residents 9, 21, and 29 were found to have occurred at a harm level. Resident identifiers: 2, 9, 21, 29, 33, and 37. Findings include: HARM 1. Resident 21 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 21's medical record was reviewed on 11/5/18. Resident 21 had a level II PreAdmission Screening Resident Review (PASRR) completed on 8/9/18. The PASRR indicated that resident 21 has a long history of treatment for [REDACTED]. over the past few years she has been psychiatrically hospitalized multiple times d/t (due to) recurrent suicidal ideation and psychotic symptoms, usually persucatory (sic) command auditory hallucinations. Pt (Patient) was just hospitalized at (name of psychiatric hospital) from 5/19/18 to 6/7/18 . she was rehosptalized on [DATE] and she has been at (name of psychiatric hospital) for nearly 2 months for ongoing stabilization. she has a history of recurrent suicidal ideation, self-cutting, and suicide attempts by overdose. The PASRR evaluator documented that resident 21 may be a substantial danger to himself/herself or others. Upon initial review of resident 21's care plan, the facility had not developed a care plan related to resident 21's psychiatric history and psychosocial needs such as coping mechanisms or interventions to prevent or address [MEDICAL CONDITION] or thoughts of self-harm. Nurses notes for resident 21 were reviewed and revealed the following: a) On 10/15/18, Patient stated 'the voices in my head are getting loud.' Patient said that they usually tell her to 'cut, kill and die.' but they they (sic) were now starting to have conversations with her and it was making her feel out of control. RA (Resident Advocate) felt patient wanted someone to talk to. Patient and RA talked for a few minutes before deciding to call the crisis hotline. Patient spoke with the hotline and identified a few things that would assist in keeping her distracted and safe. Patient was placed on 15 minute checks and was given activities to distract. Patient was also given number to the crisis hotline in case she needed help later tonight. RA will follow up with patient tomorrow to see how she is feeling. no other concerns expressed at this time. (Note: No documentation could be found to indicate that resident 21 was checked on every 15 minutes.) b) On 10/16/18 at 1:51 AM, Resident was sent to (name of hospital) via ambulance at 2230 (10:30 PM). Resident was taken for an attempted suicide with slashing her wrists with a push pins (sic). MD and family notified. c) On 10/16/18 at 4:56 AM, Resident returned from (name of hospital) via ambulance at 0450 (4:50 AM). Residents left arm is bandaged. Nurse was given verbal feedback from the crisis worker for a referral for a psychiatric office. Resident is currently resting in bed. WCTM. d) On 10/16/18 at 4:52 PM, patient was found to have taken a push pin and cut her wrist. Patient did not have a plan for suicide but stated 'I cut to take away the mental pain'. Patient consented to have all possible sharp items removed from room. Patient was placed on a one on one with a staff member. e) On 10/17/18, Resident continues on frequent Q (every) 15 minute checks for suicidal ideation and self harming. Crisis is aware, resident has been pleasant and cooperative throughout this shift, resident has not verbalized to this nurse any desires to self harm at this time. CNA is accompanying the resident as a 1 on 1 at this time. f) On 10/19/18 at 6:37 PM, the resident was discharged to (name of local hospital) following suicidal ideation. (Note: No documentation could be found to indicate what interventions had been put into place after resident 21 had expressed suicidality and harmed herself, in an effort to prevent further incidents or to assist resident 21 in coping with harmful thoughts. Resident 21 was subsequently hospitalized in a local behavioral hospital until 10/25/18.) A History and Physical (H&P) dated 10/19/18 from a local behavioral hospital was reviewed. The H&P indicated that resident stated to hospital staff I want others to hurt the way I hurt. The H&P also indicated that that the resident had a long history of [MEDICAL CONDITION]/attempts, and cutting. The H&P revealed that resident 21 had current [MEDICAL CONDITION], suicide attempts in the last 6 months, and self-harm attempts in the last 6 months. The H&P also revealed that resident 21 was at a high imminent and chronic risk of harm to self or others. Resident 21 was discharged from the local behavioral hospital on [DATE]. Facility staff completed a baseline care plan for resident 21. The care plan indicated that resident 21 had a referral sent to the local mental health department and that the resident hears voices in head. No interventions were listed on the baseline care plan for resident 21's mental health needs. The admitted listed on the care plan was 10/25/18 but the care plan was not signed or dated. On 10/31/18 a physician's note indicated that the resident was seen by the facility medical director. The physician documented that staff reports no noticeable changes in behavior, despite the resident having just returned from the local behavioral hospital. The physician did not address the residents behaviors or psychosocial needs besides a note stating Inform Social Work of possible needs. It should be noted that this exact phrasing was included in resident 21's 8/29/18 physician's note. On 11/10/18, after the resident had been hospitalized for [REDACTED]. On 11/7/18 at 2:00 PM, an interview was conducted with the facility Resident Advocate (RA). The RA stated that on 10/15/18 after resident 21 expressed suicidal ideation, the resident was placed on one on one supervision, but was still having a hard time. The RA stated that she called the crisis line with resident 21 and had a safety plan in place for resident 21. The RA stated that on 10/15/18 she left at 4:30 PM, stating that the resident was trying to self-harm and was not suicidal. (Note: The resident was sent to a local hospital at 10:30 PM that evening after cutting her wrist with a push pin.) The RA was asked if a psychosocial assessment had been completed for resident 21. The RA stated that facility staff were not completing psychosocial assessments for any of the residents because corporate had not decided which form to use yet. In addition, the RA stated that resident 21 had not been seen by the local mental health department in the 3 months since the resident had been initially admitted . On 11/8/18 an interview was conducted with the Corporate Resource Nurse (CRN). The CRN confirmed that resident 21 did not have a psychosocial assessment completed. The CRN also stated that resident 21 had not been seen by the local county mental health department, but that the RA was working on getting a caseworker assigned. The CRN did not know why resident 21 did not have a mood care plan developed upon admission. On 11/14/18 at 2:00 PM, a follow up interview was conducted with the CRN. The CRN stated that there was no documentation that she could locate to indicate the facility did 15 minute checks in (MONTH) (YEAR) for resident 21. On 11/8/18 the facility Licensed Clinical Social Worker (LCSW) notes were reviewed and revealed the following: a) (MONTH) (YEAR): Focus of the month has been on doing training with (name of RA) who is relatively new to her Resident advocate position. The RA was instructed to create a list of the 10 residents who she feels have the most challenges and to document at least every other week on the residents' progress (sic) and interventions that have been made. No documentation was found to indicate that the suicidality of multiple residents had been discussed, nor interventions that had been implemented to prevent suicidality. b) (MONTH) (YEAR): Review of how to work with nursing and medical staff in assisting residents making suicidal comments or expressing ideas of self-harm. In light of ombudsman concerns we are focusing on creating a more positive work and living environment at Lomond Peak. We are brainstorming ideas for activities and education for staff and residents to help improve morale among staff and residents. No documentation was found to indicate what, if any, training had occurred with staff regarding suicidal comments or expressing ideas of self-harm. In addition, no documentation was found to indicate if specific residents had been discussed and/or what, if any, interventions had been implemented to prevent suicidality. c) (MONTH) (YEAR): Focus for the month is on creating a positive environment for staff and residents. I did a preview of mindfulness training during the all staff meeting and will do the first breakout session with staff in October. I worked with (name of RA) to complete lethality assessments for residents expressing suicidal thoughts. We discussed approaches to address depression and anxiety as best we can with the Lomond Peak population. No documentation was found regarding specific approaches to address depression and anxiety or suicidality. d) (MONTH) (YEAR): We had a very successful session with staff on mindfulness, appreciating the positive aspects of our jobs and learning to look for positives in various situations. (The RA) will continue to need support managing challenging behavior including residents making comments regarding self-harm and suicidal ideation. No documentation was found to indicate what, if any, training had occurred regarding specific approaches to address and prevent suicidality. On 11/8/18 at 9:30 AM, an interview was conducted with the facility LCSW. The LCSW stated that she had been working in the facility way more than what I contracted. The LCSW stated that her role at the facility was still being defined. The LCSW stated that she had conducted a training for staff on how to talk to residents, be more mindful, and deal with residents more appropriately. The LCSW stated she was going to schedule trainings on behavioral therapy and mindfuless for (MONTH) or (MONTH) (YEAR). The LCSW stated that there were several residents at the facility who were depressed. The LCSW stated that she would watch for indicators of depression, such as not getting out of bed, and then ask the residents why they weren't getting out of bed, and what they don't like about their life. The LCSW stated that at a recent training, staff were complaining there weren't activities available at night for the residents, so the facility bought more games to try and make an effort. The LCSW stated that she thought that the RA was completing PHQ-9s for residents, but that this was not being done. (Note: PHQ-9 is a nine question questionnaire used to screen for the presence and severity of depression.) When asked if she was completing psychosocial assessments, the LCSW stated that neither she nor the RA had been completing them, and that he hadn't heard back from the Administrator as to whose role it was to complete those. The LCSW stated that the RA was supposed to be developing care plans. When asked what interventions had been put into place regarding the residents who had been suicidal, the LCSW stated that residents should have a caseworker with the local mental health department, see a therapist, be checked on every 15 minutes, and attend activities. The LCSW stated that she had also asked the RA to check on the residents more often because there was a need. When asked about short term interventions regarding suicidal residents, the LCSW stated I don't have a role in it. (the RA) puts them on daily checks and then sends them to the hospital. When asked about resident 21 specifically, the RA stated that resident 21 had expressed a lot of depression and that the RA was aware. (Note: The LCSW did not provide an agenda or sign in sheet for the staff training she conducted.). On 11/14/18 at 8:40 AM, an interview was conducted with the facility Medical Director (MD). When asked how the facility staff ensured that the residents were safe at the facility, the MD stated that he defaults to the nurse if they think they (the residents) are suicidal. I see them (the residents) often. We are put in this situation where we have to take care of psych (psychiatric) residents that we are not prepared for. The facility Policy and Procedure regarding Suicide Threats was reviewed and revealed the following: Policy Statement Resident suicide threats shall be taken seriously and addressed appropriately. Policy Interpretation and Implementation . 5. If the resident remains in the facility, staff will monitor the resident's mood, behavior and shall document ongoing suicidal ideation objectively in the resident's medical record until a nurse supervisor or physician has determined that a risk of suicide does not appear to be present. 2. Resident 29 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 11/5/18 at 10:20 AM, an interview was conducted with resident 29. Resident 29 stated that she had two episodes of being suicidal this year. Resident 29 stated that the first time she was suicidal was in (MONTH) (YEAR). Resident 29 stated that she was sent to the hospital for an evaluation and then returned to the facility. Resident 29 stated the second episode occurred when she took off and was out of the facility for 1 1/2 hours and that the staff were not concerned. Resident 29's medical record was reviewed on 11/7/18. Resident 29 had a level II PASRR completed on 9/15/18. The PASRR indicated that resident 29 has a lengthy history of mood as well as slef (sic)-harming (cutting) and suicide attempts by overdosing on Insulin. she has been in and out of mental health treatment since 2011 but is currently enrolled at (name of mental health facility) and sees (name of mental health worker), LCSW. She has participated in DBT (Dialectical Behavior Therapy) in the past but continues to struggle with her emotions which has contributed in suicide attempts and inpatient admissions. She is currently Involuntarily committed. Upon initial review of resident 29's care plans, the facility had not developed a care plan related to resident 29's psychiatric history and psychosocial needs such as coping mechanisms or interventions to prevent or address [MEDICAL CONDITION] or thoughts of self-harm. Nurses notes for resident 29 were reviewed and revealed the following: a) On 8/6/18 at 5:18 AM, Pt (patient) has been becoming increasing verbally hostile towards staff. Pt becomes easily frustrated due to having VS (vital signs) WNL (within normal limits) and not meeting hospital dc (discharge) criteria and blames staff for VS. Pt has been displaying such signs for the last three N[NAME] (night) shifts especially, andhas (sic) been given in report that this behavior occurs on 0600 (6:00 AM) -1800 (6:00 PM) shift as well. Pt has been displaying unstable mood swings on N[NAME] shift, and has been displaying grandiosity. b) On 8/7/18 at 2:51 AM, VS: (blood pressure) 111/69, (pulse) 96, (respirations)18, (oxygen saturation) 96% RA (room air).Resident was anxious today dt (due to) wanting attention. Resident claimed to have hot and cold flashes and had nurse take temperature but temp was found to be normal. Resident complained a lot this shift . c) On 8/22/18 at 2:27 AM, Resident was transferred VIA (local) county non-emergent transport at 2030 (8:30 PM) to (name of the hospital) for a psych (psychological) evaluation. Resident was c/o (complaining of) hearing and seeing people who are not there. Resident was throwing bottles of water and soda around her room and the nursing station.resident (sic) refused all medications and treatments tonight. resident was admitted to the facility for continuing care and evaluation. d) On 8/29/18 at 4:06 PM, .admitted to facility from (name of the hospital behavioral unit). Major [DIAGNOSES REDACTED]. Noted [MEDICAL CONDITION] of right leg. Resident alert and oriented x4 (person, place, time and situation). Quiet, withdrawn demeanor, stated that she is very happy to be back. e) On 8/31/18 at 2:42 AM, Resident refused VS. Resident was telling the nurse about the voices in her head telling her to harm herself and kill herself. She stated that it woke her up from sleeping. Resident was calm and breathing was normal while nurse was talking to her. Nurse reminded resident that the medication she is now on takes time for the effects to take. Resident is currently in bed, lowered, and call light within reach. WCTM (Will continue to monitor). f) On 8/31/18 at 2:21 PM, Resident is on alert charting for hearing voices. Resident stated the voices told her to hurt herself. Resident told nurse she has no intention or plan to hurt self. Nurse educated resident about her new meds (medications) and side effects of these meds. Resident understood. Will continue to monitor for changes. g) On 9/1/18 at 2:35 AM, VS: (blood pressure) 123/85, (pulse) 96, (respirations)16, (oxygen saturation) 93%RA. Resident is on alert charting for Q (every) 15 minute checks for [MEDICAL CONDITION]. Resident states that she hears voices that are telling her to harm herself and/or others. Resident states that she has no current plans to take her life. Resident did not sleep on this shift, and was up at the nurses station coming up with different problems every 30 minutes. Resident is seeking attention from the staff and the doctor and is trying to come up with new reasons to be sent to the ED (Emergency Department). Resident did not eat her dinner, but snacked all night long. Resident is safe, call light within reach. WCTM. h) On 9/1/18 at 6:23 PM, .Resident was continuously at the nurse's station for hours on end stating that different areas of her body were hurting. Thighs, right knee, kidneys, pancreas, appendix, and finally gall bladder. Each time she spoke she came up with a different area of pain. Resident was screaming profanities at nurse, staff and other residents. Elevated anxiety noted. Resident demanding to be seen by the MD (medical doctor). Nurse messaged the on-call nurse practitioner. Nurse encouraged resident to lay down in room and close eyes. Resident finally did this at 1100 (11:00 AM) and has not moved since. Currently supine in bed with eyes closed. Call light w/in (within) reach. i) On 9/13/18 at 6:40 PM, Appointment with (name of counselor) at (local mental health facility) @ (at) 8:30 am no new orders given. j) On 9/18/18 at 5:07 PM, Res. on alert charting for suicidal ideation. Res. has stated that voices are telling her to harm herself. Res. has been put on 15 min (minute) checks. Res has been conversing with other resident's (sic). Mood appears appropriate. Res. is currently in room on her phone.Denies (sic) any needs at this time. Vitals as follows: BP (blood pressure): 122/82, P (pulse) : 87, R (respirations): 20, T (temperature): 97, O2 (oxygen): 93 on RA (room air). k) On 10/10/18 at 4:01 PM, Patient stated 'I want to get out of this facility.' Patient requested that referrals be sent to facilities and then changed her mind frequently for which she wanted to go to. Patient was not handling the time it takes to be referred to another facility well. RA (Resident Advocate) tried to calm patient down with assistance of ADON (Assistant Director of Nursing ) (name redacted) with no success. RA and ADON asked if patient would like to talk to the crisis hotline or have a crisis worker come to see her, she refused and proceeded to call the police. Patient was thentaken (sic) to the hospital for a potential stay. l) On 10/22/18 at 10:22 AM, Resident seen at (local mental health facility) by (name redacted) APRN (Advanced Practical Registered Nurse), for medication review. No suggested medication changes at this time. m) On 10/30/18 at 3:05 PM, Resident has c/o (complaints of) feeling like the bone on her stump is going to 'pop out' and is requesting to go to the ER (emergency room ). MD notified, no order to send at this time. The resident is educated by this nurse that we, the facility and nurses, cannot send her to the ER without an order from the MD, that if she chooses to take herself to the ER that she will be responsible for the visit and insurance may choose not to cover it. Resident verbalized understanding, but continues to perseverate (sic) on the stump throughout this shift. n) On 10/30/18 at 11:05 PM, Patient had a high blood sugar due to activity earlier in the day. Patient was upset with offgoing (sic) nurse for asking her to drink water and approached myself and stated 'I am not happy with the nurse and i wont let you guys take care of my blood sugar. Iwant (sic) to go to the hospital.' I asked her to let me get report and I would do what i can to help her out. Patient then called an ambulance for herself from the public phone and left on her own. Hospital called at 2130 (9:30 PM) to give report. Gave 20 units of insulin and [MEDICATION NAME]. Patient was upset at ER (emergency room ) for refusing to give narcotics for her headache. o) On 11/1/18 at 5:31 PM, .co (complains of) of suicidal idealization she states that she has no plan. sent to (name of hospital). at 19:00 (7:00 PM) MD notified. p) On 11/1/18 at 6:16 PM, .went LOA (leave of absence) against medical advice after staff attempted to transfer her to the hospital for suicidal ideation. MD notfied (sic) at 17:00 (5:00 PM) police notified 17:03 (5:03 PM). q) On 11/2/18 at 4:06 PM, .has had several incidents of inappropriate today. She slept until 1000 (10:00 AM) and upon awakening she then told the nurse 'that he better have her meds ready' in a stern tone. The nurse politely informed her that he was ready for her meds she then said she had to use the restroom. The nurse informed her that that was fine and he would would be ready for her when she returned and he would give another person their medication while she was in the restroom. She refused meds on several occasions and would then return and ask for them to be given. she stated that the PM (evening) nurses did not give her insulin last night. She was informed she did not receive insulin because she did not return until 2330 (11:30 PM) last night from the hospital after leaving against medical advice. she raised her tone with the Am (morning) nurse and firmly stated that they need to come to her for all her medications and that she should not have to ask for her pain pills. the nurse informed her that they would be happy to give her medications and thatshe (sic) has to come to the nurse and ask for PRN (as needed) medications. She accused the nurse of only bringing medications to the nurses favorite resident. The nurse informed her that they attempt to treat patients equally and when she was finished smoking she could come inside and they would get her medications. She then raised her tome (sic) further the nurse of being unfair because when she had finished her cigarette the nurse had gotten someone else their medication. The nurse informed her that he had many patients but he can get her meds ready now and then gave her medication when asked if she would like to do her blood sugar check she declined and said she would take that later. (Note: No documentation could be found to indicate what interventions had been put into place after resident 29 had expressed suicidal ideation in an effort to prevent further incidents or to assist resident 29 in coping with harmful thoughts.) There was no documentation in resident 29's medical record that indicated that the facility LCSW had assessed or reviewed resident 29's history. Additionally, there was no documentation that the facility completed a psychosocial assessment for resident 29. On 11/5/18 at 12:56 PM, the facility interdisciplinary (IDT) committee had a meeting related to resident 29's suicidal thoughts on 11/1/18. The IDT documented, IDT members: Admin (Administrator), DON (Director of Nursing), ADON (Assistant Director of Nursing), MDS (Minimum Data Set), RA (Resident Advocate). Event Description: On 11/1/18 around 1700 (5:00 PM) resident expressed to the nurse that she was having suicidal thoughts. The nurse on duty performed a suicide lethality assessment. Resident denied having a plan and agreed to a safety plan of being in a supervised area and having q15 minute safety checks. The medical director was notified of suicidal ideation and requested that resident be sent to the hospital for a crisis evaluation. Risk Factors: Resident has mental health [DIAGNOSES REDACTED]. She does not demonstrate the ability to use coping mechanisms for stressors. She has had previous complaints of suicidal ideation. She was recently sent to (name of hospital) ER per her request on 10/30/18 for blood sugar mgmt (management) because she didn't want facility nursing staff to treat her diabetes that evening. She returned from the ER that same evening very upset that the ER MD would notgive (sic) her more narcotics for her headache. These discontented feelings of not having her needs met by ER staff on 10/30/18 in the way she wanted may have led to this suicidal ideation although resident has not expressed that. Preventative Measures: Resident is followed by (local mental health facility) and had an appointment with the LCSW (name redacted) previously in the day on 11/1/18. The findings from that appointment were that resident was stable at her baseline and there was no evidence of risk. Her next appointment was scheduled for 11/13/18. She was seen by psychiatrist (name of physician) at (local mental health facility) on 10/23/18 with no orders for changes in psychiatric medication regimen. New Interventions: The floor nurse performed a suicide lethality assessment on 11/1/18 after resident verbalized suicidal ideation. Although resident was not assessed to be at high risk for lethality, (name of physician) ordered for resident to be sent to ER for crisis evaluation.After (sic) being informed of this, resident left the faciity on an unauthorized LOA d/t not wanting to be sent out to the ER. The police were notified and their assistance was requested to locate the resident and assist her to the ER. The police located resident and brought her to the ER for evaluation. Resident returned from the ER that same evening with no new orders. Resident completed a safety plan with the crisis evaluator at the ER identifying warning signs, coping strategies and people who can help herwhen (sic) feeling in crisis. Staff will use this safety plan with resident and encourage her to implement these strategies when feeling in crisis in the future. RA followed up with resident today regarding the part of the safety plan requesting to have her own room. Resident states she sleeps better in her own room, which reduces her anxiety. Resident was educated that the IDT acknowledges this request, but no private rooms are available at this time. RA will educate resident that if a private room is essential to her, the facility is willing to search for a facility that can accommodate this request so she can be transferred. RA will follow up accordingly as resident directs. Resident has made no further complaints to staff of feeling suicidal or demonstrated any symptoms of mental health concerns. In interview with RA today, resident denied feeling suicidal. On 11/5/18, the facility staff documented the following care plans: a) (Resident 29) is/has potential to be verbally aggressive, resistive to cares and physically abusive, r/t Ineffective coping skills, Mental / Emotional illness, Poor impulse control. The goals developed include, (Resident 29) will have fewer than 3 episodes per shift of verbal abuse towards others through the review date; and (Resident 29) will verbalize understanding of need to control verbally abusive behavior through the review date. The interventions developed to meet the goals included, Administer medications as ordered. Monitor/document for side effects and effectiveness; Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document; Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc.; Assess resident's coping skills and support system.; Assess resident's understanding of the situation (and) Allow time for the resident to express self and feelings towards the situation; Give the resident as many choices as possible about care and activities; Monitor behaviors of verbal and/or physical abuse and resistive to cares (and) Document observed behavior and attempted interventions; Provide positive feedback for good behavior (and) Emphasize the positive aspects of compliance; and Psychiatric/Psychogeriatric consult as indicated. b) (Resident 29) has a mood problem r/t Dx (diagnosis) of borderline personality disorder, major [MEDICAL CONDITION] with psychotic features, generalized anxiety disorder, [MEDICAL CONDITION] disorder with frequent verbalizations of suicidal ideation, verbal outburst, verbal and physical abuse of others and is at times resistive to cares. The goal developed was, (Resident 29) will have improved mood state AEB (as evidenced by) happier, calmer appearance, no s/sx (signs or symptoms) of depression, anxiety or sadness, decreased episodes of verbalized suicidal ideation/[MEDICAL CONDITION], through the review date. The interventions developed to achieve the goal included, . will utilize her Crisis Risk Prevention/Safety Plan when experiencing increased anxiety and/or manic episodes; Administer medications as ordered. Monitor/document for side effects and effectiveness; Assist the resident, family, caregivers to identify strengths, positive coping skills and reinforce these; Behavioral health consults as needed. (Resident 29) is monitored at (mental health facility) by case management, medication management, with access to the crisis line 24/7; Encourage (resident 29) to use her crisis risk prevention/safety plan strategies for increased anxiety and manic episodes: writing in a journal, talking with friends, taking a nap, call her dad, talk to her kids, try to see her kids; (Resident 29) needs time to talk daily. Encourage the resident to express feelings; Monitor or/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therap

Based on observation, interview and record review it was determined, for 2 of 56 sample residents, the facility did not provide reasonable accommodation of needs and preferences. Specifically, one resident did not have a mobility device to accommodate his needs. The deficient practice identified was found to occur at a harm level. Additionally, another resident was found to have a bed that was not long enough to accommodate his needs. Resident identifiers: 33 and 44. Findings include: HARM 1. Resident 33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/5/18 at 8:48 AM, resident 33 was observed laying in bed. Resident 33 stated he was unable to look out the window due to the bed placement in the room and the placement of resident 33's roommate's curtain. Resident 33's bed was observed to be facing the north wall, and the window was on the south wall. A manual wheelchair was observed to be located folded up, leaning against the west wall of resident 33's room. On 11/14/18 at 1:32 PM, resident 33 was interviewed again. Resident 33 stated that he was not able to fit into the facility provided manual wheelchair. The wheelchair was located on the West side of his room. Resident 33 reported that he had been unable to leave his room since his fall on 9/14/18. Resident 33 stated that he gained weight and had developed an abdominal abscess, and no longer fit in his manual wheelchair. Resident 33 stated that the only time he was able to get out of bed was to have a shower on the shower gurney. Resident 33 stated that he was at an impasse for activities since he couldn't leave his room to attend activities. Resident 33 stated that he was unable to attend the Halloween party and he would have liked to attend Bingo. Resident 33 stated that he liked to go outside when he had a wheelchair. When it had been too cold or too hot to go outside, I would go to the front windows and look outside every day. Resident 33 stated I haven't really left my room in two months. I've been suicidal . I have no kind of life. On 11/15/18 resident 33's electronic medical record was reviewed. Resident 33's most recent quarterly Minimum Data Set (MDS) assessment was completed on 9/21/18. Resident 33 was assessed as requiring a wheelchair for his mobility device. Resident 33 had no functional contractures. The MDS look-back stated that resident 33: a. Transferred out of bed once or twice in the review period. b. Did not walk. c. Locomotion on unit occurred only once or twice with one person physical assistance. d. Locomotion off unit occurred only once or twice with one person physical assistance. e. Moving from a seated to a standing position did not occur. f. Walking with an assistive device did not occur. g. Turning around and facing the opposite direction while walking did not occur. h. Moving on and off toilet did not occur. i. Surface-to-surface transfer (transfer between bed and chair or wheelchair) did not occur. Review of the Preadmission Screening Resident Review (PASRR) level II, completed on 3/28/18 revealed that resident 33 required a wheelchair for ambulation. A review of resident 33's care plan, initiated on 1/12/18, revealed the following focus areas: a. The resident had an Activities of Daily Living (ADL) self-care performance deficit related to limited mobility. Review of the interventions for this focus area identified no interventions specific to mobility devices. b. The resident had limited physical mobility. Review of the interventions for this focus area revealed that resident 33 was referred to physical therapy and occupational therapy for evaluation and treatment on 4/5/18. c. On 9/17/18 an update was included stating that staff would monitor for satisfaction with leisure choices Invite and/or assist to/from group activities Provide adaptations to activities PRN (as needed) . Review of a recreation therapy assessment dated [DATE] revealed that resident 33 required a wheelchair to get to and from activities. Review of a Physical Therapy plan of treatment dated 5/4/18 revealed the need for a wheelchair to ambulate. Resident 33 had a short term goal to perform sit to supine to sit with min (minimal) A (assistance) to prepare for transfer to w/c (wheelchair). Resident 33 was assessed as a very good candidate for achieving that goal. Resident 33 was assessed as requiring a wheelchair and hospital bed. Prior level of function stated that resident 33 has always been in bed most of the time but he needs to get up at times. His cognitive assessment stated that resident 33 stays in bed quite a bit. He could get up, but he doesn't think to. His gait with ambulation was not assessed due to resident 33 has not ambulated in a long time, and he is too large to attempt this safely at this time. The reason for therapy was stated as it will be better for his overall health if he starts to get up everyday and spend some time out of bed. Risk factors were stated as resident 33 being very large and a fall risk. Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for decreased ability to return to prior level of assistance, depression, falls and further decline in function. Review of a Morse Fall Scale that was completed on 6/26/18 revealed that resident 33 required the use of a wheelchair for ambulation. Review of doctor's notes revealed the following: a. On 4/27/18 the note stated that resident 33 . is evidently almost completely immobile . b. On 10/10/18 the note stated, patient is social and does like to use wheelchair to maintain his ability to socialize with the residents. Review of the Nurse Practitioner (NP) notes on 8/1/18 revealed, The large obese individual mostly in bed and a (sic) difficult for him to move around this creates generalized anxiety issue with him. Review of an incident report dated 9/14/18 at 2:00 PM revealed that resident 33 may not have a wheelchair suitable to his size available for his own use. Administrator will search the facility to see if an extra wheelchair is available that is deeper for the occasions when resident requires the use of a wheelchair. On 10/4/2018 at 9:54 AM, a quarterly psychosocial note was created that stated resident 33 did not leave his bed and was unable to ambulate. Resident 33 eats his meals in his room and does not attend activities. Review of a Monthly Summary dated 10/16/18, revealed that resident 33 required a wheelchair for ambulation. On 10/26/18 an Activities Quarterly Participation Review was conducted. The review stated that resident 33 was interested in all things outdoors. On 11/15/18 at 9:24 AM, an interview was conducted with Certified Nurse Assistant (CNA) 3. CNA 3 stated that it had been at least two months since resident 33 was able to utilize his manual wheelchair. On 11/15/18 at 9:30 AM, an interview was conducted with CNA 2. CNA 2 stated that it had been a while since resident 33 was able to fit in his manual wheelchair. On 11/15/18 at 1:50 PM, the Activities Director (AD) was interviewed. The AD stated that she spent between 15 minutes and 30 minutes each week doing one-on-one time with resident 33 in his room. The AD stated that resident 33 was disappointed when he was unable to attend the Halloween party because he could not fit in his manual wheelchair. On 11/15/18 at 12:44 PM, the Physical Therapy Director (PTD) was interviewed. The PTD stated that resident 33 had not been measured or assessed by therapy for a manual wheelchair after discharge from physical therapy on 5/4/18. The PTD stated that resident 33's current wheelchair was not wide enough to accommodate resident 33. The PTD stated that if resident 33 had an adequately wide wheelchair, and staff pushed the resident while his feet were on footrests, resident 33 could move throughout the facility safely. On 11/15/18 at 1:38 PM, the Corporate Resource Nurse (CRN) was interviewed. The CRN stated that the facility was working on getting resident 33 a new chair. On 11/19/18 the Facility Administrator provided additional information. The documentation provided by the Administrator stated: In order to allow (Resident's name) to be mobile the facility purchased a wheelchair to accommodate his size (see attached invoice). The manual wheelchair purchased by the facility is an appropriate chair for (Resident's name). It may not be comfortable for extended periods of time but would be perfectly appropriate for 2-3 hours at a time. Aside from a custom wheelchair for which there is not funding this is the best option available. (Note: It should be noted that the invoice for the wheelchair provided by the facility was dated 3/14/18. This was prior to resident 33's weight gain and increased abdominal girth related to his abscess. Additionally, the physical therapy department did not assess the resident's needs regarding his wheelchair.) POTENTIAL FOR HARM 2. Resident 44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/5/18 at 2:30 PM, an interview was conducted with resident 44. Resident 44 stated that he was 6 feet 5 inches tall, and that his bed was not long enough for him. Resident 44 stated that he had been asking for a new bed for approximately 8 to 12 months, but had not received one. Resident 44 stated that he had to keep his feet and part of his legs off to one side of the bed. Resident 44 stated that if he put his feet straight out on the bed, his feet rested directly on the wooden footboard. An observation was made of resident 44's feet at that time. Resident 44's feet and part of his legs were laying over the right side of his bed. Resident 44 moved his feet to the bed, and demonstrated that his feet would be directly on the footboard if they were straight out in front of him. Resident 44's medical record was reviewed. Review of the annual MDS assessment completed by facility staff on 10/5/18 revealed that resident 44 was six foot four inches tall. On 11/15/18 at approximately 2:10 PM, resident 44 was observed while laying in bed. Resident 44's feet were observed to be up against the end of the footboard of the bed. Resident 44 was unable to fully extend his legs. Resident 44 stated that he had talked to someone eight to ten months ago about getting a longer bed. Resident 44 stated that the facility had not provided him with a longer bed. On 11/15/18 at approximately 2:15 PM, an interview was conducted with the Maintenance Director. The Maintenance Director stated that resident 44 had a bariatric bed and did not know if he would be able to get a bariatric bed that was longer to accommodate resident 44's height.

Based on observation, interview, and record review, it was determined for 2 of 56 sample residents, the facility did not ensure that each resident received adequate supervision and services to prevent accidents. Specifically, resident 41 sustained a broken nose during a fall. This was found to occur at a harm level. Additionally, one resident eloped from the facility. Resident identifiers: 18 and 41. Findings include: HARM 1. Resident 41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/5/18 at 7:43 AM, resident 41 was observed wheeling herself in her wheelchair in the common area near the nurses' station. On 11/5/18 at 12:41 PM, resident 41 was observed wheeling herself in her wheelchair in the common area near the nurses' station. On 11/6/18 at 9:25 AM, resident 41 was observed wheeling herself around the hallways and the common area near the nurses' station in her manual wheelchair. Resident 41 was leaning forward to scoot her wheelchair along. On 11/6/18, at 12:48 PM, resident 41 was observed laying in her bed. Her bed was in a low position. On 11/7/18 at 2:00 PM, resident 41 was observed wheeling herself around the hallways in her wheelchair. On 11/14/18 at 1:32 PM, resident 41 was observed wheeling herself around in hallway 3, leaning forward, scooting her wheelchair toward the north door. On 11/15/18, resident 41's electronic medical record was reviewed. Fall charting was reviewed for Resident 41. Resident 41 sustained falls on the following dates: a. Resident was on fall charting for falls on the following dates without additional information: 10/6/17, 11/8/17, 12/8/17. The dates were identified from nursing progress notes and no incident report documentation was provided by the facility. b. On 3/19/18 at 7:00 PM the incident report documented an unwitnessed fall with resident found in her room, laying on her back on the floor with no apparent injuries. Neurological checks were initiated and a fall alarm was in place. Interventions that were imitated in resident 41's care plan after this fall were to have the bed in the lowest position when resident was in bed resting or sleeping. Resident's fall alarm was removed. The Nurse Practitioner (NP) and son were notified. c. On 3/31/18 at 4:00 PM the incident report documented a witnessed fall with the resident sliding out of her wheelchair, no apparent injuries were documented, weakness was noted, and the resident was wandering. No interventions were initiated in resident 41's care plan after this fall. No documentation could be found to indicate that the physician and family were notified of the fall. d. On 4/1/18 at 3:30 PM the incident report documented an unwitnessed fall in the bedroom with resident 41 found laying on her side next to the bed. The resident sustained [REDACTED]. The resident was confused, incontinent, had impaired memory and weakness. Interventions that were initiated in resident 41's care plan after this fall were to have a fall mat to be next to the bed at all times when resident was in bed. The physician and son were notified. e. On 4/15/18 at 11:45 AM the incident report documented an unwitnessed fall in the bedroom. The resident was found with her head on the floor and body on the floor mat. The resident complained of right shoulder pain. The resident was confused, incontinent, had impaired memory and weakness. Interventions that were initiated in resident 41's care plan after this fall were to encourage staff to take resident for short walks during the day as her condition allows to reduce risk that resident will attempt to walk on her own. The resident's son indicated willingness to assist with this intervention. The physician and son were notified. f. On 4/30/18 at 9:50 PM the incident report documented an unwitnessed fall in bedroom with resident found on floor next to her wheelchair. Resident had attempted to get into bed and hit her head on the floor. The resident sustained [REDACTED]. The resident was confused, drowsy, had gait imbalance, impaired memory, and weakness. The intervention that was initiated in resident 41's care plan after this fall was for staff to assist resident into bed when she appears or states that she is tired. The physician and son were notified. g. On 5/3/18 at 8:45 PM the incident report documented an unwitnessed fall in her bedroom. The report documented that the resident was found with her face down and feet under the bed. The resident had been attempting to get out of bed. Resident 41's right ankle was swollen. The resident had clutter in room, poor lighting, and furniture that may have contributed to the fall. The resident was confused, drowsy, had gait imbalance, impaired memory and weakness. The resident was wearing improper footwear, was attempting to ambulate without assistance, and was attempting to transfer herself. The intervention that was initiated in resident 41's care plan after this fall was to ensure resident has non-skid socks or non-skid footwear on at all times due to resident's risk for self-transferring. The physician and son were notified. h. On 5/11/18 at 5:32 PM the incident report documented an unwitnessed fall, with the resident wandering in her wheelchair down the 200 hall when she fell . The resident was placed on alert charting. No predisposing factors were identified. The care plan was updated following this fall to include the intervention that staff were to assist and encourage resident to sit in an upright position when she was in her wheelchair. The physician and son were notified. i. On 6/1/18 at 9:00 PM the incident report documented an unwitnessed fall with the resident laying face down on carpet by the nurses station. The resident hit a wooden chair leg. The resident stated she was in pain before she fell . Resident 41's nose was misaligned and a laceration (cut) was noted above the right ear, facial and scalp contusions (bruising), and scrapes to resident 41's forehead were sustained from the fall. The resident had gait imbalance, impaired memory and weakness. Interventions put into place on resident 41's care plan after the fall were for staff to address the resident's level of pain when she was agitated or restless. Staff were to treat pain according to the Medical Doctor (MD) orders. The NP and son were notified. The resident was sent to the emergency department, where she was treated for [REDACTED]. j. On 6/3/18 at 4:00 PM the incident report documented a witnessed fall when resident 41 attempted to stand up out of her wheelchair in the doorway and slid her forehead against the doorway. This created a 1.5 inch laceration (cut) on the left side of her forehead above her eye. Her cut was treated by a facility nurse. The NP and Director of Nursing (DON) were notified, along with a message left for the family. The resident stated that her bottom was sore from sitting in her wheelchair and had to stand up. The resident was identified as having a gait imbalance and was attempting to ambulate without assistance. The resident was referred to physical therapy (PT) and speech therapy. Physician's assistant (PA-C) stated that staff should Monitor patient every 15-30 minutes to avoid falls and injuries. The start date for this order was 6/4/18 with an end date of 6/4/19. The intervention established for resident 41 on her care plan was for her to receive a neurologist consultation for increased falls with worsening ability to understand/follow directions. Resident 41 was seen by the neurologist and recommendations were made for the resident to receive physical therapy. (Note: Resident 41 was admitted to hospice on 6/21/18, with PT being discontinued at that time.) k. On 6/13/18 at 4:15 AM the nursing progress note documented that the resident was found on the floor of her room in the doorway on her face. The resident had stated that she was attempting to leave her room. The resident had an unstable balance and gait. Nursing progress notes revealed an intervention to Ensure frequent rounds and toileting. Neurological checks were initiated. No new interventions were included in resident 41's care plan. The physician and family were notified. l. On 7/21/18 the incident report documented an unwitnessed fall in the dining room. Resident 41 was found by a Certified Nursing Assistant (CNA) laying on her left side. The resident was unable to communicate coherently. Neurological checks were initiated. The resident was confused, had gait imbalance, impaired memory and weakness. Care plan interventions were for staff to encourage and assist the resident to attend activities between meals and when not resting in bed. The physician and son were notified. m. On 8/2/18 the incident report documented an unwitnessed fall with the resident laying on the floor of her room. Resident 41 had no apparent injuries. The resident was unable to communicate coherently and had gait imbalance and weakness. Interventions in resident 41's care plan after the fall were to Re-educate staff that when resident is in bed and restless or not able to sleep staff to assist resident into wheelchair and into a common area. The physician and son were notified. n. On 8/23/18 the incident report documented an unwitnessed fall with the resident found in the hallway by another resident. The resident was unable to state how the fall occurred. Resident 41 had no apparent injuries. The resident was reminded to use her call light. Resident was incontinent. Interventions included on resident 41's care plan were for Staff to provide incontinence cares immediately upon discovering resident has been incontinent. o. On 8/28/18 the incident report documented an unwitnessed fall with the resident found outside laying on the grass. The resident had complaints of pain in both arms. The resident was drowsy, had gait imbalance, impaired memory, weakness, and was attempting to ambulate without assistance. Resident 41 did not have a wander guard. No interventions were established after this fall. Physical and occupational therapy were recommended by the physician's assistant, but were declined by the hospice physician. The physician and son were notified. p. On 11/6/18 at approximately 3:00 PM, resident 41 sustained a ground level fall. Resident 41 tipped forward out of her wheelchair. Resident 41 hit her head and was placed on neurological checks. Resident 41 was observed wandering around in her wheelchair near the nurse's station. Resident 41 did not appear to be under distress. Resident 41's care plan was updated on 11/6/18 and 11/7/18 with no new interventions initiated. An incident report was not immediately available. (Note: The resident experienced 7 falls from 3/19/18 through 5/11/18 with little to no intervention prior to breaking her nose on 6/1/18. Despite the resident having a significant injury on 6/1/18, resident 41 had 10 additional falls after that date with little to no intervention to prevent further injury to resident 41.) The facility's Nurse Practitioner (NP) created a visit note for resident 41 dated 4/25/18. The NP stated that resident 41 was a fall risk and has fallen many times. She is very unstable and does try to climb out of her wheelchair on a regular basis. On 11/8/18 at 9:36 AM, Registered Nurse (RN) 1 was interviewed. RN 1 stated that resident 41 did not have a wander guard. RN 1 stated that resident 41's falls were due to weakness, and resident 41 had become weaker. RN 1 identified resident 41 as a wander risk. RN 1 stated that staff watched resident 41 to ensure she did not fall. On 11/8/18 at 9:40 AM, an interview was conducted with RN 5. RN 5 identified resident 41 as a wander and fall risk. RN 5 stated that resident 41 was monitored by staff frequently to help ensure that her needs were met. On 11/8/18 at 8:55 AM, an interview was conducted with the facility's Assistant Director of Nursing (ADON). The ADON stated that resident 41's care plan was not updated. The ADON stated that she was not aware of resident 41 falling since the ADON arrived at the facility, two months ago. The ADON stated that resident 41 had fallen when attempting to get up out of her chair and now that resident 41 was getting weaker, she was having fewer falls. The ADON acknowledged that weakness was one of the factors in many of resident 41's falls. On 11/15/18 at 2:00 PM, an interview was conducted with the facility's Director of Nursing (DON). The DON stated that most of resident 41's falls were before he became the DON and that he was not aware of resident 41's recent fall. The DON stated that interventions to prevent falls had previously been ineffective to prevent falls because resident 41 sat down on the floor out of her wheelchair on purpose. POTENTIAL FOR HARM 2. Resident 18 was admitted to the facility 5/16/18 and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 11/8/18 at approximately 11:10 AM an interview was conducted with CNA 3. CNA 3 stated that she has had to chase resident 18 down the road because his WanderGuard was off. CNA 3 stated that the WanderGuard was removed by Registered Nurse (RN) 2 so they wouldn't have to hear it alarming every time resident 18 went near the facility exit door. CNA 3 stated resident 18 took off down the road, and she followed him outside to get him to come back to the facility. Resident 18 had made statements that he was going to kill other people. CNA 3 stated that RN 3, who no longer worked at the facility, asked CNA 3 to give resident 18 his medications because resident 18 was refusing them and then saying he was going to kill RN 3 if he tried to make him take the medications. CNA 3 stated that resident 18 had previously made statements that he was going to break the glass in the windows in his room and that he was going to kill everybody. CNA 3 stated that on that occasion she had had to stay outside with resident 18 for three hours until his medications took effect. The nurse told CNA 3 that he wouldn't send resident 18 to the hospital because he was faking it and that the hospital would just send him back to the facility. CNA 3 further stated she didn't think that was right because resident 18 was a threat to everyone else in the building. CNA 3 stated that the nurses that night told CNA 3 that resident 18 would have to call the hospital himself if he wanted to go to the hospital. On 11/8/18 at 1:45 PM, resident 18's medical record was reviewed. Resident 18's admission Minimum Data Set ((MDS) dated [DATE] was reviewed. The MDS indicated that resident 41 had a Brief Interview for Mental Status (BIMS) score of 15. On 5/24/18, resident 18's care plan was created and revealed the following: a) FocusResident 18 is at risk for injury due to wandering. b) Goal 1. Resident 18 will be able to be redirected when wandering. Resident will not leave the facility without staff knowledge during stay. - Date Initiated: 10/9/18, Revision: 11/5/18, Target Date: 1/13/19. c) Interventions 1. Assess for emotional psychological distress, such as anxiety, fear, or feeling lost. Address and remove triggers or factors that are causing resident to try to exit seek. - Date Initiated: 7/30/18, Revision: 11/5/18 2. Assess for physical distress or needs, such as hunger, thirst, pain, discomfort, or elimination. - Date Initiated: 7/30/18, Revision: 10/11/18 3. Encourage resident 18 to stay in common areas of the building for observation if needed. - Date Initiated: 7/30/18, Revision: 10/11/18 4. Resident 18 to wear wanderguard due to wandering. Wanderguard to be checked every shift for placement and skin underneath for signs and symptoms of breakdown, and every week proper functioning. Resident 18 verbally consented to placement of the wanderguard. - Date Initiated: 9/22/18, Revision: 11/6/18. On 5/16/18 at 2:27 PM, a Wandering Risk Scale assessment was created and revealed a risk score of 7, indicating Low Risk. No specific comments were included. On 5/19/18 at 3:41 PM, a Wandering Risk Scale assessment was created and revealed a risk score of 9, indicating At Risk to Wander. No specific comments were included. On 5/23/18 at 2:01 PM, a Psychosocial Note was created and revealed the following. (Resident 18) is a long term resident, admitted from another Nursing Home. He (resident 18) was alert and oriented x3 (time, person and place) and able to make needs known. According to the previous nursing home and family, (Resident 18) has a history of wandering, and therefore has a wander guard in place. He (resident 18) is, at times, resistive to cares (Resident 18) is able to ambulate short distances, but used a w/c (wheel chair) for primary mobility, that of which he (resident 18) propels himself. (Resident 18's) mood fluctuates. At times he had become agitated and stated he is 'on fire' or his 'nerves are shot.' this seems to (be) r/t (related to) when he (resident 18) is in pain and will calmed down after receiving medication. IDT (interdisciplinary team) meeting held on this day, at which time the care plan was reviewed with the team and resident as well as his daughter. Resident 18's May, (MONTH) and (MONTH) (YEAR) Treatment Administration Records (TARs) revealed the following: Check function of wanderguard every day every day shift for Wander Risk - Note: The documentation reveals the wanderguard was checked every day, at 6:00 AM starting on 5/24/18 to 5/31/18. The order date was 5/23/18 and was discontinued on 7/9/18. On 7/9/18 at 11:48 AM, a Health Status Note was created and revealed the following. New order obtained to dc (discontinue) wander guard DC check function of wander guard every day. Resident has made no attempts to wander from the facility. On 7/9/18 at 12:09 PM, a Wandering Risk Scale assessment was created and revealed the following comments, (Resident 18) has had no attempts to wander out of the facility in the time he has been here, and therefore it is not necessary to continue with the wander guard. On 7/29/18 at 9:15 AM, a Wandering Risk Scale assessment for resident 18 was created and revealed a risk score of 14, indicating High Risk to Wander. The following comments were noted: Resident became upset on 7/29/18 and walked out of the facility front door. One of the CNA's did accompany resident and was able to redirect him back into the facility. Resident stated that he was leaving and was going to the hospital. On 9/12/18, a Baseline Care Plan was created and revealed that resident 18 was identified as being an elopement risk and that a wanderguard should be placed to reduce the risk of elopement. On 9/23/18 at 2:48 PM, a Health Status Note for resident 18 revealed the following. Resident is on alert charting following a recent elopement. Resident has been fine the majority of the shift until after lunch when they took his tray. Resident has been combative and verbally aggressive threatening to break property. Resident has also refused vital signs. On 9/24/18 at 12:39 AM, a Health Status Note for resident 18 revealed the following. this is follow up on (resident 18) after elopement. (Resident 18) has been calm and has not made any negative statements towards himself or staff.Wander guard is in place and functioning. will continue to monitor. On 11/6/18 at approximately 9:17 AM an interview was conducted with resident 18. Resident 18 stated he was angry a few weeks ago and punched the screens out of his windows. There were bent window screens observed outside lying on the grass under resident 18's window. Resident 18 stated he paid the administrator $15 for the damage to the window screens. On 11/14/18 at approximately 10:10 AM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated there was no Incident Report filled out on resident 18's elopement in (MONTH) (YEAR). The CRN stated that resident 18 did not leave the facility's property so the facility did not consider it an elopement. On 11/15/18 at approximately 12:53 PM, an interview was conducted with CNA 3. CNA 3 stated that she was the one who went out to find resident 18 when he left the facility in (MONTH) (YEAR). CNA 3 stated she found him off the facility's property in his wheel chair near Washington Boulevard (Blvd). CNA 3 stated she walked with resident 18 to Washington Blvd, at which time resident 18 allowed CNA 3 to wheel him back to the facility property. CNA 3 sat with resident 18 outside for a couple hours before bringing him back into the building at the request of the nurse. CNA 3 stated the nurse wanted her to sit with him outside until his medication kicked in. On 11/15/18 at approximately 1:53 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the WanderGuard was removed following the (MONTH) (YEAR) Wandering Risk Scale assessment to allow resident 18 an opportunity to prove he could be trusted going outside on his own to help relieve his nerves. The DON stated that the WanderGuard was put back on following the elopement in (MONTH) (YEAR). 3. On 11/6/18 at 2:54 PM, a housekeeping staff member (HSM) 1 was mopping the corridor on the 300 hall. The hall was wet from room [ROOM NUMBER] to 318. The housekeeping staff did not put out a wet floor sign. The housekeeping staff stated, I just haven't put it out yet. (Note: The 300 hall was the exit resident's used to enter the smoking area.)

Based on interview, record review and observations the facility did not ensure that pain management is provided to 2 of 56 residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, two residents reported ongoing pain. The findings for both residents will be cited at a harm level. Resident identifiers: 9 and 53. Findings include: HARM 1. Resident 53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/5/18 at 9:30 AM, an interview was conducted with resident 53. Resident 53 stated that he was experiencing phantom pain in both legs. Resident 53 was observed to have partial amputations of both legs. Resident 53 stated that he asked facility staff for as needed pain medications when the pain was especially bad but they just say it ain't time. Resident 53 stated that he did not feel that facility staff were appropriately managing his pain. Resident 53 then stated I went on hospice to get better pain meds (medications). Resident 53 stated that his pain was at a 7 out of 10 all the time. When asked what his current pain score was, resident 53 stated that he was currently at a 7 or 8. Resident 53 stated that earlier that morning he had received [MEDICATION NAME] for his pain but that's not enough. I just want to lay down all the time because the pain gets so bad. I can't do anything. He stated that he wasn't going to activities because the pain was too intense. Resident 53 also stated that he had a pressure sore on his buttocks and that at times facility staff were not medicating him prior to changing his pressure sore dressings. Resident 53's medical record was reviewed on 11/5/18. A pain care plan for resident 53 dated 4/19/18 was reviewed. The care plan stated that Resident has pain and is at risk for pain r/t (related to) pressure, surgical and arterial wounds, hx (history) of illicit substance abuse with tolerance to narcotic medications, bilateral BKA ([MEDICAL CONDITION]) with phantom limb pain, [MEDICAL CONDITIONS], broken teeth. Acceptable pain lvl (level) for resident is 7-8/10. The goal for the pain care plan was The resident will verbalize adequate pain relief of pain or ability to cope with inadequately relieved pain through the review date. Interventions included: Administer pain medications as ordered, Monitor/record pain level Q (every) shift. Notify MD (physician) of any unrelieved s/s (signs and symptoms) of pain with current interventions, Offer non-pharmacological measures as resident desires/allows for pain relief., and Resident prefers to have pain managed using medications and has a high tolerance to medication r/t hx of illicit drug abuse. (Note: The care plan had not been revised since 4/19/18.) A Pain Tool evaluation dated 4/19/18 for resident 53 was reviewed. Staff documented on the Pain Tool that resident 53 was complaining of throbbing pain at a 10/10 in his lower back which radiated to his hips. Resident 53 stated that the pain was interfering with sleep and rest, social activities, appetite, physical activity and mobility, and emotions. A Pain Tool evaluation dated 7/19/18 for resident 53 was reviewed. Staff documented on the Pain Tool that resident 53 was complaining of throbbing pain at an 8/10 in his lower back which radiated to his hips. Resident 53 stated that the pain was interfering with sleep and rest, social activities, physical activity and mobility, and emotions. It should be noted that the Pain Tool had not been revised since (MONTH) (YEAR). On 5/18/18, the hospice physician documented the following in a Certificate of Terminal Illness: . He has extensive necrosis of fingers, has had (bilateral) leg amputations and even phantom pain related to prior [MEDICAL CONDITION]. He has lost a portion of his tongue due to necrosis to to circulatory compromise. He also has a stage IV coccygeal pressure ulcer. He reports his pain at 8/10. He states that he has severe pain all over, but especially in his legs (related to) phantom pains and his lower back. He also reports that when wound care is performed his pain significantly worsens. His pain has been affecting his appetite, mood, sleep and overall functioning. Presently he takes [MEDICATION NAME] 10 mg (milligrams) (four times daily) and [MEDICATION NAME] 20 mg (twice daily). He reports that this has not been very effective for him. On 7/17/18, the hospice physician documented the following in a Certificate of Terminal Illness: . Pain is quite constant and severe. On 8/18/18 a nurses note revealed the following: Resident 53 . has refused the changing of his sacral area due to extreme pain despite receiving his scheduled pain medications and his PRN (as needed) [MEDICATION NAME]. He also stated that he was scared to be transferred with the aides that were assigned to him as they were too rough and didn't take care in transferring him to avoid pain, he therefore, refused his treatment. On 8/27/18, a wound care company staff member documented the following under a History of Past Illness note section: a) 4/9/18 . Main health problem (sic) are [MEDICAL CONDITION], liver issues, pain issues, and malnutrition . dry gangrene to right fingers. Also with pressure ulcers to sacrum and right ischium. He had a left BKA during the most recent hospitalization . b) 4/23/18 . Pt (patient) placed on hospice . c) 5/29/18 Follow-up assessment of sacral pressure ulcer, which now has necrotic tissue to central base. To (sic) painful to debride. d) 6/4/18 Pt in severe, unmanageable pain. Crying out and shacking (sic). States he knows that he is dying soon and is unable to tolerate the pain. Has been very sedated and hypotensive. Sacral wound much worse, with increased necrotic tissue, foul odor. Nurse to contact hospice doctor to discuss pain management. e) 6/11/18 (Follow up) visit. Pain better controlled with changes in meds (medications). Sacral wound unchanged from last week, remains to (sic) painful to debride necrotic tissue. f) 7/2/18 . Pressure ulcer remains very painful despite pre-medication with [MEDICATION NAME]. He calls out in pain and cried throughout assessment and dressing change. g) 7/9/18 Significant worsening of sacral pressure ulcer; . ongoing severe pain. h) 7/23/18 Resident 53 . with decreased mobility and increased pain . i) 8/13/18 Resident 53 . remains in severe pain, but refuse (sic) additional pain medication because it makes him to (sic) sleepy . j) 8/20/18 . To (sic) painful for extensive debridement. On 9/26/18, the hospice physician documented the following in a Face to Face Evaluation: . He continues to have intractable pain. He was taken off of [MEDICATION NAME] in (MONTH) and started on [MEDICATION NAME] BID (twice daily). He continues with [MEDICATION NAME] and [MEDICATION NAME] for breakthrough pain which he does use regularly. SN (?) continues to monitor and assess his pain with each visit. He has been more groggy and lethargic, staff reported that they have had to hold meds at times because he is sleepy. Without regular medications however his pain does become very severe and he becomes very anxious and irritable. Claims his pain is not adequately controlled and is awaiting pain medicine while we visit. On 10/10/18, the hospice physician documented the following in a Certificate of Terminal Illness: . evaluated for continued hospice services based on primary [DIAGNOSES REDACTED]. chronic pain including phantom pain related to prior L (left) leg amputation . Claims his pain is not adequately controlled and is awaiting pain medicine while we visit. Has pain in area of L leg stump . States some days he just withdraws to bed and refuses to get up and eat. Resident 53's (MONTH) (YEAR) Medication Administration Record [REDACTED] a) Resident 53 had an order dated 7/20/18 for [MEDICATION NAME] solution 20 mg/ml (milligrams per milliliter), one ml by mouth every 2 hours as needed for pain. Resident 53 received this dose of the as needed medication 115 times during the month of October. Only 4 of the doses were for a pain score less than 7. b) Resident 53 had an order dated 7/23/18 for [MEDICATION NAME] solution 20 mg/ml 0.5 ml every 2 hours as needed for pain. Resident 53 received this dose of the as needed medication on 2 occasions during the month of October. c) Resident 53 had an order dated 7/20/18 for [MEDICATION NAME] 10 mg every 6 hours as needed for pain. Resident 53 received this dose of the as needed medication on 35 occasions. On 13 of these occasions, resident 53 reported his pain level to be at or above a 7. d) Resident 53 had an order dated 5/24/18 that was discontinued 10/16/18 for [MEDICATION NAME] 10 mg twice daily for pain. Resident 53 reported his pain at a 7 or higher on 13 of the 31 doses. e) Resident 53 had an order dated 10/16/18 for [MEDICATION NAME] 10 mg three times daily for pain. Resident 53 reported his pain at a 7 or higher on 25 of the 46 doses. On 11/8/18 at 11:10 AM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated that some days the resident would be screaming because his sore was painful. CNA 3 also stated that at times the resident would rather stay in bed than get up in his wheelchair because of the pain. On 11/15/18 at 1:00 PM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN was informed of the concerns regarding resident 53's pain management. No additional information was provided. 2. Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/8/18 at 7:35 AM, an interview was conducted with resident 9. Resident 9 stated that her whole body hurt. Resident 9 stated that her legs were swollen from her feet to her thighs. Resident 9 stated that she had pain in her shoulder. Resident 9 stated she was unable to sleep at night because of the pain in her body. Resident 9 stated she had been in constant pain since she was admitted to the facility. Resident 9 stated that she had received pain medication between 5:00 AM and 6:00 AM that morning and her pain was at a 7. Resident 9 stated that her pain was tolerable when it was less than 7. (Note: A pain scale was 0 for no pain and 10 for excruciating pain.) Resident 9's medical record was reviewed on 11/15/18. A quarterly Minimum Data Set ((MDS) dated [DATE] revealed that resident 9 received scheduled and as needed pain medication in the last 5 days. The MDS revealed that resident 9 did not receive non-medication interventions for pain. Resident 9 complained of pain almost constantly in the last few days. A care plan dated 2/21/18 and revised on 6/19/18 revealed, The resident has chronic pai[DIAGNOSES REDACTED]. The goal developed was, Resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain for 90 days. The interventions were, Administer scheduled and PRN pain medications as per orders. Give 1/2 hour before treatments or cares., Monitor and document side effects of pain medication. Notify MD, Monitor and record pain level every shift and with every administration of PRN pain medication. Monitor and report to nurse any non-verbal signs/symptoms of pain, such as: breathing changes (noisy, deep/shallow, labored, fast/slow), abnormal vocalizations (grunting, moans, yelling out, silence), mood/behavior changes (more irritable, restless, aggressive, squirmy, constant motion), eye changes (wide open/squinting, glazed over, tearing), facial changes (sad, crying, worried, scared, clenched teeth, grimacing), and/or changes in body (tense, rigid, rocking, curled up, thrashing). A pain tool assessment dated [DATE] revealed that resident had left knee pain. The assessment further revealed that pain affected resident 9's sleep and rest, social activities, physician activity and mobility, and emotions. Resident 9 further described that resident is effective (sic) ice is not that effective medications are effective most of the time. A Pain Tool dated 5/2/18 revealed that resident 9 had chronic right knee pain. The tool further revealed that resident 9's pain affected her physical activity and mobility. The form revealed, Patient stated it is chronic pain all the time. Resident stated she can continue with ADL's (Activities of Daily Living) with coping mechanisms such as keeping herself busy or conversing with other residents. She stated her baseline IS A 4/10 PAIN. Resident 9's physician orders [REDACTED]. a. 5/29/18, [MEDICATION NAME] Tablet 10-325 MG ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet by mouth three times a day for bilateral knee pain related to chronic pai[DIAGNOSES REDACTED]. b. 4/11/18, Tylenol Tablet 325 MG ([MEDICATION NAME]) Give 650 mg by mouth every 6 hours as needed for Pain. NTE (not to exceed) 3 doses in 24 hour period. c. 3/2/18, [MEDICATION NAME] Tablet 400 MG. Give 800 mg by mouth every 6 hours as needed for pain No more than 3 doses in 24 hours. Resident 9's Medication Administration Record [REDACTED] a. 10/2/18, At 6:00 AM her pain was an 8. At 2:00 PM, her pain was a 7 and at 8:00 PM, her pain was 9. b. 10/3/18, At 6:00 AM, her pain was a 9. c. 10/8/18, At 2:00 PM, her pain was an 8. At 8:00 PM, her pain was an 8. d. 10/9/18, At 6:00 AM, her pain was an 8. e. 10/10/18 at 8:00 PM, her pain was an 8. f. 10/11/18 at 2:00 PM, her pain was an 8. g. 10/12/18 at 2:00 PM, her pain was an 8. h. 10/13/18 at 6:00 AM, her pain was an 8. i. 10/14/18 at 2:00 PM, her pain was at a 9. j. 10/15/18 at 8:00 PM, her pain was an 8. k. 10/16/18 at 6:00 AM, her pain was a 9. At 2:00 PM, her pain was a 9. l. 10/20/18 at 2:00 PM, her pain was an 8. m. 10/24/18 at 2:00 PM, her pain was an 8. n. 10/25/18 at 8:00 PM, her pain was an 8. o. 10/26/18 at 8:00 PM, her pain was an 8 p. 10/27/18 at 6:00 AM, her pain was an 8. q. 10/28/18 at 2:00 PM, her pain was a 9. At 8:00 PM, her pain was a 9. r. 10/29/18 at 6:00 AM, her pain was an 8. Resident 9's (MONTH) (YEAR) MAR indicated [REDACTED] a. 11/1/18 at 2:00 PM, her pain was an 8. b. 11/2/18 at 2:00 PM, her pain was an 8. c. 11/5/18 at 2:00 PM, her pain was an 8. At 8:00 PM, her pain was an 8. d. 11/6/18 at 6:00 AM, her pain was an 8. At 2:00 PM her pain was an 8. A review of resident 9's Treatment Administration Record (TAR) for (MONTH) and (MONTH) were reviewed. There was no information regarding interventions for pain that were non-pharmacological. On 11/5/18 at 2:07 PM, an interview was conducted with the CRN. The CRN stated that resident 9's physician did not want to increase her pain medication. The CRN stated that non-pharmacological interventions were to provide one on one visits, repositioning, but that the resident would refuse interventions at times. The CRN stated that non-pharmacological interventions used to alleviate pain were documented on the resident's MAR. The CRN stated that there were no non-pharmacological interventions documented to alleviate pain on the MAR indicated [REDACTED]

Based on observation, interview and record review, it was determined that the facility did not promote and facilitate resident self-determination through support of resident choice for 3 of 56 sample residents. Specifically, a resident's right to leave the facility without supervision was revoked due to his history of [MEDICAL CONDITION]. The deficient practice identified for resident 12 was found to have occurred at a harm level. Additionally, two residents requested daily showers which was not honored. Resident identifiers: 12, 29 and 32. Findings include: HARM 1. Resident 12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/6/18 at 8:32 AM, an interview was conducted with resident 12. Resident 12 stated, I hope to be transferred somewhere, anywhere but here. Resident 12 stated, I got caught drinking and was given a 30 day notice. Resident 12 stated that he appealed the 30 day notice and that the 30 day notice was revoked. Resident 12 stated, Since then, I am restricted to the facility and I am not allowed to go out and buy cigarettes. Resident 12 stated, I am only allowed to leave the facility if I am escorted. Resident 12 stated, I'm a prisoner and don't have any rights. Resident 12 further stated that he was required to attend Alcoholic Anonymous (AA) meetings as a condition of being allowed to stay at the facility. Resident 12's medical record was reviewed on 11/7/18. Review of the quarterly Minimum Data Set (MDS) Assessment completed by facility staff on 11/8/18 revealed that resident 12 was assessed as having a Brief Interview for Mental Status (BIMS) score of 15 meaning that resident 12 was alert and oriented. On 2/17/18, the facility staff developed an Independent Pass/outings Privileges care plan. The facility staff documented, (Resident 12) understand (sic) it is against Medical advice to go alone. (Resident 12) signed an informed refusal to continue to go out on his own. The goal developed was, Resident will remain safe on passes through next review. Resident will use passes to gain or maintain independent living skills and pursue leisure interests. The interventions developed to achieve the goal were: Review safety and health considerations at least quarterly as it relates to passes; Provide resident with safety guidelines and education to help maintain safety; Encourage resident to pursue of variety of meaningful activities while on pass. On 6/19/18 at 1:34 PM, a facility nurse documented .He is alert and oriented x3 (person, place and time), and able to make needs known. (Resident 12) will frequently leave the facility to drink alcohol and then return. His PASS (?) privilegehas (sic) been revoked for this reason. On 6/20/18 at 5:39 PM, a facility nurse documented, .was informed that he is no longer approved for PASS as he has repeatedly left the facility to drink alcohol. He has been brought back by the police, come back and been unsafe in transfers, etc. A 30 day discharge notice was given to resident 12 on 9/12/18 related to bringing drugs and alcohol into the facility, keeping it in his room repeatedly and returning from outing obviously intoxicated. The 30 day notice was signed by the facility Administrator and Director of Nursing (DON). On 9/13/18 at 10:51 AM, a facility nurse documented, Administrator and Director of Nursing met with resident to issue 30 day discharge notice due to non-compliance with the facility drug and alcohol policy. Resident advocate will assist in finding a safe discharge location for the resident. On 10/2/18 at 5:02 PM, a facility staff member documented, Patient, Ombudsman, RA (Resident Advocate), and Administrator met today. Patient was issued a 30 day notice, 15 days ago. Ombudsman supports decision of facility and is helping patient find a new facility along side the RA. Team and patient talked about individual drug and alcohol counseling. Patient agreed to go to counseling. Patient recognizes that his drinking is a problem and is working on drinking less. Patient is understanding and accepting of moving to another facility. Patient didn't express any other concerns at this time. RA will follow up and make the appointment for independent counseling. On 10/15/18 at 2:23 PM, a facility staff member documented, Patient, Ombudsman, and facility came to an agreement regarding patients 30 day notice. As long as patient does not drink he will be allowed to continue living in (the facility). Patient consented to attend drug and [MEDICAL CONDITION] counseling as well as not leave with out staff accompanying him to prevent patient from drinking. Patient understands that his drinking is a problem and causes him to be a risk to the facility and himself. if patient chooses to drink, he will be discharged from the facility. Patient understands consequences, ombudsman agrees they are fair and he has a adequate understanding of them. Facility will monitor patient and take him to his counseling. On 10/27/18 at 4:00 PM, a facility nurse documented, .Resident states he understands he cannot leave as he agreed he would not buy and consume alcohol, . On 11/7/18 at 7:40 AM, an interview was conducted with the ombudsman who stated that both she and facility staff had told resident 12 he could not leave the facility. On 11/7/18 at 2:55 PM, an interview was conducted with the RA. The RA stated that they had recommended that resident 12 not leave the facility, but that the resident had never had his PASS rescinded. On 11/8/18 at 9:30 AM, an interview was conducted with the facility Licensed Clinical Social Worker (LCSW). When asked specifically about resident 12, the LCSW stated that she had never met with him, and was not aware of him being restricted from leaving. On 11/8/18 at 9:15 AM, an interview was conducted with the DON. The DON stated that resident 12 had a PASS assessment completed in (MONTH) (YEAR). The DON stated that resident 12 required supervision during leaves of absences to prevent him from buying alcohol. On 11/8/18 at 11:49 AM, an interview was conducted with Certified Nurse Assistant (CNA) 3. CNA 3 stated that resident 12 was not allowed to leave the facility unsupervised to prevent him from buying alcohol. POTENTIAL FOR HARM 2. Resident 29 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 11/5/18 at 10:20 AM, an interview was conducted with resident 29. Resident 29 stated that she has requested to have daily showers and has been told that there wasn't enough staff for her to have a shower daily. Resident 29's medical record was reviewed on 11/7/18. On 9/11/18, the facility staff completed a quarterly MDS assessment for resident 29. The facility staff assessed resident 29 has needing supervision with set up help for dressing, transfers, toilet, and locomotion on and off the unit. The facility staff further assessed resident 29 as needing a one person assist for showers with supervision assistance of one person for personal hygiene. 3. Resident 32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/5/18 at 1:52 PM, an interview was conducted with resident 32. Resident 32 stated that she has requested to have a daily shower and that she was told that she could not have a daily shower. Resident 32 was observed to have greasy and unkempt hair. Resident 32's medical record was reviewed on 11/15/18. On 9/17/18, the facility staff completed a quarterly MDS assessment for resident 32. The facility staff assessed resident 32 as needing supervision assistance with step help for transfers, ambulation, dressing, toilet, personal hygiene and showers. On 11/8/18 at 8:20 AM, an interview was conducted with the DON. The DON stated that the CNA Coordinator scheduled showers based on personal preferences. The DON stated, We do the very best that we can when asked about resident requests for daily showers. The DON further stated that it is a work in progress right now.

Based on interview, observation, and record review it was determined that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible. (Residents 19, 20, 58, 66, and 74). The deficient practice identified for resident 58 was found to have occurred at an Immediate Jeopardy level. The deficient practice identified for resident 19 was found to have occurred at a Harm level and will not be included in the Immediate Jeopardy. The deficient practice identified for residents 20, 66, and 74 was found to have occurred at a potential for harm and will also not be included in the Immediate Jeopardy. Review of resident 58's medical record revealed that resident 58 had made multiple statements and written letters about committing violence against other residents within the facility. Observations of resident 58's room revealed multiple objects that could be used to harm other residents. Facility staff allowed resident 58 to have the objects despite resident 58's continued verbal and written threats of harm against residents. Review of resident 19's closed medical record revealed that resident 19 experienced 23 falls over a 6 month period. Resident 19 experienced significant injuries with the falls including a subdural hematoma and multiple abrasions. Facility staff did not implement additional or effective interventions to prevent resident 19 from sustaining additional falls and injuries. Resident 20 was assessed by facility staff as being unsafe to leave the facility without the supervision of staff. Facility staff allowed resident 20 to leave the facility without staff supervision where resident 20 became lost and had to be retrieved by facility staff. Additionally, facility staff were allowing resident 20 to leave the facility under the supervision of another resident that could find her way back to the facility. Resident 66 was assessed as requiring supervision while smoking. Facility staff allowed resident 66 to have smoking materials in his possession. Resident 66 was found on multiple occasions to be smoking without facility staff supervision and smoking within his room at the facility. Resident 74 did not have a functioning call light which caused resident 74 to fall in her bathroom. Resident 74 waited for staff assistance, after the fall reaching for her call light, until resident 74 eventually pulled herself up from the bathroom floor to get back into her wheel chair. NOTICE: Notice of Immediate Jeopardy was given verbally to the Corporate Administrator on 9/15/16 at 1:40 PM. The Corporate Administrator was asked to develop an immediate plan to ensure resident safety. PLAN: On 9/20/16 at 8:00 AM, the Corporate Administrator provided the surveyors with a written plan of action to remove the Immediate Jeopardy to residents in the facility. The written plan dated 9/16/16 stated the following: (Long Term Care Manager) Long Term Care Survey Section Dear (Long Term Care Manager), This email serves as our allegation of removal of the immediate jeopardy as of 1600 (4:00 PM) September 19th, 2016. We believe the facility has implemented sufficient corrective measures and that the condition constituting immediate jeopardy has been removed. Lomond Peak has implemented and completed the following consistent with the action plan: 1. Beginning on September 15th at approximately 1430 hours (2:30 PM) the facility systematically and deliberately began searching every resident occupied room in the facility and removed any item that could be deemed hazardous or dangerous to the population of Lomond Peak and/or it's employees and visitors. This search continued through the 15th, 16th, and was completed at 1400 hours (2:00 PM) on September 17th. This search required resident participation and permission, but resulted in the removal of any dangerous item. Personal belongings where (sic) either labeled and stored by the facility or turned over to the resident's family whenever possible. 2. Beginning on September 16th at approximately 1000 hours (10:00 AM) Lomond Peak contracted with a third-party CSW (Clinical Social Worker) to evaluate all current residents known to be aggressive or to have any history of aggression or violent behavior. The CSW utilized a tool to analyze resident responses to identify those residents who had a higher than normal risk of acting our (sic) violently with others. These interviews continued through September 16th and were completed at 1400 hours on September 17th. Out of the twenty residents interviewed none of the residents interviewed showed a high risk of violent behavior in the facility, one showed a moderate risk of aggression or violent behavior. This resident's care plan was modified to track and monitor for any signs of aggression or violent outburst. 3. Beginning on September 15th, 2016 at approximately 1600 hours (4:00 PM) training was initiated by the Director of Social Services for all staff working. They were trained on managing aggressive behaviors, staff interventions of resident to resident interactions, and how to appropriately handle an aggressive interaction. They were further educated on the identification and removal of any weapon, tool, or device that could cause injury to staff or residents. This was concluded with the responsibility to notify their supervisor and administrator any time these events occur. This training was ongoing through the course of the 15th, 16th, and 17th. Included was an all staff meeting on the 17th at 1200 hours where each employee was informed that if they could not attend, they would not be allowed to work until their training was documented. Each employee signed an in-service attendance form signifying their understanding of the training provided. Further signs were posted at the nursing station, dietary office, housekeeping supply room, and the laundry room educating all staff repeatedly on the above events. The training's completed with the final shift on the 17th at 2230 hours (10:30 PM). 4. Lomond Peak has not admitted any residents since the findings constituting immediate jeopardy on September 15th. However, as part of this review it was felt pertinent to adjust our admission practices to identify those residents who could potentially display aggressive and violent tendencies and prevent them from entering Lomond Peak until we can ensure adequate training and staff to manage those behaviors. So the admission process was changed to screen for any history of aggressive or violent behaviors. Those with such a history will not be allowed to enter Lomond Peak. This addition to the admission process was enacted September 15th, but will not be in force until these measures are deemed sufficient by the survey team and the facility is placed back into compliance. 5. On September 15th, 2016 the admission agreement was also modified to inform perspective residents that the possession of any type of weapon, tool, or any device that could be construed as a weapon was prohibited at Lomond Peak. The possession of any of the above will result in immediate discharge from Lomond Peak to an appropriate level of care in order to ensure adequate safety and security for our residents and staff. 6. The staff of Lomond Peak will continue to monitor the interactions between residents and the possessions in their rooms daily as they continue to assist and provide for the individual ADL (activities of daily living) needs of the residents. The fore-mentioned (sic) training, along with on-going efforts, will ensure staff are intervening and notifying their supervisor and administrator whenever an aggressive behavior is witnessed, or a weapon/device that may cause harm is identified. 7. On September 19th 2016 at 0730 (7:30 AM) it was identified that one resident which had not been evaluated by the CSW had a number of knitting needles in her room, some of which had been sharpened and glued into a wooden dowel which caused them to be of concern as a weapon to the staff. These items had been removed from the room in order to ensure the safety and security of the other residents. 8. At 1230 hours (12:30 PM) the CSW entered the resident room and completed the evaluation and found her to be at moderate risk of aggression or violent behavior. With this information the Regional Administrator interviewed the resident and discussed moving her knitting supplies to the activity room where she could do her knitting in supervision. She agreed and the supplies were moved to the activities room. 9. At 1500 (3:00 PM) a care plan was written that included monitoring of her behavior by the staff interacting with her multiple times a day. It also included the activity program plan that allows her to check in and out her knitting supplies to be used in a supervised setting. The resident has agreed to this as well and is appreciative of us monitoring her supplies. The staff of Lomond Peak continue to be committed to providing the residents with a safe and secure environment. We have performed the above interventions with this goal in mind and feel we have accomplished the task at hand. We are alleging removal of immediate jeopardy with F Tag 323 providing an environment as free of accident hazards as is possible at 1600 hours (4:00 PM) on September 19th, 2016. On 9/20/16 at 10:14 AM, the surveyors confirmed the abatement of the Immediate Jeopardy. Deficient practice with actual harm that is not Immediate Jeopardy remained for the risk of injury. Findings include: IMMEDIATE JEOPARDY: Resident 58 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 58's medical record was reviewed on 9/14/16. Review of resident 58's significant change Minimum Data Set (MDS) assessment dated [DATE], revealed that resident 58 had behaviors. Facility staff assessed resident 58 as having verbal behaviors towards others for 1-3 days during the assessment period and other behaviors not toward other residents for 1-3 days during the assessment period. Review of resident 58's care plan revealed a care plan for Voicing thoughts of suicide. Facility staff had initiated the care plan on 9/3/15 with revisions or updates made to the care plan on 4/5/16 and 8/18/16. One of the interventions listed on the care plan was for facility staff to ensure room is free of Hazards that could be used to hurt self. Review of the medical record revealed the following Progress Notes: a. 7/24/16 at 5:21 PM, Resident has been very agitated for the last few hours. He is upset with a resident for reasons this nurse doesn't fully understand and has been threatening with violence to the other resident and staff members. This resident has been verbally bantering and upsetting many other residents in the facility going up and down the hall yelling and cursing. Attempts have been made to calm resident down, resident is currently in room yelling but no one is with him. b. 7/25/16 at 6:57 AM, Resident is on alert charting for behaviors. Vitals this shift were refused. Resident has been agitated and yelling at staff and other residents, threatening to kill them with his hammer. Nurse re-direction successful. Resident informed that police will be called if he threatens anyone's life again. c. 8/4/16 at 12:46 PM, CSW met with (resident 58) today for a counseling session. Before the session SSW (Social Services Worker) informed CSW that resident had written letters and given them to SSW and DON (Director of Nursing), saying odd things and expressing his anger. Resident started the session stating, 'There are a couple of people in here I want to beat the[***]out of.' He (resident 58) began to speak out, 'never getting out of here and getting the things he needs.' Resident would like to 'finish projects' and needs to go and get materials. Resident then stated he, 'hates (name of other resident)', he (resident 58) stated he, '(expletive deleted) gets in the way of (name of a facility licensed nurse) and me.' Resident then continued to state how much he, 'hates (name of other resident), he is (expletive deleted) stupid', and how much anger he has toward (name of other resident). Resident did state he would, 'murder or kill people', and mentioned (name of other resident). Resident stated he will, 'die here, and has nothing to lose', 'what are they going to do to me?' Regarding if he chooses to kill people. d. 8/4/16 at 1:50 PM, When SSW came in this morning there were several pages of notes from (name of resident 58). He wrote about hurting other people. SSW gave a referral to CSW to do therapy with (name of resident 58). When CSW talked to (name of resident 58) he did tell her that he wanted to hurt another resident and (name of resident 58) talked about killing people. e. 8/19/16 at 8:48 AM, Last evening, (name of resident 58), came to SSW's office and just wanted to talk. (Name of resident 58) stated he feels very lost in his life. f. 8/22/16 at 3:12 PM, (Name of resident 58) came to SSW's office today to talk. He seems depressed but stated he will not do anything to himself. On 8/4/16, resident 58 was involuntarily admitted to an acute care hospital psychiatric unit for suicidal and homicidal ideation. On 8/7/16, resident 58 was readmitted to the facility. On 9/14/16 at 7:23 AM, an interview was conducted with the facility SSW. The SSW stated that when resident 58 was discharged to the hospital in August, the facility Administrator removed items from resident 58's room that could be used as a weapon against himself and other residents within the facility. The SSW further stated that upon resident 58's readmission to the facility, the facility Administrator had a heart to heart with resident 58 and returned the tools to resident 58 so resident 58 could continue making his crafts. No documentation could be found to show that the above listed conversation happened or that the facility staff removed dangerous objects from resident 58's room. On 9/13/16 at approximately 8:00 AM, observations of resident 58's room revealed a power tool or drill lying on the floor of resident 58's room. On 9/13/16 at 9:23 PM, facility staff documented the following in resident 58's medical record: (Resident 58) who was at the smoke shack before the fight was feeling rather down. Resident 51 tried to talk to him and (resident 58) was not interested in conversation and turned to leave. Resident 51 said, 'Well (expletive removed) you' as he turned to leave. Resident 58 had metal pipes that he uses to make wind chimes in his hands as he wheeled away, but turned around to come back with vulgar words of his own. Resident 51 felt threatened by the pipes and swung at Resident 58 with his Nalgene water bottle. Resident 58 came back inside without any physical retaliation. On 9/14/16 at 3:00 AM, observations revealed resident 58 had the following items on his floor by his bed: 7-10 eight to twenty-four inch metal pipes, a pair of scissors, and a power tool drill. On 9/14/16 at 7:30 AM, an interview was conducted with the facility Administrator in Training (AIT). The AIT stated that resident 58 had been placed on 15 minute observation checks by the staff and that she had called the local police after the altercation on the evening of 9/13/16. On 9/14/16 at approximately 8:00 AM, an observation of resident 58's room, from the hallway, revealed that the power tool drill was still by resident 58's bed. No documentation could be found to show that facility staff monitored resident 58 to ensure that resident 58 did not use the items, listed above, to harm other residents. On 9/15/16 at 8:00 AM, an interview was conducted with the facility AIT. The AIT stated that the facility nurse had not completed the 15 minute observation checks because resident 58 and the other residents involved in the altercation had apologized to each other. On 9/15/16 at approximately 9:30 AM, observations of resident 58's room revealed a pair of scissors, a large cymbal, multiple electronic cords, fishing line, metal pieces from a wheel chair and various other items that could be used as a weapon. No documentation could be found to show that facility staff were removing items, that could be used as weapons, from resident 58's room after resident 58 expressed aggression towards other residents or after resident 58 reported to staff that he wanted to kill other residents. HARM: 1. Resident 19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/13/16 resident 19's medical record was reviewed. Review of the medical record revealed that resident 19 experienced 23 falls over a 6 month time frame. Review of resident 19's care plan revealed the following care plan dated 1/26/16: Potential for Fall and/or Injury related to Physical Mobility Impairment, Impaired Ability to Communicate Needs, Impaired Safety Awareness, Impulsiveness as evidenced by: Gait and Balance Impairments, Fall History, Impaired Coordination with Abnormal Movements, Impaired Ambulation Abilities. The goal listed on the care plan was: The Resident will be free of any noted injury, related to episode of fall, through next review. Facility staff listed the following interventions to help resident 19 achieve the stated goal: a. Assess for signs and symptoms of significant adverse reaction related to medication use; report and document. b. Monitor for signs and symptoms of pain; report and document. c. Administer pain medication as ordered; document effectiveness. d. Ensure bed side call light in reach. e. Offer resident assist with daily mobility needs, as indicated. f. Wheelchair use for out of bed mobility as indicated. g. Ensure floor mat in place near side of bed; bed in lowest position at all times. h. Use of bed sensor pad alarm at all times when in bed. i. Ensure environment clean and free of debris at all times. j. Promote use of appropriate foot wear. k. Provide Activities that promote exercise and strength building where possible. l. Provide 1:1 activities if bed bound. m. PT (Physical Therapy) consult for strength and mobility. The above listed interventions were implemented on 1/26/16 n. Promote supervised setting when resident in wheelchair. o. Resident to use helmet on head surface to decrease risk of injury for resident. p. Use of Personal Alarm device (Tab alarm) at all times when resident in wheelchair. The above listed interventions were implemented on 1/31/16. q. Assist resident with toileting and hygiene needs at regular intervals. r. PT/ OT (occupational therapy) evaluation as if indicated. s. Restorative Nursing Program for AAROM (Active range of motion) as per order. t. Use of self-release seat belt when resident in wheelchair to assist to maintain sitting posture/positioning when resident in wheelchair. The above listed interventions were implemented on 2/29/16. No documentation could be found to show that resident 19's care plan was updated or different interventions utilized after 2/29/16. Review of the Progress Notes revealed the following entries: a. 3/2/16 5:37 AM: At approximately 0100 (1:00 AM) on 3/2/16, when CNA (Certified Nursing Assistant) went in to perform cares, resident was discovered on his knees on his bathroom floor. Bed alarm was not sounding. Resident stated he was taking himself to the bathroom. Call light in reach but not used. Full assessment by nurse revealed two small abrasions to left knee. Knee cleaned and bandaged. Upon inspection of bed alarm, the wire had been disconnected from the alarm. Resident stated he could've done that by accident. MD (medical doctor) notified. No new orders. Message left with resident's POC (?). DON (Director of Nursing) notified. Incident added to alert charting and 24-hour report. Review of facility incident reports revealed that facility staff did complete an incident report for the above documented fall. Attached to the incident report was a Plan of Care Note dated 3/26/16. Facility staff documented on the Plan of Care Note to Continue with residents current plan of care at this time. Plan is to resume use of specialty wheel chair with use of self-release belt upon wheelchair upon arrival (sic). Continued promotion of supervised area when in wheelchair. It should be noted that the Plan of Care Note made for the fall on 3/2/16 occurred 24 days after the fall. b. 3/5/16 9:27 AM: At 0900 (9:00 AM) the aides informed this writer that this patient was found on his floor. He was in his wheelchair and he went to stand up, lost his balance, and fell . There were not witnesses, he denied pain, and no injuries were noted. He was found next to a bookshelf and cardboard box. He was able to get into a standing position with minimal assistance, and lied down in bed. No new orders. Review of facility incident reports revealed that facility staff did complete an incident report for the above documented fall. Attached to the incident report was a Plan of Care Note dated 3/26/16. Facility staff documented on the Plan of Care Note to Continue with residents current plan of care at this time. Plan is to resume use of specialty wheel chair with use of self-release belt upon wheelchair upon arrival (sic). Continued promotion of supervised area when in wheelchair. It should be noted that the Plan of Care Note made for the fall on 3/5/16 occurred 21 days after the fall. Additionally, no documentation could be found to show if resident 19's personal alarm was sounding at the time of the fall. No documentation could be found to show if facility staff investigated if all equipment was functioning properly at the time of the fall. c. 3/5/16 14:34 (2:34 PM): At 1330 (1:30 PM) patient had a second fall. He was able to propel himself in the wheelchair he is in, getting back to his room, tries to ambulate on his own, and then falls. After speaking with the family and the ADON (Assistant Director of Nursing), it was decided to remove the wheelchair and use a gerichair to help prevent him from getting to an area where he cannot be supervised. After he fell , he was found by this writer in his room with his back to the bed. He stated that his back hurt, once he stood up and he was noted to have an abrasion along his spine. It was cleansed with NS (normal saline) and covered with a bordered gauze dressing, he was assisted to his bed where he is resting comfortably. New orders for wound care have been provided. Review of facility incident reports revealed that facility staff did complete an incident report for the above documented fall. Attached to the incident report was a Plan of Care Note dated 3/26/16. Facility staff documented on the Plan of Care Note to Continue with residents current plan of care at this time. Plan is to resume use of specialty wheel chair with use of self-release belt upon wheelchair upon arrival (sic). Continued promotion of supervised area when in wheelchair. It should be noted that the Plan of Care Note made for the fall on 3/5/16 occurred 21 days after the fall. Additionally, no documentation could be found to show if resident 19's personal alarm was sounding at the time of the fall. No documentation could be found to show if facility staff investigated if all equipment was functioning properly at the time of the fall. d. 3/13/16 17:30 (5:30 PM): Resident was in his GeriChair in the common area with tab alarm on and helmet on. Resident pushed his feet into the foot rest and straightened his legs HARD, propelling himself up and over the side of his chair. Resident assessed for injuries; none apparent. Resident c/o (complains of) pain in his shoulders. Physician aware, ordered bilateral shoulder x-rays. Review of facility incident reports revealed that facility staff did complete an incident report for the above documented fall. Attached to the incident report was a Plan of Care Note dated 3/26/16. Facility staff documented on the Plan of Care Note to Continue with residents current plan of care at this time. Plan is to resume use of specialty wheel chair with use of self-release belt upon wheelchair upon arrival (sic). Continued promotion of supervised area when in wheelchair. It should be noted that the Plan of Care Note made for the fall on 3/13/16 occurred 13 days after the fall. According to documentation, resident 19 did not have his specialty wheel chair when the falls occurred and was still without his specialty wheel chair when the Plan of Care Note was made on 3/26/16. e. 3/14/16 17:27 (5:27 PM): Resident fell from his chair at approximately 1130 - 1145 in the common area before lunch. Tab alarm on, helmet on, chair in reclined position with brakes on. No apparent injuries. No c/o pain. ADON informed. No documentation could be found to show that facility staff completed an incident report for the above mentioned fall. No documentation could be found to show that facility staff implemented additional interventions to prevent resident 19 from falling. f. 4/15/16 11:17 AM: Pt (patient) found in bathroom this morning by CNA at around 6:45 AM on the floor underneath the sink in supine position. Pt complains of 9/10 pain in head, reports that he fell and hit it on the floor while attempting urgent morning urination. Pt was not wearing helmet. Pt. conscious (sic), vitals were . neuro function normal, pupils dilated but responsive to light, grip strength bilaterally equal. Pt agitated for the rest of the morning while waiting for breakfast, complains of hunger. When breakfast is served, Pt eats none of it and complains of stomach pain. (Resident 19) just wanted to get in bed, but complained of consistent head pain. Sudden change in baseline behavior had several staff concerned. Contacted (name of physician), and family, advised sending to ER (emergency room ) for CT (computed tomography). Emergent transport contacted and report given to paramedics. 4/15/16 17:45 (5:45 PM): Report from ER CT scan of brain without contrast: . Impressions: 1) Small to moderate, subacute left frontoparietal subdural hematoma. 2) minimal rightward subfalcine herniation measuring approximately 0.2 cm (centimeters). Review of facility incident reports revealed that facility staff did complete an incident report for the above documented fall. Staff documented on the incident report that resident 19's pressure alarm was disabled by the resident and that resident 19's call light was not in reach. Additionally, no documentation could be found to show that facility staff initiated neurological checks after resident 19 reported hitting his head and complaining of pain in his head. No documentation could be found to show that facility staff implemented additional interventions to prevent resident 19 from falling. It should be noted that resident 19 discharged to the local acute care hospital on [DATE] and readmitted to the facility on [DATE]. Additionally, upon readmission to the facility, resident 19 was placed in a room closer to the nurses station. g. 4/28/16 18:10 (6:10 PM): At 1800 patient got himself to his room, tried to get himself to bed, tab alarm went off, and by the time I got to his room he was on the floor. He stated that he did not hit anything, and had no pain. Neuro checks started. Review of facility incident reports revealed that facility staff did complete an incident report for the above documented fall. Staff documented on the incident report that resident 19's wheel chair brakes and seat belt were off. No documentation could be found to show that facility staff implemented additional interventions to prevent resident 19 from falling. h. 4/29/16 12:58 PM: Resident fell from lower bed to floor mat, resident hit his head on wall during the fall. Resident c/o of pain 9/10 on his head no bruising present. Resident alert and oriented, coma score 15, grip strength equal, movement in all extremities. Neurological checks started. No documentation could be found to show that facility staff completed an incident report for the above mentioned fall. No documentation could be found to show that facility staff implemented additional interventions to prevent resident 19 from falling. i. 5/3/16 19:29 (7:29 PM): Resident had fall from low bed to floor. Resident stated he hit his head on the wall. RN (Registered Nurse) assessed grip strength equal, full rom (range of motion) in all extremities. Alert and oriented. Skin assessment no new skin tears or bruising. Neurological checks done. Resident has had no complaints of pain. 5/3/16 19:36 (7:36 PM): Resident had fall from bed to floor mat . grip strength equal, Pupils round and reactive to light. Skin assessment no new injuries no complaints of pain . RN kept resident close to med (medication) cart resident was watched closely all day. Review of the facility incident reports revealed that facility staff completed one incident report for the two falls. Additionally, no documentation could be found to show that facility staff initiated neurological checks. No documentation could be found to show that facility staff implemented additional interventions to prevent resident 19 from falling. j. 5/10/16 1700 (5:00 PM): Resident attempted to get out of bed and transfer himself to his chair. Bed alarm on and functioning, alerted nursing staff to resident's room. Resident fell on to his bottom and hit the back of his head on his wheelchair. 'Goose egg' bump on back of head. No further injuries. Started standard 24 hr (hour) neuro checks. Review of facility incident reports revealed that facility staff completed an incident report for the above documented fall. No documentation could be found to show that facility staff implemented additional interventions to prevent resident 19 from falling. k. 5/19/16 15:33 (3:33 PM): At 0845 (8:45 AM) patient was trying to get himself to the bathroom to use the toilet and fell down. He was found in his room on his back half on the floor mat and half on the tile. He did not hit anything, but he did say that he did hit his head. Neuros (neurological) were started. Review of facility incident reports revealed that facility staff completed an incident report for the above documented fall. Additionally, no documentation could be found to show if resident 19's bed alarm was sounding at the time of the fall. No documentation could be found to show if facility staff investigated if all equipment was functioning properly at the time of the fall. No documentation could be found to show that facility staff implemented additional interventions to prevent resident 19 from falling. l. 5/20/16 19:00 (7:00 PM): . During this shift he was witnessed falling to the ground again after his tab alarm went off, no injuries and he did not hit his head. no other issues this shift with him trying to transfer himself. No documentation could be found to show that facility staff completed an incident report for the above mentioned fall. No documentation could be found to show that facility staff implemented additional interventions to prevent resident 19 from falling. m. Review of incident reports revealed that resident 19 experienced a fall on 5/22/16 8:45 AM. Facility staff documented the following on the incident report: Staff walked into TV area and noticed (resident 19) up. Staff promptly approached him, but he fell right before staff was able to assist back to chair. He landed g

Based on interview and record review it was determined that the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the deficient practice identified for resident 58 was found to have occurred at an Immediate Jeopardy level. The facility failed to ensure that the resident environment remained as free of accident hazards as was possible. Additionally, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanceed each resident's dignity, the facility failed to ensure that residents received medically-related social services, the facility failed to ensure that residents received services to attain their highest practicable physical, mental, and psychosocial well being related to pain management, the facility failed to ensure that a resident who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrated that they were unavoidable, the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and prevent further decrease in range of motion, the facility failed to ensure that residents maintained acceptable parameters of nutritional status, the facility failed to ensure that residents were free of any significant medication errors, the facility failed to ensure that sufficient nursing staff was provided, the facility did not provide or promptly refer a resident with lost or damaged dentures to a dentist, and the nurses station was not equipped to receive resident calls through a communication system from resident rooms. Resident identifiers: 8, 11, 12, 17, 19, 20, 22, 25, 27, 30, 32, 38, 40, 45, 51, 58, 69, 73, and 74. Findings include: 1. The facility administration failed to ensure that the resident environment remained as free of accident hazards as was possible. Specifically, for a resident that had made multiple statements and written letters about committing violence against other residents within the facility, and a resident with multiple falls sustained significant injuries with the falls including a subdural hematoma and multiple abrasions. Resident identifiers: 19 and 58. (Cross refer to F323) 2. The facility administration failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality. Specifically, one resident did not receive incontinence care, one resident did not receive assistance changing clothing, one resident that was continent chose to wear at brief at night because staff were unable to help her, and a resident did not get assistance with his urinary catheter. Resident identifiers: 12, 20, 32, and 74. (Cross refer to F241) 3. The facility administration failed to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, a resident exhibited increased signs and symptoms of depression since the discontinuation of one of her anti-depressant medications with no social services intervention. A resident with paranoid [MEDICAL CONDITION] with the behaviors of wandering and calling out received no social services intervention or behavior modification plans. One resident who had been assessed as needing supervision had been allowed to leave the facility without staff supervision because the Ombudsman had told them to remove the wanderguard and allow her to leave the facility and a resident, who had been expressing increased thoughts of hurting other residents and had shown signs of increased depression, did not receive any social services interventions. Resident identifiers: 27, 45, 58, and 69. (Cross refer to F250) 4. The facility administration failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the assessment and plan of care. Specifically, two residents did not receive physician ordered pain medication resulting in high levels of pain. One resident's physician was not notified immediately after a fall. One resident was not medicated for pain prior to treatments being provided for her pressure ulcer and one resident did not receive her physician ordered showers for a documented skin condition. Resident identifiers: 11, 22, 30, 73, and 40. (Cross refer to F309) 5. The facility administration failed to ensure that a resident who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrated that they were unavoidable. Specifically, a resident who entered the facility with no documented pressure ulcers, developed a pressure ulcer six days after admission. Facility staff did not implement the wound care recommendations, ordered by a wound care physician, thus allowing the wound to become infected and larger in size. Resident identifier: 30. (Cross refer to F314) 6. The facility administration failed to ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and prevent further decrease in range of motion. Specifically, facility staff discontinued restorative nursing services for a resident that had decreased range of motion. The resident continued to have decreased range of motion to both hands. Resident identifier: 45. (Cross refer to F318) 7. The facility administration failed to not ensure that residents maintained acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrated that this was not possible. Specifically, a tube fed resident experienced a 21.8 % total loss of his body weight in a 60 day period after not receiving the physician ordered feeding due to product availability and was evaluated by the Registered Dietitian once during the 60 day time frame. Additionally, a resident, who was observed to be missing her bottom dentures, experienced a 5 % loss of her body weight with no dietary interventions. Resident identifiers: 19 and 25. (Cross refer to F325) 8. The facility administration failed to ensure that residents were free of any significant medication errors. Specifically, two resident did not have pain medications available per physician's orders [REDACTED]. (Cross refer to F333) 9. The facility administration failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Specifically, five residents were not provided sufficient showers, one resident was not provided incontinence cares, one resident was not provided assistance with changing his clothing, one resident had to wait an extended period of time for pain medication, and five residents complained of extended call light wait times. Resident identifiers: 8, 11, 12, 17, 20, 32, 38, 40, and 51. (Cross refer to F353) 10. The facility administration failed to provide or promptly refer a resident with lost or damaged dentures to a dentist. Specifically, a resident who was missing bottom dentures was unable to eat the regular diet provided and experienced a 5% (percent) loss of her body weight. Resident identifier: 25. (Cross refer to F412) 11. The facility administration failed to ensure that the nurses station was equipped to receive resident calls through a communication system from resident rooms. Specifically, one resident's call light did not have a pull cord and the resident had to stand up to manually turn on the call light, fell and fractured her femur. One resident fell and had to crawl, then stand on her amputated stump to manually turn on the call light. Multiple call lights were found either on the floor or not in the resident's reach. Resident identifiers: 8 and 74. (Cross refer to F463) 12. The facility administration failed to maintain a quality assessment and assurance committee that identified quality of care concerns and implemented plans of action to correct the identified concerns. (Cross refer to F520)

Based on interview, observation, and record review it was determined that the facility failed to maintain a quality assessment and assurance committee that identified issues with respect to which quality assessment and assurance activities are necessary. The deficient practice identified for resident 58 was found to have occurred at an Immediate Jeopardy level. The facility failed to ensure that the resident environment remained as free of accident hazards as was possible. Additionally, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity, the facility failed to ensure that residents received medically-related social services, the facility failed to ensure that residents received services to attain their highest practicable physical, mental, and psychosocial well being related to pain management, the facility failed to ensure that a resident who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrated that they were unavoidable, the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and prevent further decrease in range of motion, the facility failed to ensure that residents maintained acceptable parameters of nutritional status, the facility failed to ensure that residents were free of any significant medication errors, the facility failed to ensure that sufficient nursing staff was provided, the facility did not provide or promptly refer a resident with lost or damaged dentures to a dentist, and the nurses station was not equipped to receive resident calls through a communication system from resident rooms. Resident identifiers: 8, 11, 12, 17, 19, 20, 22, 25, 27, 30, 32, 38, 40, 45, 51, 58, 69, 73, and 74. Findings include: 1. The facility quality assessment and assurance (QAA) committee failed to ensure that the resident environment remained as free of accident hazards as was possible. Specifically, for a resident that had made multiple statements and written letters about committing violence against other residents within the facility, and a resident with multiple falls sustained significant injuries with the falls including a subdural hematoma and multiple abrasions. Resident identifiers: 19 and 58. (Cross refer to F323) 2. The facility QAA committee failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality. Specifically, one resident did not receive incontinence care, one resident did not receive assistance changing clothing, one resident that was continent chose to wear at brief at night because staff were unable to help her, and a resident did not get assistance with his urinary catheter. Resident identifiers: 12, 20, 32, and 74. (Cross refer to F241) 3. The facility QAA committee failed to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, a resident exhibited increased signs and symptoms of depression since the discontinuation of one of her anti-depressant medications with no social services intervention. A resident with paranoid [MEDICAL CONDITION] with the behaviors of wandering and calling out received no social services intervention or behavior modification plans. One resident who had been assessed as needing supervision had been allowed to leave the facility without staff supervision because the Ombudsman had told them to remove the wanderguard and allow her to leave the facility and a resident, who had been expressing increased thoughts of hurting other residents and had shown signs of increased depression, did not receive any social services interventions. Resident identifiers: 27, 45, 58, and 69. (Cross refer to F250) 4. The facility QAA committee failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the assessment and plan of care. Specifically, two residents did not receive physician ordered pain medication resulting in high levels of pain. One resident's physician was not notified immediately after a fall. One resident was not medicated for pain prior to treatments being provided for her pressure ulcer and one resident did not receive her physician ordered showers for a documented skin condition. Resident identifiers: 11, 22, 30, 73, and 40. (Cross refer to F309) 5. The facility QAA committee failed to ensure that a resident who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrated that they were unavoidable. Specifically, a resident who entered the facility with no documented pressure ulcers, developed a pressure ulcer six days after admission. Facility staff did not implement the wound care recommendations, ordered by a wound care physician, thus allowing the wound to become infected and larger in size. Resident identifier: 30. (Cross refer to F314) 6. The facility QAA committee failed to ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and prevent further decrease in range of motion. Specifically, facility staff discontinued restorative nursing services for a resident that had decreased range of motion. The resident continued to have decreased range of motion to both hands. Resident identifier: 45. (Cross refer to F318) 7. The facility QAA committee failed to not ensure that residents maintained acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrated that this was not possible. Specifically, a tube fed resident experienced a 21.8 % total loss of his body weight in a 60 day period after not receiving the physician ordered feeding due to product availability and was evaluated by the Registered Dietitian once during the 60 day time frame. Additionally, a resident, who was observed to be missing her bottom dentures, experienced a 5 % loss of her body weight with no dietary interventions. Resident identifiers: 19 and 25. (Cross refer to F325) 8. The facility QAA committee failed to ensure that residents were free of any significant medication errors. Specifically, two resident did not have pain medications available per physician's orders [REDACTED]. (Cross refer to F333) 9. The facility QAA committee failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Specifically, five residents were not provided sufficient showers, one resident was not provided incontinence cares, one resident was not provided assistance with changing his clothing, one resident had to wait an extended period of time for pain medication, and five residents complained of extended call light wait times. Resident identifiers: 8, 11, 12, 17, 20, 32, 38, 40, and 51. (Cross refer to F353) 10. The facility QAA committee failed to provide or promptly refer a resident with lost or damaged dentures to a dentist. Specifically, a resident who was missing bottom dentures was unable to eat the regular diet provided and experienced a 5% (percent) loss of her body weight. Resident identifier: 25. (Cross refer to F412) 11. The facility QAA committee failed to ensure that the nurses station was equipped to receive resident calls through a communication system from resident rooms. Specifically, one resident's call light did not have a pull cord and the resident had to stand up to manually turn on the call light, fell and fractured her femur. One resident fell and had to crawl, then stand on her amputated stump to manually turn on the call light. Multiple call lights were found either on the floor or not in the resident's reach. Resident identifiers: 8 and 74. (Cross refer to F463) 12. The facility QAA committee failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. (Cross refer to F490) On 9/27/16 at 9:15 AM, an interview was conducted with the Administrator in Training (AIT). The AIT stated that she had started at the building on 8/8/16. The AIT stated that the facility had QAA meetings monthly. (Note: Upon review of the QAA meetings book the MD had not attended the meetings since July 2016.)

Based on observation, interview, and record review, it was determined that for 10 of 36 sample residents, the facility did not have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Specifically, five residents were not provided sufficient showers, one resident was not provided incontinence cares, one resident was not provided assistance with changing his clothing, one resident had to wait an extended period of time for pain medication, and five residents complained of extended call light wait times. Resident identifiers: 8, 11, 12, 17, 20, 32, 38, 40, and 51. Findings included: 1. Resident 20 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 20 was interviewed on 8/24/16 at 1:29 PM. Resident 20 stated that she wets herself (urinates in her incontinence brief) all the time and was wet at the time of the interview, but had not reported it to the facility staff because, it doesn't do any good. Resident 20 told survey staff, I'm not happy here at all. They ignore me. Resident 20 stated that she usually has to wait 35-40 minutes for assistance to be taken to the toilet after she turned on her call light. Resident 20 stated, I want to die. On 9/13/16 at 3:54 PM, resident 20 was interviewed. Resident 20 stated that, I cannot get an aide (Certified Nursing Assistant) to give me a shower! I don't get a shower when I should. Resident 20 confirmed that she was scheduled for three showers a week. Resident 20 stated that, There are not enough CNA's. Resident 20 stated that she urinated on the floor that morning because she could not get staff assistance with toileting and stated , That is a major problem with me! Resident 20 reported that, The CNA's will not come (when she calls). The night nurses ignore me completely. Resident 20 stated that she had been, crying an awful lot and that she had recently been sent to the emergency room at a local hospital for [MEDICAL CONDITION] because, No one would listen to me. I just wanted someone to talk to. Resident 20's medical record was reviewed on 9/13/16. A Minimum Data Set ((MDS) dated [DATE] documented resident 20 had a BIMS (Brief Interview for Mental Status) score of 15 which meant that resident 20 was cognitively intact. It documented that resident 20 was incontinent of bladder and was totally dependent on two or more persons' physical assist for toileting and bathing. Resident 20's activity of daily living (ADL) documentation for September 2016 revealed that of 6 scheduled opportunities for a shower, resident 20 received 2. Resident 20's ADL documentation for August 2016 revealed that of 13 scheduled opportunities for a shower, resident 20 received 8. Resident 20's July 2016 ADL documentation revealed that for 13 scheduled opportunities for a shower, resident 20 received 7. Resident 20's ADL documentation for June 2016 revealed that for 13 scheduled opportunities for a shower, resident 20 received 7. For all four months, there was no documentation that resident 20 refused cares or showers. A Continence Evaluation dated 7/27/16 documented that resident 20 was aware of the urge to void urine, was aware of urine being passed, was aware when she was wet, and that resident 20 was able to ask for assistance. A Progress Note dated 8/26/16 documented that resident 20 had reported suicidal thoughts to the nurse and stated, I wish I could overdose on something and die. The note documented that resident 20 was sent to the emergency room for evaluation and returned early the following morning. On 9/5/16, the Social Service Worker (SSW) documented that resident 20 reported to her that she was sent to the hospital because she had been crying and had felt suicidal. Resident 20 reported to the SSW that she, just wanted someone to talk to. CNA 3 was interviewed on 9/26/16 at 1:57 PM. CNA 3 stated that if the ADL documentation was blank, then that meant it either was not completed or not documented. CNA 3 stated that if a shower was refused, it would be documented on the ADL documentation or a Shower Sheet. (Note: no shower sheets were found for resident 20.) CNA 3 stated that resident 20 was continent/incontinent of bladder and was able to report to staff when she was wet. CNA 3 stated that resident 20 required extensive assistance with changing her incontinence brief. Registered Nurse (RN) 1 was interviewed on 9/26/16 at 2:00 PM. RN 1 stated that resident 20 does not typically refuse showers. RN 1 stated that resident 20 was, for the most part continent of bladder and would report to staff when she was wet and needed assistance to be changed. The DON (Director of Nursing) was interviewed on 9/26/16 at 2:17 PM. The DON stated that she was unsure if resident 20 ever refused cares or showers. The DON stated that if documentation was blank, then something was not done or not documented. The DON further stated that if a shower was refused, then the CNA should have documented the refusal on the ADL documentation with an R. The DON stated that resident 20 was continent/incontinent of bladder and required assistance with incontinence cares. 2. Resident 32 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Resident 32 was interviewed on 8/24/16 at 9:50 AM. Resident 32 stated that his care in the facility was, beneath living quality. We're so used to waiting for hours (for assistance) .We don't want to ask for help because we know what they're (staff) going to say, 'We'll be back.' I have to tell them, 'This chair will be covered with (expletive)!' That's what I have to do to get help. Resident 32 stated that he had to threaten to contact the State Survey Agency in order to receive assistance. Resident 32 stated that he overfilled his urinal earlier and had accidentally spilled it on himself. Resident 32 stated, I am sitting in my own filth right now. I told them (staff) about it an hour ago. Resident 32 stated that he is supposed to receive 3 showers a week. Resident 32 stated, I'm lucky if I get one (a week). During the interview with resident 32 an observation was made. The white blanket that resident 32 was sitting on was visibly soiled with yellow urine and there was an evident urine odor. Resident 32 was observed to tell the Medical Records Clerk (MRC) at 10:02 AM, I need to be changed. The MRC stated, I'm answering call lights. Resident 32 was re-interviewed on 9/26/16 at 1:08 PM. Survey staff asked resident 32 about the incident on 8/24/16. Resident 32 stated that he did not receive assistance with changing his clothing until the following day. Resident 32 stated that it was uncomfortable because the urine burns and he was concerned that his skin would break down. Resident 32 stated, I am beyond pissed off. I feel helpless. Resident 32 confirmed that he required assistance with changing his shorts. Resident 32 stated that at times, he has refused his shower, if he was in pain. Resident 32 stated that occasionally the CNA has offered a bed bath instead, but only certain CNA's have offered. Resident 32's medical record was reviewed on 9/26/16. An MDS dated [DATE] documented that resident 32 had a BIMS score of 15, meaning resident 32 was cognitively intact. It also documented that resident 32 was dependent on two person extensive physical assistance for dressing and bathing. Resident 32's ADL (activities of daily living) documentation for August 2016 documented that resident 32 had not refused any cares on 8/24. It also had no documentation that resident 32 was assisted with dressing or personal hygiene until the NOC (night 10 PM-6 AM) shift that day. The documentation for September 2016 revealed that for 8 scheduled opportunities for a shower, resident 32 received 7. The documentation for August 2016 revealed that for 13 scheduled opportunities for a shower, resident 32 received 6 showers. The documentation for June 2016 revealed that for 13 scheduled opportunities for a shower, resident 32 received 10. The documentation for May 2016 revealed that for 13 scheduled opportunities for a shower, resident 32 received 9. For those four months, there were 3 incidents charted in which resident 32 refused cares or showers. CNA 3 was interviewed on 9/26/16 at 1:57 PM. CNA 3 stated that resident 32 did not often refuse showers, but at times preferred bed baths. RN 1 was interviewed on 9/26/16 at 2:00 PM. RN 1 stated that resident 32 did not often refuse showers, but was particular about which CNA provides them. 3. Resident 38 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 9/19/16 at 9:16 AM, resident 38 was interviewed. Resident 38 stated that he had not received a shower in over a week and that he would prefer two or three showers a week. On 9/19/16, resident 38's medical record was reviewed and revealed an MDS dated [DATE]. The MDS documented that resident 38 had a BIMS score of 13, which meant resident 38 was cognitively intact. It also documented that resident 38 required the extensive assistance of one person for bathing. Resident 38's ADL documentation for September 2016 revealed that of 7 scheduled opportunities for a shower, resident 38 received 3. Two opportunities were documented as refused. The ADL documentation for August 2016 revealed that of 13 scheduled opportunities for a shower, resident 38 received 1. Two opportunities were documented as refused. CNA 3 was interviewed on 9/26/16 at 1:57 PM. CNA 3 stated that resident 38 had refused showers. RN 1 was interviewed on 9/26/16 at 2:00 PM. RN 1 stated that resident 38 refused showers, but was not certain how frequently. On 9/26/16 at 2:17 PM, the DON was interviewed. The DON stated that she would check resident 38's ADL charting for showers. The DON stated that there had been issues identified with staff not charting showers. No further information was provided. 4. On 9/19/16 at 9:15 AM, an interview was conducted with resident 73. Resident 73 stated that there was not enough staff. Resident 73 stated I wake up about 3:00 AM because I'm in pain and need my pain medications. Resident 73 stated that My call light doesn't get answered for about two hours, then I get told that they are doing report and can't bring my pain medications to me. 5. On 9/19/16 at 9:41 AM, an interview was conducted with resident 17. Resident 17 stated that there was not enough staff. Resident 17 stated that, It takes them about 30 minutes to answer my call light, and it's worse in the afternoons and evenings. 6. On 9/19/16 at 10:19 AM, an interview was conducted with resident 8. Resident 8 stated that there was not enough staff. Resident 8 stated that it takes facility staff 40 minutes to answer my call light. 7. On 9/19/16 at 12:26 PM, a family interview was conducted on behalf of resident 40. Resident 40's daughter stated that, Sometimes they are short staffed and they get busy when two or three staff members have to work with one resident. 8. On 9/20/16 at 2:13 PM, an interview was conducted with CNA 1. CNA 1 stated that she no longer worked at the facility, that she had quit on 9/6/16. CNA 1 stated that she felt like she was treated badly and not appreciated by administration. CNA 1 stated that the reason she was frustrated with administration was that they were always short staffed and would work her from 6:00 AM until 10:00 PM. CNA 1 further stated that she would work 16 hour shifts frequently and often without them asking if she could work the 16 hour shifts. 9. On 9/13/16 at 3:00 PM, an interview was conducted with residents 11 and 12. (Note: Residents 11 and 12 were room mates.) Residents 11 and 12 stated that residents with behaviors received more attention than residents that did not complain. Residents 11 and 12 stated that staff would take up to an hour to answer their call light. Resident 11 stated she used her cell phone to call the front desk when staff did not response to the call light alarming. Resident 11 stated that her cell phone was being turned off because she could not afford it and was really concerned about alerting staff. Resident 11 stated that there were not enough staff to shower her daily as her physician had ordered. 10. On 9/13/16 at 8:55 AM, an interview was conducted with resident 51. Resident 51 stated that there were not enough staff. Resident 51 stated that he had to use his cell phone to call the front desk to get assistance. Resident 51 stated that his call light had alarmed for over an hour before staff members responded. Resident 51 stated there were only 2 CNAs at night and he needed 2 CNAs for his Activities of Daily Living. Resident 51 further stated he was not getting showers as scheduled because there were not enough staff. 11. On 9/14/16 at 3:20 AM, an interview was conducted with CNA 5. CNA 5 stated that that there were 2 CNAs during the night shift. CNA 5 stated that there was not enough time for a break or lunch because there were not enough staff. CNA 5 stated that she did the best she could with only 2 CNAs during the night shift. CNA 5 stated that the other CNA was with another resident for 3 hours during the shift which made it hard to care for the other residents alone. Cross reference F 241, F 246, F 309, and F 312.

Based on observation, interview, and record review, it was determined that for 4 of 36 sample residents, the facility did not promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Specifically, one resident did not receive incontinence care, one resident did not receive assistance changing clothing, one resident that was continent chooses to wear at brief at night because staff are unable to help her, and a resident does not get assistance with his urinary catheter. Resident identifiers: 12, 20, 32, and 74. Findings included: 1. Resident 20 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 20 was interviewed on 8/24/16 at 1:29 PM. Resident 20 stated that she wets herself (urinates in her incontinence brief) all the time and was wet at the time of the interview, but had not reported it to the facility staff because, it doesn't do any good. Resident 20 told survey staff, I'm not happy here at all. They ignore me. Resident 20 stated that she usually has to wait 35-40 minutes for assistance to be taken to the toilet after she turned on her call light. Resident 20 stated, I want to die. Resident 20 was re-interviewed on 9/13/16 at 3:54 PM. Resident 20 stated that she urinated on the floor that morning because she could not get staff assistance with taking her to the toilet. Resident 20 stated, That is a major problem with me! Resident 20 reported that, The CNA's (Certified Nursing Assistants) will not come (when she calls). The night nurses ignore me completely. Resident 20 stated that she had been, crying an awful lot and that she had recently been sent to the emergency room at a local hospital for [MEDICAL CONDITION] because, No one would listen to me. I just wanted someone to talk to. Resident 20's medical record was reviewed on 9/13/16. A Minimum Data Set ((MDS) dated [DATE] documented resident 20 had a BIMS (Brief Interview for Mental Status) score of 15 which meant that resident 20 was cognitively intact. The MDS documented that resident 20 was incontinent of bladder. The MDS also documented that resident 20 was totally dependent on two or more persons' physical assist for toileting. A Continence Evaluation dated 7/27/16 was reviewed. The Director of Nursing (DON) documented in the Continence Evaluation that resident 20 was aware of the urge to void urine, was aware of urine being passed, and was aware when she was wet. The DON also documented that resident 20 was able to ask for assistance. A Progress Note dated 8/26/16 documented that resident 20 had reported suicidal thoughts to the nurse and stated, I wish I could overdose on something and die. The note documented that resident 20 was sent to the emergency room for evaluation and returned early the following morning. On 9/5/16, the Social Service Worker (SSW) documented that resident 20 reported to her that she was sent to the hospital over the weekend because she had been crying and had felt suicidal. Resident 20 reported to the SSW that she, just wanted someone to talk to. On 9/26/16 at 1:57 PM, CNA 3 was interviewed. CNA 3 stated that resident 20 was continent/incontinent of bladder and was able to report to staff when she was wet. CNA 3 stated that resident 20 required extensive assistance with changing her incontinence brief. On 9/26/16 at 2:00 PM, RN (Registered Nurse) 1 was interviewed. RN 1 stated that resident 20 was, for the most part continent of bladder and would report to staff when she was wet and needed assistance to be changed. On 9/26/16 at 2:17 PM, the DON was interviewed. The DON stated that resident 20 was continent/incontinent of bladder and required assistance with incontinence cares. 2. Resident 32 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Resident 32 was interviewed on 8/24/16 at 9:50 AM. Resident 32 stated that his care in the facility was, beneath living quality. We're so used to waiting for hours (for assistance) .We don't want to ask for help because we know what they're (staff) going to say, 'We'll be back.' I have to tell them, 'This chair will be covered with (expletive)!' That's what I have to do to get help. Resident 32 stated that he had to threaten to contact the State Survey Agency in order to receive assistance. Resident 32 stated that he overfilled his urinal earlier and had accidentally spilled it on himself. Resident 32 stated, I am sitting in my own filth right now. I told them (staff) about it an hour ago. During the interview with resident 32 an observation was made. The white blanket that resident 32 was sitting on was visibly soiled with yellow urine and there was an evident urine odor. Resident 32 was observed to tell the Medical Records Clerk (MRC) at 10:02 AM, I need to be changed. The MRC stated, I'm answering call lights. Resident 32 was re-interviewed on 9/26/16 at 1:08 PM. Survey staff asked resident 32 about the incident on 8/24/16. Resident 32 stated that he did not receive assistance with changing his clothing until the following day. Resident 32 stated that it was uncomfortable because the urine burns and he was concerned that his skin would break down. Resident 32 stated, I am beyond pissed off. I feel helpless. Resident 32 confirmed that he required assistance with changing his shorts. Resident 32's medical record was reviewed on 9/26/16. A MDS dated [DATE] documented that resident 32 had a BIMS score of 15, meaning resident 32 was cognitively intact. The MDS also documented that resident 32 was dependent on two person extensive physical assistance for dressing. Resident 32's ADL (activities of daily living) documentation was reviewed. The ADL sheet for August 2016 documented that resident 32 had not refused any cares on 8/24. It also had no documentation that resident 32 was assisted with dressing or personal hygiene until the NOC (night 10 PM-6 AM) shift that day. CNA 3 was interviewed on 9/26/16 at 1:57 PM. CNA 3 stated that if the ADL documentation was blank, then that meant it either was not completed or not documented. The DON was interviewed on 9/26/16 at 2:17 PM. The DON stated that if documentation was blank, then something was not done or not documented. 3. Resident 12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/13/16 at 3:00 PM, an interview was conducted with resident 12. Resident 12 stated that the facility did not have enough catheter bags in the facility and his bag had a leak on 9/11/16. Resident 12 stated that the bag was changed and continued to leak so facility staff taped his bag to stop the leak. Resident 12 stated that the catheter bag would fall under his electric wheel chair if staff did not attach the bag to the wheel chair correctly. Resident 12 was observed to have his catheter bag on the floor under his wheel chair. The bag was not attached to the wheel chair. Resident 12 further stated that he had to drive backwards in his electric wheel chair because he was outside and the catheter bag fell under his electric wheel chair. Resident 12 stated that he did not want to pull the catheter out so he drove backwards to the facility to get the staff to help him. Resident 12 stated it was embarrassing having to drive backwards and his catheter bag fell off regularly. Resident 12's medical record was reviewed on 9/13/16 through 9/27/16. There was no physicians order for resident 12's catheter and no documentation that the catheter had been changed regularly. A Nurse Practioner Note dated 8/7/16 revealed, Seen at request of resident who is complaining of episodic discomfort to his urinary catheter. In discussion with him, discomfort appears to be related to position of his brief. If it is 'pulled up too high', he feels 'pinched'. Encouraged resident to discuss discomfort with staff at time of brief placement. Catheter is draining without difficulty, complaints are not consistent. On 9/22/16 at 9:20 AM, an interview was conducted with the facility DON and Cooperate Administrator (CA). The DON stated she was not aware the facility was out of catheter bags and that resident 12 had to have his catheter bag taped to stop leaks. The CA stated that another facility would provide catheter bags if the facility ran out. 4. Resident 74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/11/16, a medical record review was conducted for resident 74. Resident 74's MDS was not available due to the fact that the resident was newly admitted . On 9/13/16 at 1:45 PM, an interview was conducted with Resident 74. Resident 74 stated that she was continent of both bowel and bladder, but because the call lights were not answered promptly at night, she feels she has no choice but to wear incontinence briefs at night. On 9/13/16 at 2:55 PM, an interview was conducted with CNA 2. CNA 2 stated that resident 74 does everything on her own except pulling her pants down in restroom.

Based on interview, observation and medical record review it was determined, for 4 of 36 sample residents, that the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, a resident exhibited increased signs and symptoms of depression since the discontinuation of one of her anti-depressant medications with no social services intervention. A resident with paranoid schizophrenia with the behaviors of wandering and calling out received no social services intervention or behavior modification plans. One resident who had been assessed as needing supervision had been allowed to leave alone because the Ombudsman had told them to remove it and allow her to leave the facility and a resident, who had been expressing increased thoughts of hurting other residents and had shown signs of increased depression, did not receive any social services interventions. Resident identifiers: 27, 45, 58, and 69. Findings include: 1. Resident 27 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/26/16 resident 27's medical record was reviewed. Review of the medical record revealed the following Psychotropic Drug Review Notes: a. On March 24, 2016, facility staff indicated in their Psychotropic Drug Review Notes that resident 27 was receiving 60 mg (milligrams) of Cymbalta (an anti-depressant) for Major Depressive Disorder. The facility Medical Director made a notation on the form that she recommended that resident 27 start Celexa 10 mg by mouth daily due to resident 27's Major Depressive Disorder. Additionally, resident 27 was to continue taking the Cymbalta. According to the notes, the committee was to review resident 27's medications in 30 days. b. On April 22, 2016, facility staff indicated in their Psychotropic Drug Review Notes that resident 27 was receiving Cymbalta 60 mg daily and Celexa 10 mg daily. A recommendation was made that resident 27's Cymbalta be increased so the Celexa could be discontinued. According to the notes, the facility Medical Director agreed with the annotated recommendation. Additionally, the committee was to review resident 27's medications in 60 days. c. On June 24, 2016, facility staff indicated in their Psychotropic Drug Review Notes that resident 27 was receiving Cymbalta 60 mg daily and Celexa 10 mg daily. A recommendation was made to discontinue resident 27's Celexa. According to the notes, the facility Medical Director agreed with the annotated recommendation. Review of the physician's orders [REDACTED]. No documentation could be found to show that resident 27's Cymbalta was increased. No documentation could be found to show that an additional anti-depressant was ordered to replace the Celexa. Review of the medical record revealed the following facility documented weights for resident 27: a. 6/1/16: 120 pounds b. 9/1/16: 114 pounds It should be noted that resident 27 experienced a 5 % (percent) loss of her body weight after being taken off of the Celexa. (Note: weight loss is also a symptom of depression.) Review of the Progress Notes revealed the following entries: a. 7/10/16: Res. (resident) has refused all AM meds (medications) for 3 days in a row. I have offered and encouraged X2 (times 2) each day, but states she is too tired and doesn't feel well. b. 8/7/16: Recertification visit. Staff monitoring for wt (weight) loss, 126 to 118 (pounds) with BMI (body mass index) 23, over several months. abnormal wt loss: on appropriate supplements . c. 9/1/16: Resident has not gotten out of bed all day; however, she has not stated she is pain or nausea all day long. She received the PRN (as needed) pain medication and nausea medication this morning and since then she has been in bed. d. 9/2/16: resident did not complain of nausea until about 1600 (4:00 PM) today. Until that point she was in bed and sleeping. e. 9/3/16: Husband called to report concerns of increased nausea, pain, and dizziness with a decrease in appetite. Notes made to take (sic) with husband for next MD (medical doctor) appointment. f. 9/22/16: . Nursing report increase in depression lately. Tried to meet with (resident 27) and discuss wt loss concern. (Resident 27) said that she didn't want to talk r/t (related to) not feeling well and asked me to leave. Lunch tray was on bedside table untouched. Wt. loss of sig (significant) amount, unable to make dietary recommendations at this time r/t resident refusal to discuss wt loss/nutrition with RD (Registered Dietitian). Will try to follow-up next visit. On 9/26/16 at approximately 1:00 PM, resident 27 was interviewed. Resident 27 stated that she had felt better in May and June while taking the Celexa. Resident 27 stated that she had started feeling more depressed since July. No documentation could be found to show that the facility Social Worker had met and discussed resident 27's increased depression. On 9/27/16 the facility Corporate Administrator (CA) was interviewed. The CA stated that since the State Surveyor had notified staff that resident 27 had not received an increased dose of Cymbalta and the Celexa was discontinued, the staff had made an appointment for resident 27 to be seen by an outside Mental Health Provider. Additionally, the CA stated that resident 27 was told a couple of months ago that the doctors were out of options for treating her (resident 27) cancer and that resident 27 had been more depressed since then. 2. Resident 69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/13/16, the facility Social Services Worker (SSW) was interviewed. The SSW stated that the facility had placed a Wanderguard on resident 69 upon admission. (Note: a Wanderguard was a portable device worn on an individuals' person that alerted staff when the wearer exits the building.) The SSW stated that resident 69 had dementia and the Interdisciplinary Team (IDT) felt that resident 69 was unsafe to be out in the community without supervision from staff. The SSW stated that resident 69 had been upset because of the Wanderguard and wanted to go out into the community by herself. The SSW stated that the facility had contacted the local Long Term Care Ombudsman to come out and visit with resident 69 regarding supervision out in the community. The SSW stated that the Ombudsman had told the facility to remove the Wanderguard and allow resident 69 to leave the facility without staff supervision. The SSW stated that the IDT felt resident 69 was unsafe to be in the community without staff supervision but was going to remove the wander guard because the Ombudsman had told the IDT to remove it. The SSW further stated that resident 69 had promised the Ombudsman that she would not leave the facility grounds. On 9/26/16 resident 69's medical record was reviewed. Review of the medical record revealed the following Progress Notes: a. 6/8/2016 13:30 (1:30 PM) Psychosocial Note Late Entry: Note Text: SS (Social Services) Admit Note: (Resident 69) was admitted to this facility from (name of Skilled Rehabilitation Facility). She is alert and oriented with forgetfulness and confusion. (Resident 69) can voice her wants and needs. b. 9/13/2016 12:13 (12:13 PM) Psychosocial Note Note Text: (name of Ombudsman), Ombudsman, talked with (Resident 69) and came back to SSW and stated she had an agreement with (Resident 69) that her wander guard (sic) could come off if (Resident 69) agrees to sign herself out and goes outside but does not leave facility grounds. (Name of Ombudsman) said she told (Resident 69) that if she leaves facility grounds, then the wander guard (sic) can be put back on. (Name of Ombudsman) stated (Resident 69) agreed to these conditions. c. 9/14/2016 05:25 (5:25 AM) Psychosocial Note Note Text: Ombudsman was called because IDT team had talked about (Resident 69) improved cognition and safety awareness. A MOCA (Montreal Cognitive Assessment) had been done which (Resident 69) passed. She passed the BIMS (Brief Interview for Mental Status). Some of (Resident 69's) meds had been changed. AIT (Administrator in Training) had talked with facility doctor who also felt comfortable with (Resident 69) having the wander guard (sic) taken off as long as she did not leave facility grounds for now. IDT team wanted to know what the Ombudsman's opinion would be. d. 9/14/2016 09:34 (9:34 AM) Psychosocial Note Note Text: SSW took the contract to (Resident 69) regarding taking off the wander guard (sic) and signing herself out but not leaving facility grounds. (Resident 69) was really happy about this. She signed the contract. SSW reminded (Resident 69) that she has a phone call appointment with Social Security next Wednesday. Then we can work on the New Choice Waiver. (Resident 69) was very excited and said she understood. It should be noted that the entries for 9/13/16 - 9/14/16 were made by the facility SSW after the State Survey Team had interviewed the SSW regarding resident 69's Wanderguard. On 9/14/16 at approximately 10:30 AM, the facility SSW was reinterviewed. The SSW stated that she had written up a contract for resident 69 to sign regarding resident 69's promise to the Ombudsman. The SSW stated that the IDT did not feel comfortable removing resident 69's Wanderguard and letting resident 69 leave the facility unsupervised. Review of the medical record revealed the following piece of paper: I, (Resident 69), agree that I want my wander guard (sic) taken off and that I will be able to sign myself out, go outside but will not leave the facility grounds. If I do leave the facility grounds, I will take the chance of having the wander guard (sic) being put back on. I have made this promise to (name of Ombudsman) the Ombudsman. And I am signing this agreement, making this promise to (name of facility). 3. Resident 45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/13/16 at 8:35 AM, an observation was made of resident 45. Resident 45 was observed in the 300 hall yelling repeatedly, It's my shower day. Resident 45 was taken to the shower at 9:35 AM. Resident 45 was observed to yell out for an hour. On 9/13/16 at 8:52 AM, an interview was conducted with resident 51. Resident 51 stated that resident 45 repeatedly yelled in the hallway all day. Resident 51 stated that he felt bad for resident 45. Resident 51 stated that resident 45 woke-up him up yelling almost every morning. Resident 51 stated that staff would tell resident 45 to quiet down. On 9/13/16 at 3:00 PM, an interview was conducted with residents 11 and 12. Residents 11 and 12 stated that resident 45 woke them up at 5:00 AM yelling in the hallway. Residents 11 and 12 stated that staff told resident 45 to quiet down but had not observed staff implement other interventions with resident 45. On 9/15/16 at 8:50 AM, an observation was made of resident 45. Resident 45 was observed in the 300 hall yelling and mumbling that he wanted a shower. On 9/19/16 at 9:00 AM, an observation was made of resident 45. Resident 45 was observed to be yelling for lunch outside of the dining room. On 9/21/16 at 10:17 AM, resident 45 was observed in the dining room yelling for food. The AIT and Dietary Manager (DM) 2 were observed in the dining room and did not offer resident 45 any food. On 9/21/16 at 2:06 PM, resident 45 was observed in the dining room. Resident 45 was yelling for dinner. Dietary Aide (DA) 1 stated that resident 45 stayed in the dining room for hours. DA 1 stated that resident 45 did not ask for food when he was in the dining room. DA 1 stated that resident 45 waited for his meals after asking for lunch or dinner repeatedly. On 9/22/16 at 9:10 AM, an observation was made of resident 45. Resident 45 was observed to be walking in and out of his room. Resident 45 was observed to repeatedly yell two women's names. Resident 45 was observed to walk to the dining room at 9:45 AM. At 10:18 AM, resident 45 began yelling repeatedly, lunch, coffee, milk and juice. At 10:21 AM, the AIT was observed to look into the dining room and ask resident 45 to quiet down. At 10:53 AM, resident 45 was observed to repeatedly yell, Lunch, somehow. On 9/26/16 at at 8:25 AM, an observation was made of resident 45. Resident 45 was yelling at the end of the hall. Resident 45's medical record was reviewed 9/14/16 through 9/27/16. A care plan dated 4/6/16 and updated 7/22/16 revealed a focus, Resident will yell out, not related to pain, and will continue to scream and make repetitive nonsensical noises in public. The goal developed for resident 45 was, Resident will have a reduction in screaming out not related to pain to none per day. The interventions developed were, Procedure if the behavior occurs: 1. Calmly try to intervene and focus resident attention on other activities when he starts screaming. 2. Do not engage in the screaming tantrum if resident will not calm down. Ensure the resident is safe, leave the area, and let resident know you will be back once he has calmed down. 3. 1:1 (one on one) with trusted staff to help calm resident. 4. Remove from area if needed, redirect to a quiet calm area. Invite resident back when he is calm. 5. Assist with the continual r/o (rule out) of any medical, environmental, or social issues affecting behavior. 6. Ensure environment is calm and low stimulus. 7. Do not argue with him. Procedure to prevent the behavior: 1. Involve resident in activities of his choice to keep him busy and develop a sense of well-being. Encourage family visits, listen to music, reminisce about the past. 2. Assess if resident is in pain, uncomfortable, side effects from medication, lack of sleep and address need. 3. Assess if the environment is too loud, busy, or cluttered for resident and remove resident from environment to a quieter place. 4. Remove from public place if he will not stop screaming more than 5 minutes continuously. 5. Speak to resident in very simple, concrete words. Ask simple yes or no questions loudly and clearly. 6. Avoid asking too many questions or giving too many instructions at once. Make it simple, slow, and step by step. 7. Use memory cues, such as posted notes around the room or a schedule board for cares and meal times. 8. Keep resident?s (sic) schedule as consistent as possible. SSW notes revealed the following entries: On 5/25/16, SS Quarterly Note.- (resident 45) appears alert and oriented to person and surroundings. His short term memory and long term memory appears impaired. (Resident 45) does not make his own decisions. (Resident 45) can say yes, no and don't. Staff anticipate his wants and needs. Goal 1: Resident will not be distressed by hallucinations or delusions Q (every) daily (sic). Evaluation: (Resident 45) does not appear distressed about his hallucination/delusions. Goal 2: the resident will maintain current level of cognitive function. Evaluation: (Resident 45) does appear to maintain his current level of cognitive function. Goal 3: The resident will maintain optimal quality of life within limitation imposed by visual function through the review date. Evaluation: (Resident 45's) quality of life appears to be maintained. He walks to dining room and where ever he wants to go in the facility. Goal 4: Resident will be cooperative with cares. Evaluation: (Resident 45) will cooperative (sic) with some cares but resists some at times also. Goal 5: .Goal 6: I will attend (passively at times) at least 1 adaptive activities for adapting to cognitive level per week X (times) 90 days. I will accept at least 1 1:1 visits for sensory and encouragement per week X 90 days. I will show increased participation in activities of importance by next review. I will exhibit appropriate behaviors during activities weekly.Goal 7: (Resident 45) will have less than one episode per shift/per day of repetitive verbalizations through the review date. Evaluation: (Resident 45) has repetitive verbalizations continuously during the day. Goal 8: (Resident 45) will exhibit anxiety with a frequently on no more than 1 X day through next review date.Evaluation: (Resident 45) appears anxious most of the day with his repetitive verbalizations and movements. On 7/22/16, .(Resident 45) appears alert and oriented to person.(resident 45) can say yes, no and don't. Staff anticipate his wants and needs. On 9/8/16, SSW tries every morning to ask (resident 45) to quiet down. He yells and chants words in between meals. Most of the time (resident 45) will quiet down but then starts up as soon as SSW turns around. (Resident 45) paces the hallways and then stands at the dining room door while chanting. Then he starts pacing again. Or if dining room door is open, (resident 45) will sit in dining room for a few minutes chanting then gets up and starts pacing hallway again. On 9/14/16 at 7:05 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 45 can be redirected by female staff members. LPN 1 stated that he was not aware of interventions developed by the SSW to redirect resident 45. On 9/26/16 at 8:35 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 45 will fixate on one thing at a time and yell repeatedly in the hallway. RN 1 stated that when resident 45 began yelling she would ask him to be quiet. RN 1 stated she did not know of other interventions developed by the social worker to redirect resident 45 when he was yelling out. On 9/26/16 at 9:00 AM, an interview was conducted with the SSW. The SSW stated that resident 45 was motivated by food and will repeat, Eat lunch, Eat lunch. The SSW stated that staff will remind resident 45 to quiet down when he repeats himself. The SSW stated that resident 45 was referred to community mental health services for his yelling out and repetitive behaviors. The SSW stated that the community mental health did not provide notes or information to the facility regarding treatment for [REDACTED]. On 9/27/16 at 9:50 AM, an interview was conducted with RN 3. RN 3 stated that when resident 45 began yelling out she would ask him to quiet down. RN 3 stated that she was not aware of other interventions to calm resident 45. RN 3 stated that the SSW had not discussed interventions with RN 3. 4. Resident 58 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 58's medical record was reviewed on 9/14/16. Review of the medical record revealed the following Progress Notes: a. 7/24/16 at 5:21 PM, Resident has been very agitated for the last few hours. He is upset with a resident for reasons this nurse doesn't fully understand and has been threatening with violence to the other resident and staff members. This resident has been verbally bantering and upsetting many other residents in the facility going up and down the hall yelling and cursing. Attempts have been made to calm resident down, resident is currently in room yelling but no one is with him. b. 7/25/16 at 6:57 AM, Resident is on alert charting for behaviors. Vitals this shift were refused. Resident has been agitated and yelling at staff and other residents, threatening to kill them with his hammer. Nurse re-direction successful. Resident informed that police will be called if he threatens anyone's life again. c. 8/4/16 at 12:46 PM, CSW (Certified Social Worker) met with (resident 58) today for a counseling session. Before the session SSW informed CSW that resident had written letters and given them to SSW and DON (Director of Nursing), saying odd things and expressing his anger. Resident started the session stating, 'There are a couple of people in here I want to beat the (expletive) out of.' He (resident 58) began to speak out, 'never getting out of here and getting the things he needs.' Resident would like to 'finish projects' and needs to go and get materials. Resident then stated he, 'hates (name of other resident)', he (resident 58) stated he, '(expletive) gets in the way of (name of a facility licensed nurse) and me.' Resident then continued to state how much he, 'hates (name of other resident), he is (expletive) stupid', and how much anger he has toward (name of other resident). Resident did state he would, 'murder or kill people', and mentioned (name of other resident). Resident stated he will, 'die here, and has nothing to lose', 'what are they going to do to me?' Regarding if he chooses to kill people. d. 8/4/16 at 1:50 PM, When SSW came in this morning there were several pages of notes from (resident 58). He wrote about hurting other people. SSW gave a referral to CSW to do therapy with (resident 58). When CSW talked to (resident 58) he did tell her that he wanted to hurt another resident and (resident 58) talked about killing people. e. 8/19/16 at 8:48 AM, Last evening, (resident 58), came to SSW's office and just wanted to talk. (Resident 58) stated he feels very lost in his life. f. 8/22/16 at 3:12 PM, (Resident 58) came to SSW's office today to talk. He seems depressed but stated he will not do anything to himself. A review of resident 58's September 2016 Medication Administration Record (MAR) documented that resident 58 had not been prescribed an antidepressant. Review of resident 58's care plan dated 9/3/15, revealed a focus of, Voicing thoughts of suicide. Facility staff revised the care plan on 4/5/16 and 8/18/16. The interventions listed on the care plan were for facility staff to,Ensure the room is free of hazards that could be used to hurt himself, offer one on one visits with social services for support and an opportunity for him to express his feelings, and refer to (a local mental health care provider) for medication management and counseling. Review of resident 58's care plan dated 10/13/15, revealed a focus of, Impaired mood/social interactions manifested by my mood problems: depression/anxiety; I have problems with coping; I need reminders of activities; I have behaviors: Verbal; Suicidal ideations (sic) Facility staff revised the care plan on 2/24/16. The interventions listed on the care plan were for facility staff to: Supply me with independent leisure materials, remind resident of safety issues when using tools, invite and/or assist to/from group activities, encourage me to participate in activities of interest, support the continuation of my life roles, monitor for fall risk, ensure I have proper lighting and sufficient space for activities both in and out of my room, support my family/friend involvement and my need for privacy during visits, coordinate with Certified Nursing Assistant (CNA) to help assist with my setup/positioning/toileting needs during activities. On 9/14/16 at 6:35 AM, an interview was conducted with the SSW. The SSW stated that resident 58 has refused therapy services. The SSW stated that resident 58 will talk with the Licensed Clinical Social Worker (LCSW) but not on a therapeutic basis. The SSW stated that resident 58 was on the list to see the LCSW but she was not sure if resident 58 had been seen yet. The SSW further stated that resident 58 had not been on a behavior contract.

Based on observation, interview and record review, it was determined, for 9 of 36 sample residents, that the nurses station was not equipped to receive resident calls through a communication system from resident rooms. Specifically, one resident's call light did not have a pull cord and the resident had to stand up to manually turn on the call light, fell and fractured her femur. One resident fell and had to crawl, then stand on her amputated stump to manually turn on the call light. Multiple call lights were found either on the floor or not in the resident's reach. Resident identifiers: 8 and 74. 1. Resident 8 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/13/16, resident 8's medical record was reviewed. A nurses note dated 7/2/16 at 9:15 PM, revealed Patient had a fall, unwitnessed, in her room at approximately 20:40 (8:40 PM) and was sent to (hospital) for evaluation. She said she twisted her right leg at the knee and it was hurting her very much and rated the pain 10/10. (Based on the pain scale of 1-10 with 1 being no pain and 10 being the worst pain possible.) She was given her evening medications and requested [MEDICATION NAME] for her anxiety from the fall. Her med (medication) list and history along with face sheet and transfer form were sent to the ER (emergency room ) with the paramedics. They left the facility at 21:15 (9:15 PM). A nurses note dated 7/3/16 at 7:04 PM revealed Per resident's father, she is currently being treated at (hospital) for a broken femur. A facility incident report dated 7/2/16 at 8:40 PM revealed patient was found lying next her her bed with her head toward the foot of the bed. She had diarrhea on the floor next to her and she was only dressed in her brief. She was crying and said she did not mean to fall and that she was reaching for the call light when she twisted her right leg under her and fell . On 9/14/16 at 7:10 AM, an interview was conducted with resident 8. Resident 8 stated that she fell on [DATE] because the call light was broken, that there was only a small piece of wire through the call light and no pull cord. Resident 8 stated that she tried to yell for facility staff for assistance but nobody could hear her because her door was closed. Resident 8 stated that she had to stand up and manually pull the lever to activate the call light. Resident 8 stated that she caught her right leg as she fell , twisting the leg and fractured her femur. Resident 8 stated that while she was on the floor, she had diarrhea. Resident 8 further stated that she again tried to yell out for facility staff to help her, but they could not hear her. Resident 8 did not know how long she laid on the floor. The Minimum Data Set (MDS) assessment dated [DATE] revealed that resident 8 was alert and oriented. The MDS revealed that resident 8 was totally dependent with a 2 person assist for bed mobility, transfers, toileting and hygiene needs. The CAA (Care Area Assessment) Summary revealed that resident 8 triggered for falls and that falls were care planned. The care plan dated 5/31/16 and revised on 7/8/16 revealed the following: Focus -Potential for fall and/or injury related to neuromuscular and musculoskeletal impairments, chronic pain status, episodes of anxiety. Goal -Resident will be free of any noted injury related to episode of fall, through next review. Interventions -Assist resident to reposition in bed at regular intervals as needed/indicated. -Ensure bed side call light in residents reach at all times; reinforce use to resident as needed. On 9/15/16 at 11:00 AM, an interview was conducted with the facility DON (Director of Nursing). The facility DON stated that they did not know that the resident's call light had been broken, but, that the call light should have been at the resident bedside. On 9/16/16 at 6:05 PM, an interview was conducted with RN (Registered Nurse) 3. RN 3 stated that we get a lot of misinformation from the residents, that they can transfer themselves when they can't and we are trusting their word before really assessing their abilities. 2. On 9/15/16 at 8:35 AM, an observation was made of the call light on the floor in room 104A. 3. On 9/15/16 at 8:36 AM, an observation was made of the call light in room 104B. The call light did not light when pulled. 4. On 9/15/16 at 8:40 AM, an observation was made of the call light in room 102. The call light consisted of a string that was attached to a thin wire that was through the hole on the call light lever. The thin wire had a gap of approximately half a centimeter. The thin wire was at risk of pulling apart while activating the call light. 5. On 9/15/16 at 8:47 AM, an observation was made of the call light on the floor in room 210B. 6. On 9/15/16 at 9:03 AM, an observation was made of the call light hung on the glove basket on the wall at the foot of the bed. 7. On 9/15/16 at 9:05 AM, an observation was made of the double call light in room 204A. The call light did not light when pulled. 8. On 9/15/16 at 9:07 AM, an observation was made of the call light in room 404A. There was no string attached to the call system for a resident to activate the call system. The bathroom call system had no string attached for a resident to activate the call system. 9. On 9/15/16 at 9:12 AM, an observation was made of the call light in room 410A. There was a string but it was not attached to the call light system. 10. On 9/15/16 at 8:43 AM, an observation was made of room 303 bed B. There was no call light on the wall for the resident residing in bed B. The resident stated that she yelled to get staff assistance and did not know why there was no call light. On 9/15/16 at 9:10 AM, an interview was conducted with RN 3. RN 3 stated that the resident residing in room 303 bed B was able to use a call light. RN 3 stated that she did not know the resident did not have a call light. On 9/15/16 at 9:11 AM , an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated that the resident in room 303 bed B was able to use a call light. CNA 3 stated that she did not know there was no call light. 11. On 9/15/2016 at 8:40 AM, testing of call lights was initiated with the following findings: a) Pull cord was missing from bathroom call light and lever was loose making it difficult to turn on in joint bathroom for rooms 301 and 303. b) Bathroom call light located outside of room 302 was not functional 12. Resident 74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Incident reports were reviewed and revealed that resident 74 had a fall on 9/10/16 and 9/11/16. On 9/13/16 at 1:45 PM, an interview was conducted with resident 74. Resident 74 stated that she had a fall on 9/11/16. Resident 74 stated that after her fall she needed help getting off of the floor but the cord to the call light was missing. Resident 74 stated that she had to crawl to the call light, kneel on her left leg and the stump of her right leg to reach the call light lever and activate the call system. Resident 74 stated that she told the nurse on duty, Administrator in Training (AIT), and another person in management but did not know what had been done to fix the problem or if it had been reported. An observation was conducted of the joint bathroom for rooms 301 and 303 on 9/13/16, 9/15/16, and 9/26/16. The call light cord continued to be absent. A review of the facility Work Order Log indicated that the missing call light cord had not been reported or noted despite it being reported by resident 74 to the AIT, nurse on duty, or management.

Based on observation, interview, and record review it was determined, for 5 of 36 sample residents, that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the assessment and plan of care. Specifically, two residents did not receive physician ordered pain medication resulting in high levels of pain. One resident's physician was not notified immediately after a fall. One resident was not medicated for pain prior to treatments being provided for her pressure ulcer and one resident did not receive her physician ordered showers for a documented skin condition. Resident identifiers: 11, 22, 30, 73, and 40. Findings include: 1. Resident 30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at approximately 1:30 PM, observations were made of resident 30 while facility staff changed the dressing on her right heel. Resident 30 was observed to wince and pull her foot back when staff touched the wound or manipulated her foot. During the observation, Registered Nurse (RN) 2 stated that resident 30 appeared to be in pain whenever the dressing was changed. Licensed Practical Nurse (LPN) 1 stated that resident 30 had experienced a significant amount of pain on [DATE] when the physician had debrided the wound. On [DATE] during resident 30's dressing change, LPN 1 confirmed that he had not given resident 30 anything for pain before changing the dressing. Both RN 2 and LPN 1 stated that resident 30 had Tylenol ordered for pain as needed. On [DATE] resident 30's medical record was reviewed. Review of resident 30's care plan revealed the following care plan: (Resident 30) does not speak d/t (due to) dysphagia and disease process. The goal listed on the care plan was, Staff will anticipate (resident 30's) wants and needs. Facility staff listed the following interventions to help resident 30 achieve the stated goal: Staff will watch for facial expressions and gestures that signal distress and/or comfort so as to make sure (resident 30's) wants and needs are being met. Review of the physician orders [REDACTED]. Give 650 mg by mouth two times a day for Pain. (Note: The order for Tylenol was received when resident 30 admitted to the facility. Resident 30 was also assessed by facility staff as not having any skin issues or pressure ulcers.) No documentation could be found to show that facility staff received any additional orders for pain medication after resident 30 developed the pressure ulcer and began to receive treatment for [REDACTED]. Review of the Progress Notes revealed the following entries: a. [DATE]: . patient does have pain at site. Site is a stage 2 pressure ulcer. b. [DATE]: . Site has slough over the wound and wound is slightly moist. Pain is noted at site. There was odor. c. [DATE]: Dressing change done on R (right) heel. Wound is 4 cm (centimeters) X (by) 3 cm, dark red, open wound, clean dry dressing applied. Res (resident) showed signs of increased pain during dressing change. d. [DATE]: Cont. (continues) on abtx (antibiotics) for infected wound on heel. Tylenol given for pain. e. [DATE]: Wound care to Right heel completed per MD (medical doctor) orders, wound healing, antibiotic taken as ordered. Pain controlled with scheduled medications. (It should be noted that resident 30 was not receiving scheduled pain medications.) f. [DATE]: Dressing changed twice today, uncovered to show husband and state survey team the wound on her heel. Pt (patient) feels discomfort during manipulation of the foot, but settles down quickly. On [DATE], review of resident 30's physician orders [REDACTED]. No documentation could be found to show that facility staff had notified the doctor of resident 30's pain during manipulation of her foot. 2. Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On [DATE] resident 22's medical record was reviewed. Review of the medical record revealed the following entries: a. [DATE] 16:51 (4:51 PM) Admission Summary Note Text: pt readmitted to room [ROOM NUMBER] this afternoon following hospitalization at (name of local acute care hospital) hospital for fluid overload r/t (related to) [MEDICAL TREATMENT], SOB (shortness of breath), pleural effusion, ascities, end stage [MEDICAL CONDITION], pt AxOX3 (alert and oriented times three) forgetful at times, skin warm and dry, flaky skin to extremities, [MEDICAL TREATMENT] fistula to left arm intact, dressing in place, no bleeding noted, several bruises on arms from hospital IV (intravenous) sites, no [MEDICAL CONDITION] noted at present, abdomen obese, BS (bowel sounds) x 4 (in all four quadrants) present, reports minimal generalized discomfort at present,v/s (vital signs) stable, pt oriented to room and facility, MD notified of patients return to facility, no complaints at present, will continue to monitor. b. [DATE] 17:58 (5:58 PM) Orders - Administration Note Note Text: [MEDICATION NAME] HCl ([MEDICATION NAME]) Tablet 5 MG Give 5 mg by mouth four times a day for Pain Pain in legs, stomach cramps; ,[DATE] (pain scale). c. [DATE] 02:28 (2:28 AM) Orders - Administration Note Text: [MEDICATION NAME] Tablet 30 MG Give 30 mg by mouth two times a day for Pain resident readmitted from hospital this afternoon. Arrived with new medication order for [MEDICATION NAME] 30 mg PO (by mouth). Report was given to night shift that medication would be in pharmacy delivery this evening. Medication was not delivered this evening. Medication not present in E-kit (Emergency Kit) to be pulled. Resident passed away before after hours pharmacist could provide delivery details. No documentation could be found to show that facility staff reassessed resident 22 after the administration of the [MEDICATION NAME] to determine the effectiveness of the pain medication. According to documentation, resident 22 expired before staff could administer the physician ordered [MEDICATION NAME] for pain. 2. Resident 73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 9:13 AM, an interview was conducted with resident 73. Resident 73 stated that he is in a lot of pain. Resident 73 stated that he wakes up about 3:00 AM in pain. Resident 73 stated that he would turn on his call light to ask for pain medications, but his call light doesn't get answered for about two hours, then I get told that they are doing report and can't bring my pain medications. Resident 73 stated that his pain medications took a long time to come in from the pharmacy and that his pain had gotten so out of control that he got pretty angry with staff and didn't want to be around anyone. On [DATE], resident 73's medical record was reviewed. A nurses note dated [DATE] at 7:08 PM revealed, .he (resident 73) complains of chronic pain; phantom, teeth and [MEDICAL CONDITION] Pain level: 9 sharp and constant; phantom limb, [MEDICAL CONDITION], teeth and chronic pain. (NOTE: Pain levels were based on a pain scale from ,[DATE] with 1 being the least amount of pain and 10 being the greatest amount of pain with the pain medication given.) A nurses note dated [DATE] at 5:31 PM revealed, that resident 73 had .C/O (complains of) chronic throbbing pain throughout. Phantom pain in left lower extremity . Resident 73's medication orders from the hospital revealed an order for [REDACTED]. On [DATE] at 2:43 PM, an interview was conducted with the facility DON (Director of Nursing). The facility DON stated that resident 73 was admitted to the facility on [DATE] just one day prior to her going on vacation. The DON stated that the medication list from the hospital was considered to be physician's orders [REDACTED]. The DON stated that she would look into why the [MEDICATION NAME] was missed upon transcription to the physician's orders [REDACTED]. On [DATE], resident 73's medical record was again reviewed. Resident 73's physician's orders [REDACTED]. The interim care plan for resident 73, dated [DATE] revealed that resident 73 had Pain. The outcome/goal for resident 73 was Resident's pain will be managed at a level which will allow normal function. The interventions for resident 73 was Provide [MEDICATION NAME] medication as ordered. Monitor for effectiveness of [MEDICATION NAME] and notify physician ASAP (as soon as possible). Offer alternatives to [MEDICATION NAME] like turning and repositioning, meditation, distraction, etc (etcetera). The facility Pain Scale Summary for resident 73 revealed the following pain levels and pain medication administration: a. On [DATE] at 9:34 PM, resident 73's pain level was documented as being at an 8. Resident 73's MAR indicated [REDACTED]. The facility Emergency Drug Kit Slip revealed that [MEDICATION NAME] 5 mg 2 tablets was pulled from the facility emergency kit at 9:30 PM. (NOTE: [MEDICATION NAME] 5 mg 2 tablets was pulled from the facility emergency kit 2 hours and 26 minutes after resident 73 had complained to the DON of his pain level at 9.) b. On [DATE] at 4:16 AM, resident 73's pain level was documented as being at a 7. Resident 73's MAR indicated [REDACTED]. No facility Emergency Drug Kit Slip could be located to show that [MEDICATION NAME] 5 mg 2 tablets was pulled from the facility emergency kit to be administered to resident 73 at 4:16 AM. c. The facility Emergency Drug Kit Slip dated [DATE] at 10:00 AM revealed that [MEDICATION NAME] 5 mg 2 tablets was pulled from the facility emergency kit for resident 73. The MAR for resident 73 revealed that there was no entry of a pain level on [DATE] at 10:00 AM nor of the [MEDICATION NAME] 5 mg 2 tablets being administered to resident 73 at 10:00 AM. d. On [DATE] at 3:55 PM, resident 73's pain level was documented as being at a 10. Resident 73's MAR indicated [REDACTED]. (NOTE: [MEDICATION NAME] 5 mg 2 tablets was pulled from the facility emergency kit and administered to resident 73 at 3:55 PM, 18 hours and 55 minutes after the initial administration of [MEDICATION NAME] 5 mg 2 tablets were administered on [DATE] at 9:34 PM.) e. On [DATE] at 6:53 AM, resident 73's pain level was documented as being at a 10. Resident 73's MAR indicated [REDACTED]. (NOTE: [MEDICATION NAME] 5 mg 2 tablets was administered 15 hours and 58 minutes after the second administration of [MEDICATION NAME] 5 mg 2 tablets on [DATE] at 3:55 PM.) f. On [DATE] at 8:46 PM, resident 73's pain level was documented as being at a 10. Resident 73's MAR indicated [REDACTED]. No Emergency Drug Kit Slip could be located to show that [MEDICATION NAME] 5 mg 2 tablets was pulled from the facility emergency kit to be administered to resident 73 on [DATE] at 8:46 PM. Documentation under the [MEDICATION NAME] ER 15 mg revealed that the nurses progress notes should be looked at. The nurses progress notes dated [DATE] revealed a set of vital signs for resident 73. (It should be noted here that a telephone order had been written for the [MEDICATION NAME] ER 15 mg BID and that the [MEDICATION NAME] order had been added to resident 73's MAR.) g. On [DATE] at 11:16 AM, resident 73's pain level was documented as being at a 10. Resident 73's MAR indicated [REDACTED]. A nurses note dated [DATE] at 6:31 PM revealed .Resident agitated because PRN [MEDICATION NAME] had not be (sic) delivered from pharmacy. Pharmacy carified (sic) that it was 5 days too early to refill resident's prescription. Administrator approved to bill facility instead of insurance. [MEDICATION NAME] was delivered at aprox (approximately) 1630 (4:30 PM) . A pharmacy services delivery sheet revealed that resident 73's [MEDICATION NAME] 10 mg and [MEDICATION NAME] ER 15 mg had been delivered on [DATE] at approximately 4:30 PM. ( It should be noted that resident 73's MAR indicated [REDACTED].) On [DATE] at 3:30 PM, a follow up interview was conducted with the facility DON. The facility DON stated that the medication was not missed, but, instead had to be clarified with the facility MD (Medical Doctor) so they could get a hard copy of a prescription. (It should be noted that no hard copy of a prescription for [MEDICATION NAME] ER 15 mg BID could be located in the medical record, other than the physician orders [REDACTED].) No documentation could be located in the medical record to show that resident 73's physician had been notified of the need to clarify the [MEDICATION NAME] order upon admission. No documentation could be located in the medical record that resident 73's physician had been notified of resident 73's pain levels. 3. Resident 40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] resident 40's medical record was reviewed. A nurses note dated [DATE] at 3:50 AM, revealed When CNA walked past resident's room, she heard resident calling out for help. Upon entry into resident's room, CNA found resident face down on the floor, on her fall mat. CNA notified nurses immediately. Head-to-toe assessment revealed a small skin tear and hematoma to right side of forehead. No other injuries. Resident denies any pain. Steri-strips applied to skin tear. Neuro (neurological) checks were within normal limits. Resident was promptly helped back to bed by nurses and CNA's who were present Hospice nurse notified . No other entry could be located in the facility progress notes by LPN 2 regarding resident 40's status. A nurses note dated [DATE] at 7:35 AM, revealed Called hospice to let them know that resident's vitals were Blood Pressure (BP) ,[DATE], Pulse (P) 64, Respirations (R) 12. O2 (Oxygen) ranging between ,[DATE]% on room air. Resident is unresponsive when moved, spoken to. Left message for daughter. Called and spoke to daughter in law who is on her way into the facility and requests only that resident be 'kept comfortable.' Resident is laying in bed in no obvious distress. Hospice to come into facility to evaluate. On [DATE] at 8:10 AM, an interview was conducted with RN 1. RN 1 stated that the report she received when coming on shift was that a CNA had noticed some redness to resident 40's left hip, had scooted resident 40 back on the bed and then rolled her to her right side. RN 1 stated that about 15 minutes later, the CNA heard resident 40 calling out for help and was found on the floor with a skin tear to her right forehead as well as a hematoma. RN 1 stated that neuro checks had been implemented, that she had been given a [MEDICATION NAME] ,[DATE] mg at 4:00 AM by the night nurse. RN 1 stated that she had been told that resident 40 had taken a turn for the worse, was comatose, vital signs (VS) were changing and that resident 40 had earlier reported that her head felt like a watermelon and that resident was giddy and laughing. RN 1 stated that her report from the night nurse was that she should watch resident 40. RN 1 stated that she was not going to just watch her, I knew I needed to call the physician. On [DATE] resident 40's medical record was again reviewed and revealed the following neuro checks: [DATE] at 3:30 AM - P 69, R 14, BP ,[DATE] [DATE] at 3:45 AM - P 70, R 14, BP ,[DATE] [DATE] at 4:00 AM - P 70, R 14, BP ,[DATE] [DATE] at 4:15 AM - P 68, R 12, BP ,[DATE] [DATE] at 4:45 AM - P 68, R 12, BP ,[DATE] [DATE] at 5:15 AM - P 70, R 14, BP ,[DATE] [DATE] at 5:45 AM - P 70, R 14, BP ,[DATE] [DATE] at 6:15 AM - P 66, R 16, BP ,[DATE] [DATE] at 7:15 AM - P 64, R 12, BP ,[DATE] The Neurological Assessment for resident 40 revealed that resident 40's blood pressure started to change within 15 minutes of the fall. Resident 40's respirations started to change within 45 minutes of the fall. Resident 40's care plan dated [DATE] revealed the following focus: (Resident 40) is a high risk for falls r/t (related to) unaware of safety needs, deconditioning, psychoactive drug use, vision/hearing problems, gait/balance problems. The goal for resident 40 was will be free of falls through the review date and will not sustain serious injury through the review date. The interventions for resident 40 were as follows: -Anticipate and meet (Resident 40's) needs. -Be sure (Resident 40's) call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. -Educate (Resident 40's) family/caregivers about safety reminders and what to do if a fall occurs. -Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate (Resident 40)/family/caregivers/IDT (Interdisciplinary Team) as to causes. On [DATE] at 8:25 AM, an interview was conducted with Resident 40's daughter in law. Resident 40's daughter in law stated that she was called at about 7:00 AM by RN 1 and notified of resident 40's fall and changes in cognition. Resident 40's daughter in law stated that she had to stop at resident 40's daughter's home to inform her of resident 40's fall because she turns her phone off at night. On [DATE] at 8:36 AM, an interview was conducted with the Hospice RN. The Hospice RN stated that she received the call informing her of resident 40's fall at 6:59 AM per her cell phone. The Hospice RN stated that they should have called when the fall happened because we like to get eyes on them as quickly as possible. The Hospice RN stated that she called and talked with the Hospice Physician and informed him of resident 40's fall and that she was unresponsive. On [DATE] at 1:10 PM, a call was placed to LPN 2. LPN 2 did not pick up and a message was left for her to return my call. On [DATE] at 2:30 PM, LPN 2 returned my call and a telephone interview was conducted. LPN 2 stated that she was on duty when resident 40 had her fall and confirmed the findings. LPN 2 stated that she then started neuro checks and VS (vital signs). LPN 2 stated that she called hospice and reported the incident to them soon after and that resident 40 reported to that her head hurt. LPN 2 stated that she asked resident 40 if her head hurt where she had the skin tear and bruise and resident 40 reported that it did and that her head felt like a watermelon. LPN 2 stated that she then administered [MEDICATION NAME] ,[DATE] mg and that it took a little while for the [MEDICATION NAME] to become effective and but when it did, resident 40 finally went to sleep. LPN 2 stated that sometimes resident 40 would say funny things like that as she has stated before that her back has had pain and she reported that she felt like a whale was on her back. On [DATE] at 3:00 PM, an interview was conducted with resident 40's daughter. Resident 40's daughter stated that the Hospice RN had called and informed her that the Hospice MD felt as though resident 40 had a cranial bleed and asked if they wanted to have her sent to the hospital for possible surgery. Resident 40's daughter stated, We just want to make her comfortable. On [DATE] at 2:49 PM, a telephone interview was conducted with the Hospice On Call RN. The Hospice On Call RN stated that she was the one who was called by the facility when they reported that resident 40 had fallen. The Hospice On Call RN stated that the call came in at 6:58 AM by RN 1. The Hospice On Call RN stated that she had not received a call from LPN 2 immediately following resident 40's fall. The Hospice On Call RN stated that she called resident 40's Hospice RN at 6:59 AM. 4. Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 3:00 PM, an interview was conducted with resident 11. Resident 11 stated that her physician ordered for her to have daily showers but there was not enough staff to shower her daily. Resident 11 stated that her skin will broke out with impetigo when she did not receive daily showers. Resident 11's medical record was reviewed from [DATE] through [DATE]. An admission Minimum (MDS) data set [DATE] revealed that resident 11 was totally dependent with 2 person assistance for bathing. The Care Area Assessment revealed that resident's Activities of Daily Living (ADLs) was to be care planned. There was no care plan for ADLs. A dermatologist visit dated [DATE] revealed, .Irritant contact [MEDICAL CONDITION].Recommended lukewarm bath/showers ,[DATE] minutes once per day. A form titled, .Health Care ADL Sheet. for [DATE] revealed, that resident 11 did not receive a shower on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 1:00 PM, an interview was conducted with the DON. The DON stated that resident 11 requested daily showers. The DON stated that resident 11 had not been provided daily showers. The DON stated that a shower book was implemented on [DATE] because residents' showers were being missed.

Based on observation, interview and record review it was determined, for 1 of 36 sample residents, that the facility did not ensure that a resident who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrated that they were unavoidable. Specifically, a resident who entered the facility with no documented pressure ulcers, developed a pressure ulcer six days after admission. Facility staff did not implement the wound care recommendations, ordered by a wound care physician, thus allowing the wound to become infected and larger in size. Resident identifier: 30 Findings include: Resident 30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/19/16, resident 30 was observed to be sitting in a recliner chair. Resident 30 was observed to have a heel shaped pillow over her left heel. Resident 30 was observed to have her right heel resting against the foot rest placed under her legs. Resident 30 was observed to be in the same position from 8:30 AM until 11:00 AM. No observations were made of staff repositioning resident 30. The heel foam boot remained over resident 30's left heel. On 9/20/16, resident 30 was observed with her right heel resting against the heel of her left foot. Resident 30 was observed to be in the same position from 8:30 AM until 11:00 AM. On 9/20/16 at approximately 1:30 PM, resident 30's spouse was interviewed. Resident 30's spouse stated that he had come to visit resident 30 on 9/19/16 around 2:00 PM and had noticed that the foam boot was on the wrong foot. Resident 30's spouse stated that resident 30 did not have a pressure ulcer when she entered the facility but had developed the pressure ulcer a few days after admission. Resident 30's spouse stated that the wound kept getting worse and that a facility nurse had approached him and told him to complain to administration about the wound so the wound orders would be changed and the wound could heal. Resident 30's spouse stated that he went to the Business Office Manager, in August, to complain about the wound getting worse. Resident 30's spouse stated that the facility just contacted him on 9/13/16 to let him know that they had changed the treatment plan for resident 30's wound. Resident 30's spouse further stated that he was not told on 9/13/16 that resident 30 had an infection in her wound. On 9/20/16 resident 30's medical record was reviewed. Review of the medical record revealed the following entries: a. 4/27/16: . Skin appears CDI (clean, dry, intact) throughout. No noted skin integrity issues upon admission, heels present with redness. b. 5/3/16: Patient had a shower this AM. Skin check was done and patient was noted to have a Stage 2 pressure sore on her right ball of foot. Site measures 4 cm (centimeters) X (by) 4 cm X 0.1 cm. On admission it was noted that patient had reddened heels, and precautions were not implemented at that time. Site was a blister over the heel, but opened up while clothing was being removed. After site opened there was a small amount of bleeding, but stopped quickly. Site was cleansed in the shower with soap and water, dried, and covered with [MEDICATION NAME] foam. Soft boot were applied to heels. c. 5/3/16: New orders per (name of physician), MD (Medical Doctor): Wound care to right ball of heel 1) Cleanse sit with dermal wound cleaner. 2) Apply skin prep around the site 3) Apply [MEDICATION NAME] foam to ball of foot 4) Change dressing daily. Add patient to wound care rounds. d. 5/11/16: Wound/Skin care provided: 1) Right Ball of Foot Measures 3.5 cm X 3.5 cm X 0.1 cm. Site has red granulated tissue, small amount of bleeding from the 7 o'clock position. Old dressing had moderate amount of dried drainage. Old bandage has been in place for approx. (approximately) 6 days. Site did have a malodorous smell when removed. However, site has no surrounding redness, no puss discharge, and no warmth around the site. Site was cleansed with NS (normal saline) and dried with sterile 4X4 gauze. Wound was covered with [MEDICATION NAME] foam. Soft boots were also applied to site. e. 6/8/16: Pt S/B (seen by) (name of physician), wound specialist for right medial heel wound, wound measures 3.5 X 5.2 X UTD (unable to determine), minimal amount of bloody drainage, no odor noted, eschar in place, N.O (new order) for hydrogel and boarder foam dressing daily. f. 7/30/16: Resident alert, wound care done to Right heel, Toe nails clipped per husband request. Wound staying unchanged, non healing. g. 8/21/16: Resident's heel right wound care given as ordered. Husband requesting changes be made to promote healing to wound. h. 9/13/16: (name of wound care doctor) into (sic) see resident this am for observation of wound to right inner heel area. Measurements of site as follows: 4.5 cm x 4.0 cm; noted center of wound site with presence of slough, necrotic appearing tissue present. Odor noted upon removal of previous dressing per (name of wound care doctor). Sharp debridement completed of wound bed per (name of wound care doctor) as noted. New order noted from (name of wound care doctor) as follows: Clean wound with 10% (percent) Dakins solution for 10-15 minutes than apply Santyl/Alginate dressing. Dressing change to be done daily. Begin [MEDICATION NAME] 875 mg (milligrams) PO (by mouth) BID (twice daily) for 14 days. i. 9/16/16: . Wound dressing changed; wound is not improving. j. 9/17/16: . Day shift nurse did report that wound does not appear to be healing. Review of the medical record revealed an admission Minimum Data Set (MDS) assessment dated [DATE]. Facility staff assessed resident 30 as having one stage 2 pressure ulcer that was not present upon admission to the facility. Additionally, facility staff indicated on the MDS that the treatment for [REDACTED]. No other treatments were indicated on the MDS. The Care Area Assessment for pressure ulcers was triggered and facility staff indicated that the area of pressure ulcers would be care planned. Review of resident 30's care plans revealed that facility staff did not initiate a care plan for resident 30's pressure ulcer. On 5/4/16, facility staff completed a Braden Scale for Predicting Pressure Sore Risk for resident 30. Facility staff assessed resident 30 as being At Risk for developing a pressure ulcer. According to documentation, resident 30 had already developed the pressure ulcer when the Braden Scale was completed. Review of the Progress Notes made by the Wound Care doctor revealed the following Wound Orders made after treating and assessing resident 30: a. 6/8/16: Cleanse wound with cleanser, Apply Hydrogel to wound bed, Cover wound with Bordered Foam, Change daily, Change PRN (as needed) for soiling and/or saturation. Follow Facility Pressure Ulcer Prevention Policy/Protocol, Offload heels per Facility Policy/Protocol. Plan of care discussed with Facility Staff. b. 6/29/16: Cleanse wound with: - 10 % Dakin's soaked gauze for 10 minutes, Apply Alginate to wound bed, Apply to wound bed: - [MEDICATION NAME], Cover wound with Bordered Foam, Change daily, Change PRN for soiling and/or saturation. Follow Facility Pressure Ulcer Prevention Policy/Protocol, Offload heels per Facility Policy/Protocol. Plan of Care discussed with Facility Staff. c. 7/12/16: Cleanse wound with: - 10 % Dakin's soaked gauze for 10 minutes, Apply Alginate to wound bed, Apply to wound bed: - [MEDICATION NAME], Cover with Bordered Foam, Change daily, Change PRN for soiling and/or saturation. Follow Facility Pressure Ulcer Prevention Policy/Protocol, Offload heels per Facility Policy/Protocol. Plan of Care discussed with Facility Staff. d. 7/26/16: Cleanse wound with: - 10 % Dakin's soaked gauze for 10 minutes, Protect periwound with: - [MEDICATION NAME] or Dermaseptin, Apply Hydrogel to wound bed, Cover wound with Bordered Foam, Change daily. Offload heels per Facility Policy/Protocol. Plan of Care discussed with Facility Staff. e. 8/2/16: Cleanse wound with: - 10 % Dakin's soaked gauze for 10 minutes, Protect periwound with: - [MEDICATION NAME] or Dermaseptin, Apply Hydrogel to wound bed, Cover wound with Bordered Foam, Change daily. Offload heels per Facility Policy/Protocol. Plan of Care discussed with Facility Staff. f. 8/9/16: Cleanse wound with: - 10 % Dakin's soaked gauze for 10 minutes, Protect periwound with: - [MEDICATION NAME] or Dermaseptin, Apply Hydrogel to wound bed, Cover wound with Bordered Foam, Change daily. Offload heels per Facility Policy/Protocol. Plan of Care discussed with Facility Staff. g. 8/16/16: Cleanse wound with: - 10 % Dakin's soaked gauze for 10 minutes, Protect periwound with: - [MEDICATION NAME] or Dermaseptin, Apply Hydrogel to wound bed, Cover wound with Bordered Foam, Change daily. Offload heels per Facility Policy/Protocol. Plan of Care discussed with Facility Staff. h. 8/23/16: Cleanse wound with: - 10 % Dakin's soaked gauze for 10 minutes, Protect periwound with: - [MEDICATION NAME] or Dermaseptin, Apply Santyl to wound bed, Cover wound with Bordered Foam, Change daily. Offload heels per Facility Policy/Protocol - Pillow under calves. Plan of Care discussed with Facility Staff. i. 9/13/16: Cleanse wound with: - 10 % Dakin's soaked gauze for 10 minutes, Protect periwound with: - [MEDICATION NAME] or Dermaseptin, Apply Santyl to wound bed, Cover wound with Bordered Foam, Change daily. Offload heels per Facility Policy/Protocol - Pillow under calves. Antibiotic: - [MEDICATION NAME] 875 mg. PO, BID for 14 days. Plan of Care discussed with Facility Staff. Review of the physician's orders [REDACTED]. 1. 5/2/16: Apply skin prep to both heels BID for protection, one time a day. 2. 6/8/16: Cleanse right medial heel with normal saline and apply hydrogel to wound and cover with border foam dressing daily one time a day for wound care. 3. 6/10/16: Cleanse right medial heel with normal saline and apply hydrogel to wound and cover with border foam dressing daily one time a day for wound care. 4. 7/1/16: Cleanse R (right) heel with wound cleanser, apply layer of [MEDICATION NAME], cover with alginate then secure with foam boardered (sic) dressing one time a day for Wound. 5. 8/1/16: Cleanse R medial heel with wound cleanser apply [MEDICATION NAME] or selonsilver, cover with bordered dressing. Change daily one time a day for Wound. 6. 8/3/16: Cleanse R medial heel with wound cleanser apply [MEDICATION NAME] or selonsilver, cover with calcium alginate then bordered gauze dressing. Change daily one time a day. 7. 8/16/16: Cleanse R medial heel with wound cleanser apply [MEDICATION NAME] or selonsilver, apply collagen, cover with calcium alginate then bordered gauze dressing. Change daily one time a day. 8. 8/23/16: Apply thin layer of Santyl topically, followed by bordered foam dressing. Change dressing daily one time a day. (Note: The physician's orders [REDACTED].) On 9/26/16, the facility Director of Nursing (DON) was interviewed. The DON stated that she had coded the MDS wrong in May and that the facility had actually been providing more treatment for [REDACTED]. The DON further stated that the wound care doctor had been treating resident 30 for her pressure ulcer since about June. The DON stated that the facility did not always institute his orders because some of the staff did not like using the Dakins solution that he ordered. The DON stated that the facility would use something other than the Dakins solution to cleanse resident 30's pressure ulcer. The DON stated that even though the wound care doctor had been ordering that since June, the facility staff had just started using the Dakins.

Based on observation, interview, and record review it was determined that based on the comprehensive assessment of a resident, the facility must ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and prevent further decrease in range of motion for 1 of 36 sample residents. Specifically, facility staff discontinued restorative nursing services for a resident that had decreased range of motion. The resident continued to have decreased range of motion to both hands. Resident identifier: 45. Findings include: Resident 45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/13/16 at 8:30 AM, an observation was made of resident 45. Resident 45 was observed to have both hands contracted. On 9/19/16 at 10:15 AM, an interview was conducted with the facility Director of Nursing (DON). The DON stated that resident 45's hands were contracted but he refused therapy. Resident 45's medical record was reviewed on 9/19/16. An annual Minimum (MDS) data set [DATE] revealed that resident 45 had impairment to both upper extremities. A care plan initiated on 6/25/15 and revised on 4/5/16 revealed the following problem, (Resident 45) has an ADL (activities of daily living) self-care performance deficit r/t (related to) limited mobility, . There were no goals developed. One of the interventions developed for resident 45 were, . Nursing Rehab/Restorative: Splint/brace program #1 RNA (Restorative Nursing Assistant) program - apply splints to bilateral hand contractures and leave in place for 2 hours as tolerated (times) 6-7 days per week. A physician order [REDACTED]. There were no RNA notes in resident 45's medical record. Facility staff provided forms titled, Restorative care Plan that were dated March and April 2016. The form revealed that resident 45 had a treatment_Plan: RNA Program - apply splints to bilateral hands contractures and leave in place for 2 hours as tolerated 6-7 days a week. Another Treatment_Plan: RNA Program - Res (resident) to have PROM to bilateral hands (secondary to) contractures 15 minutes (times) 6-7 days a week. A Nursing_Evaluation: 4/4/15 - Resident had splints applied x (times) 4 this week to both hands from RNA. Resident tolerates Splints on 2 hrs each day.4/11/16 - Resident had splints applied to both hands x 4 this week from RNA, tolerates 2 hours on each day.4/18/16 Resident had splints applied x 4 this week to both hands from RNA. Tolerates 2 hours on each day. 4/23/16 - Dc'd (discontinued) Restorative Program 4/22/16. On 9/22/16 at 9:15 AM, an interview was conducted with RNA 1. RNA 1 stated that resident 45 received RNA services about 5 months ago for help with eating lunch before other residents lunch because he constantly asked for lunch after breakfast. RNA 1 stated that resident 45 refused services so the services were discontinued. RNA 1 further stated that resident 45 refused splints for his hands. On 9/26/16 at 9:35 AM, a follow up interview was conducted with RNA 1. RNA 1 stated that resident 45 had a decrease in range of motion to his hands since having RNA services discontinued. RNA 1 stated that resident 45 did the RNA program about 4 days a week prior to being discharged . RNA 1 stated she did not know why the RNA services were discontinued. On 9/26/16 at 10:09 AM, an interview was conducted with the Physical Therapy Assistant (PTA). The PTA stated that he was the director of the therapy department. The PTA stated that contractures were only measured when there was a physicians order. The PTA stated that resident 45 did not have a physician order [REDACTED]. The PTA stated that resident 45 refused to work with the Physical Therapist (PT). The PTA stated that he did not know why resident 45 was discontinued from services when the documentation revealed that resident 45 was accepting RNA services 4 times per week. On 9/26/16 at 10:05 AM, an interview and observation was made with the Assistant Director of Nursing (ADON). The ADON stated that she had not observed resident 45's contractures. The ADON further stated that the contractures were not measured. The ADON was observed to approach resident 45 and take his hand gently. Resident 45 was observed to allow the ADON to try and open his hand. Resident 45 stated Ouch when the ADON attempted to open his left hand. Resident 45 continued to allow the ADON to open and close his hand as much as it would open.

Based on observation, interview and medical record review it was determined for 2 of 36 sample residents, that the facility did not ensure that residents maintained acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrated that this was not possible. Specifically, a tube fed resident experienced a 21.8 % total loss of his body weight in a 60 day period after not receiving the physician ordered feeding due to product availability and was evaluated by the Registered Dietitian once during the 60 day time frame. Additionally, a resident, who was observed to be missing her bottom dentures, experienced a 5 % loss of her body weight with no dietary interventions. Resident identifiers: 19 and 25. Findings include: 1. Resident 19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/13/16 resident 19's medical record was reviewed. Review of the medical record revealed the following documented weights: a. 7/1/16: 128 pounds b. 7/28/16: 129 pounds c. 8/4/16: 119 pounds d. 8/8/16: 112 pounds e. 8/15/16: 115 pounds f. 8/25/16: 113 pounds g. 9/1/16: 100 pounds Review of the weights revealed that resident 19 experienced at 7.75% weight loss in 7 days (7/28/16 - 8/4/16), a 13% weight loss in 11 days (7/28/16 - 8/8/16) and a 22% weight loss in approximately 34 days. Review of the Dietary progress notes revealed the following entries: a. 7/28/2016 12:02 Nutrition/Dietary Note Note Text: Wt (weight) = 127.4# (pounds) (7-20-2016), gradual weight gain trend desired from 123# on 4-18-2016; BMI (Body Mass Index) now at 19.4 (Resident 19) is now NPO (nothing by mouth) (r/t (related to) dysphagia) with PEG (Percutaneous Endoscopic Gastrostomy) tube feedings of [MEDICATION NAME] 1.5, 300 ml (milliliters) bolus feeds QID (four times a day) with 100 ml water flush before/after each bolus feed QID. This schedule provides: 1200 ml formula, 1800 calories, 82 grams protein, > (greater than) 1800 ml total free-water, 128% RDI's (Recommended Daily Intake) for vitamins and minerals per day. He tolerates bolus feedings well. He pulled PEG feeding tube 7-26-2016; tube replaced. Enteral feeding provides 31 kcal/kg/day (kilocalories/kilogram/day)and 1.4 grams protein/kg/day. PEG tube site and small open area to left upper leg (r/t friction to side of w/c (wheel chair)), both with tx (treatment); skin otherwise,intact. No new labs Present nutritional support remains appropriate and meets 100% of estimated nutrient needs. b. 8/11/2016 10:19 Weight Change Note Note Text: RD (Registered Dietitian) note: Wt loss noted. NPO status started 7/14. Recently admitted to hospice. Wt: 111.4 (8/8/16.). Represents 13% loss x 30 days, 10.7% loss x 90 days, 10% loss x 180 days. BMI: 16.9 ALb ([MEDICATION NAME]) 3.1 Usual wt: 125 lbs. TF (Tube feed) order: 300 ml bolus feed of [MEDICATION NAME] 1.5 via TF QID. Flush with 100 ml H2O (water) before and after feeding. Additional water order 200 ml QID. Order to start liquid vitamin when obtained noted. A/P (Assessment and Plan): Wt loss of sig (significant) amt (amount), recommend increasing TF to support wt stability and comfort. Give 400 ml [MEDICATION NAME] 1.5 QID. Give 300 ml H2O QID. Feeding will provide >100% DRI (Dietary Reference Intake) for key micronutritents. Liquid vitamin can be discontinued. Feeding will provide TV (Total Volume) of 1600 ml and provide 2400 kcal (48 kcal/kg), 109 g (grams) pro (protein) (2.2 g/kg), 1222 ml H2O. Feeding plus water flush will provide total of 2422 ml fluid (48 ml/kg) Will follow. No other documentation could be found to show that the facility RD reassessed resident 19 or made adjustments to resident 19's tube feed despite resident 19's continued weight loss. Review of the facility's Policy and Procedure for Weight Assessment and Intervention revealed the following: Policy Statement The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Policy Interpretation and Implementation Weight Assessment . 3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. 4. The Dietitian will respond within 24 hours of receipt of written notification. 5. The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for 'significant' weight change has been met. No documentation could be found to show that the facility RD was notified of the continued weight loss. Review of the Progress Notes revealed the following entries: a. 8/21/2016 13:04 Orders - Administration Note Note Text: Enteral Feed Order four times a day Give 400mL bolus feed of [MEDICATION NAME] 1.5 QID per feeding tube. Give 300mL H2O Flush QID, HOB (head of bed) up 30* (degrees) during feedings. Gave FiberSource per new order until [MEDICATION NAME] 1.5 is available. b. 8/28/2016 16:18 Orders - Administration Note Note Text: Enteral Feed Order four times a day Give 400mL bolus feed of [MEDICATION NAME] 1.5 QID per feeding tube. Give 300mL H2O Flush QID, HOB up 30* during feedings. hold pending [MEDICATION NAME] delivery c. 8/29/2016 07:05 Orders - Administration Note Note Text: Enteral Feed Order four times a day Give 400mL bolus feed of [MEDICATION NAME] 1.5 QID per feeding tube. Give 300mL H2O Flush QID, HOB up 30* during feedings. Pending delivery d. 8/29/2016 14:32 Orders - Administration Note Note Text: Enteral Feed Order four times a day Give 400mL bolus feed of [MEDICATION NAME] 1.5 QID per feeding tube. Give 300mL H2O Flush QID, HOB up 30* during feedings. Duplicate order; pending delivery of [MEDICATION NAME] e. 8/29/2016 16:17 Orders - Administration Note Note Text: Enteral Feed Order four times a day Give 400mL bolus feed of [MEDICATION NAME] 1.5 QID per feeding tube. Give 300mL H2O Flush QID, HOB up 30* during feedings. Duplicate order; pending delivery f. 8/30/2016 00:36 Orders - Administration Note Note Text: Enteral Feed Order four times a day Give 400mL bolus feed of [MEDICATION NAME] 1.5 QID per feeding tube. Give 300mL H2O Flush QID, HOB up 30* during feedings. 400ml Diabetisource given. g. 8/30/2016 07:20 Orders - Administration Note Note Text: Enteral Feed Order four times a day Give FiberSource 400mL QID via feeding tube (until [MEDICATION NAME] 1.5 is available). Flush QID with 300mL water. HOB up 30* during feedings Duplicate order; [MEDICATION NAME] delivered this shift It should be noted that resident 19 received no Enteral nutrition from 8/28/16 at approximately 4:00 PM until 8/30/16 at midnight. Resident 19 went 32 hours with no food. No documentation could be found to show that resident 19 received the water that was ordered and being administered with the food. On 9/27/16, the facility Corporate Administrator (CA) was interviewed. The CA stated that if the facility did not have a resident's physician ordered tube feeding, the facility should contact the doctor and collaborate with the RD to get an order to give the resident a different tube feed that was similar in value until the ordered product could be delivered. The CA stated that there was not reason for a resident to go without some sort of food. The CA stated that the company that delivered the tube feed product was only 30 minutes from the facility and the ordered product should have been delivered within a couple of hours. The CA was not able to provide information to explain why resident 19 went 32 hours without food. 2. Resident 25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations of resident 25 on 9/13/16 - 9/27/16 revealed that resident 25 was missing her bottom dentures. On 9/22/16, resident 25 was interviewed. Resident 25 stated that she had been missing her bottom dentures for awhile and that she had not been able to eat much do to her not having her bottom dentures. Resident 25 stated, I need my bottom dentures to eat, honey! Resident 25 further stated that she had reported the missing dentures to staff. On 9/22/16, resident 25's medical record was reviewed. Review of the medical record revealed a significant change Minimum Data Set (MDS) assessment dated [DATE]. Facility staff assessed resident 25 as having no issues or concerns with her teeth. Review of the facility documented weights revealed the following: a. 5/7/16: 136 pounds b. 6/1/16: 132 pounds c. 7/1/16: 133 pounds d. 8/15/16: 126 pounds e. 9/1/16: 128 pounds Review of the weights revealed that resident 25 experienced a 5.26 % weight loss in approximately 30 days. No documentation could be found to show that the facility RD evaluated resident 25 for the weight loss. Review of the physician orders [REDACTED]. Additionally, the orders revealed that resident 25 was receiving a fortified regular diet with a regular consistency. Review of the dental list provided by the facility revealed that resident 25 had not been seen by the dentist. Review of the dietary notes in the electronic medical record revealed that the last dietary note made by the RD was in June 2015. On 9/22/16 at 10:40 AM, Registered Nurse (RN) 4 was interviewed. RN 4 stated that she was not aware that resident 25 was missing her bottom dentures. On 9/22/16 at 10:45 AM, Certified Nursing Assistant (CNA) 6 was interviewed. CNA 6 stated that she had been working at the facility for 3 weeks and that she knew that resident 25 had been missing her bottom dentures. On 9/22/16 at 11:00 AM, CNA 7 was interviewed. CNA 7 stated that she had been working at the facility for 4 years and as a CNA since May of 2016. CNA 7 stated that she had provided care to resident 25 on 9/21/16. CNA 7 stated that she had not noticed that resident 25 was missing her bottom dentures. CNA 7 further stated that if resident 25 was missing an item, she always lets the staff know. On 9/26/16 at 9:00 AM, the facility CA was interviewed. The CA stated that residents who had lost 5 % of their body weight should have their meal percentage tracked. The CA stated that the facility did not track meal consumption percentage on every resident, only residents at risk were tracked. No documentation could be found to show that facility staff were tracking resident 25's meal consumption percentage.

Based on interview and medical record review, it was determined, for 2 of 36 sample residents, that the facility did not ensure that residents were free of any significant medication errors. Specifically, two resident did not have pain medications available per physician's orders [REDACTED]. Findings include: 1. Resident 73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 9:13 AM, an interview was conducted with resident 73. Resident 73 stated that he is in a lot of pain. Resident 73 stated that he wakes up about 3:00 AM in pain. Resident 73 stated that he would turn on his call light to ask for pain medications, but his call light doesn't get answered for about two hours, then I get told that they are doing report and can't bring my pain medications. Resident 73 stated that his pain medications took a long time to come in from the pharmacy and that his pain had gotten so out of control that he got pretty angry with staff and didn't want to be around anyone. On [DATE], resident 73's medical record was reviewed. A nurses note dated [DATE] at 1908 (7:08 PM) revealed, .he (resident 73) complains of chronic pain; phantom, teeth and [MEDICAL CONDITION] Pain level: 9 sharp and constant; phantom limb, [MEDICAL CONDITION], teeth and chronic pain. (NOTE: Pain levels were based on a pain scale from ,[DATE] with 1 being the least amount of pain and 10 being the greatest pain with the pain medication given.) A nurses note dated [DATE] at 1731 (5:31 PM) revealed, that resident 73 had .C/O (complains of) chronic throbbing pain throughout. Phantom pain in left lower extremity . Resident 73's medication orders from the hospital revealed an order for [REDACTED]. On [DATE] at 2:43 PM, an interview was conducted with the facility DON (Director of Nursing). The facility DON stated that resident 73 was admitted to the facility on [DATE] just one day prior to her going on vacation. The DON stated that the medication list from the hospital was considered to be physician's orders [REDACTED]. The DON stated that she would look into why the [MEDICATION NAME] was missed upon transcription to the physician's orders [REDACTED]. On [DATE], resident 73's medical record was again reviewed. Resident 73's physician's orders [REDACTED]. A nurses note dated [DATE] at 1831 (6:31 PM) revealed .Resident agitated because PRN [MEDICATION NAME] had not be (sic) delivered from pharmacy. Pharmacy carified (sic) that it was 5 days too early to refill resident's prescription. Administrator approved to bill facility instead of insurance. [MEDICATION NAME] was delivered at aprox (approximately) 1630 (4:30 PM) . A pharmacy services delivery sheet revealed that resident 73's [MEDICATION NAME] 10 mg and [MEDICATION NAME] ER 15 mg had been delivered on [DATE] at approximately 4:30 PM. ( It should be noted here that resident 73's MAR indicated [REDACTED]. On [DATE] at 3:30 PM, a follow up interview was conducted with the DON. The DON stated that the medication was not missed, but, instead, had to be clarified with the facility MD (Medical Doctor) so they could get a hard copy of a prescription. (It should be noted here that no hard copy of a prescription for [MEDICATION NAME] ER 15 mg BID could be located in the medical record, other than the physician orders [REDACTED].) No documentation could be located in the medical record to show that resident 73's physician had been notified of the need to clarify the [MEDICATION NAME] order upon admission. 2. Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On [DATE] resident 22's medical record was reviewed. Review of the medical record revealed the following entries: a. [DATE] 16:51 (4:51 PM) Admission Summary Note Text: pt (patient) readmitted to room [ROOM NUMBER] this afternoon following hospitalization at (name of local acute care hospital) hospital for fluid overload r/t (related to) [MEDICAL TREATMENT], SOB (shortness of breath), pleural effusion, ascities, end stage [MEDICAL CONDITION], pt AxOX3 (alert and oriented times three) forgetful at times, skin warm and dry, flaky skin to extremities, [MEDICAL TREATMENT] fistula to left arm intact, dressing in place, no bleeding noted, several bruises on arms from hospital IV (intravenous) sites, no [MEDICAL CONDITION] noted at present, abdomen obese, BS (bowel sounds) x 4 (in all four quadrants) present, reports minimal generalized discomfort at present, v/s (vital signs) stable, pt oriented to room and facility, MD notified of patients return to facility, no complaints at present, will continue to monitor b. [DATE] 17:58 (5:58 PM) Orders - Administration Note Note Text: [MEDICATION NAME] HCl ([MEDICATION NAME]) Tablet 5 MG Give 5 mg by mouth four times a day for Pain Pain in legs, stomach cramps; ,[DATE] c. [DATE] 02:28 (2:28 AM) Orders - Administration Note Note Text: [MEDICATION NAME] Tablet 30 MG Give 30 mg by mouth two times a day for Pain resident readmitted from hospital this afternoon. Arrived with new medication order for [MEDICATION NAME] 30 mg PO (by mouth). Report was given to night shift that medication would be in pharmacy delivery this evening. Medication was not delivered this evening. Medication not present in E-kit (Emergency Kit) to be pulled. Resident passed away before after hours pharmacist could provide delivery details No documentation could be found to show that facility staff reassessed resident 22 after the administration of the [MEDICATION NAME] to determine the effectiveness of the pain medication. According to documentation, resident 22 expired before staff could administer the physician ordered [MEDICATION NAME] for pain.

Based on observation, interview, and record review it was determined, for 1 of 36 sample residents, that the facility did not provide or promptly refer a resident with lost or damaged dentures to a dentist. Specifically, a resident who was missing bottom dentures was unable to eat the regular diet provided and experienced a 5% (percent) loss of her body weight. Resident identifier: 25. Findings include: Resident 25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations of resident 25 on 9/13/16 - 9/27/16 revealed that resident 25 was missing her bottom dentures. On 9/22/16, resident 25 was interviewed. Resident 25 stated that she had been missing her bottom dentures for a while and that she had not been able to eat much due to missing her bottom dentures. Resident 25 stated, I need my bottom dentures to eat, honey! Resident 25 further stated that she had reported the missing dentures to staff. On 9/22/16, resident 25's medical record was reviewed. Review of the medical record revealed a significant change Minimum Data Set (MDS) assessment dated [DATE]. Facility staff assessed resident 25 as having no issues or concerns with her teeth. Review of the facility documented weights revealed the following: a. 5/7/16: 136 pounds b. 6/1/16: 132 pounds c. 7/1/16: 133 pounds d. 8/15/16: 126 pounds e. 9/1/16: 128 pounds Review of the weights revealed that resident 25 experienced a 5.26 % weight loss in approximately 30 days. No documentation could be found to show that the facility Registered Dietitian (RD) evaluated resident 25 for the weight loss. Review of the physician's orders [REDACTED]. Additionally, the orders revealed that resident 25 was receiving a fortified regular diet with a regular consistency. Review of the dental list provided by the facility revealed that resident 25 had not been seen by the facility dentist. Review of the dietary notes in the electronic medical record revealed that the last dietary note made by the RD was in June 2015. On 9/22/16 at 10: 40 AM, Registered Nurse (RN) 4 was interviewed. RN 4 stated that she was not aware that resident 25 was missing her bottom dentures. On 9/22/16 at 10:45 AM, Certified Nursing Assistant (CNA) 6 was interviewed. CNA 6 stated that she had been working at the facility for 3 weeks and that she knew that resident 25 had been missing her bottom dentures. On 9/22/16 at 11:00 AM, CNA 7 was interviewed. CNA 7 stated that she had been working at the facility for 4 years and as a CNA since May of 2016. CNA 7 stated that she had provided care to resident 25 on 9/21/16. CNA 7 stated that she had not noticed that resident 25 was missing her bottom dentures. CNA 7 further stated that if resident 25 was missing an item, she always lets the staff know. On 9/26/16 at 9:00 AM, the facility CA was interviewed. The CA stated that residents who had lost 5 % of their body weight should have their meal percentage tracked. The CA stated that the facility did not track meal consumption percentage on every resident, only residents at risk for nutrition problems were tracked. No documentation could be found to show that facility staff were tracking resident 25's meal consumption percentage.

Based on observation, interview and record review, it was determined the facility did not provide necessary care and services to attain or maintain the highest practical physical, mental and psychosocial well-being for 6 of 49 sample residents. Specifically, residents were not appropriately assessed for pain management effectiveness. The deficient practice for residents 60, 88, 89 and 93 was cited at the scope and severity of a pattern of harm. Resident identifiers: 15, 60, 83, 88, 89 and 93. Findings include: HARM: 1. Resident 93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/2/16 at 8:50 AM, Licensed Practical Nurse (LPN) 2 stated that resident 93 was admitted yesterday and that his medications had not been delivered from the pharmacy yet and that she would have to pull his medications from the emergency kit. On 2/2/16 at 10:20 AM, resident 93 was standing at the nurses station asking for his pain medication. Resident 93 was told that the pain medication had not been delivered from the pharmacy yet. On 2/2/16 at 10:45 AM, LPN 2 was observed while preparing and administering medications to resident 93. Resident 93 was told that the ordered [MEDICATION NAME] had not been delivered from the pharmacy yet. Resident 93 stated that his pain was at a 10 on a scale of 1-10 and that he was unable to sleep. Resident 93 stated, I need it bad. I'm going through detox and withdraws. Resident 93 stated that he had been without any pain medications for 15-18 hours. Resident 93 stated, I'm chilled and going through withdraws. Resident 93's medical record was reviewed on 2/8/16. Review of the admission orders [REDACTED]. On 2/1/16 at 3:30 PM, a facility LPN documented, Resident transferred to facility . New orders for [MEDICATION NAME] and [MEDICATION NAME] this shift. On 2/2/16 at 4:45 AM, a facility LPN documented, .Resident's medications arrived from pharmacy tonight, with the exception of his [MEDICATION NAME] for pain management. Upon calling pharmacy, this nurse was told that resident's [MEDICATION NAME] order cannot be processed, as it cannot be crushed and given through an NG tube. MD (Medical Doctor) notified and gave new orders for [MEDICATION NAME] and [MEDICATION NAME]. Scripts faxed to pharmacy with a STAT (immediate) delivery request. Resident's reported pain level is a 10/10 at this time. On 2/2/16 at 3:30 AM, an order was received to D/C (discontinue) [MEDICATION NAME]; cannot be crushed. [MEDICATION NAME] 0.5 mg via NG tube 4Xdays (four times a day) for anxiety. [MEDICATION NAME] 10/325 mg via NG tube 4Xday for pain. On 2/2/16 at 10:45 AM, LPN 2 contacted the contracted pharmacy. LPN 2 stated that the pharmacy was unable to fill the [MEDICATION NAME] and [MEDICATION NAME] orders, or give a code to get the [MEDICATION NAME] and [MEDICATION NAME] out of the emergency kit because the physician had not signed the order yet. On 2/2/16 at 2:00 PM, LPN 2 stated that resident 93's [MEDICATION NAME] and [MEDICATION NAME] had arrived from the pharmacy and that she had just administered the medications. (Note: Resident 93 waited over 23 hours the ordered pain medications to be administered.) On 2/9/16 the facility Director of Nursing (DON) was interviewed. The DON acknowledged that the facility staff had not administered resident 93's pain medication appropriately. 2. Resident 88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/3/16 at 10:30 AM, an interview was conducted with resident 88. Resident 88 stated that he was at a 10 on the pain scale at all times and that despite being on multiple pain medications, he did not feel his pain was being adequately controlled. Resident 88 stated that the scheduled medications were not reducing his pain, and that he was not prescribed anything for breakthrough pain. In addition, resident 88 stated that he was receiving a muscle relaxer every 4 hours at his previous facility, but that the current facility physician was not prescribing enough of the muscle relaxer to control his muscle spasms. Resident 88 stated that he had not been getting out of bed because the pain was so intense. Resident 88 stated that he mostly tried to sleep, because it's the only way I get relief from the pain. Resident 88 stated that he was discouraged because of the pain as he felt it was getting in the way of his recovery, and ultimately the ability to move back to his home state with his family. Resident 88's medical record was reviewed on 2/2/16. Review of resident 88's History and Physical dated 1/6/16 indicated that resident 88 had had his foley catheter positioned in his urethra and was experiencing abdominal pain. On 1/9/16 facility staff completed a pain evaluation for resident 88 which indicated that his pain was at a 7. Facility staff documented that resident 88 reported relief from his chronic pain fom repositioning and medication. The facility staff member did not complete the other sections of the form, such as the effect the pain was having on resident 88's daily life. On 1/9/16 facility staff completed a pain interview for resident 88 which indicated that the resident was in pain almost constantly. Resident 88 indicated that the pain had made it hard for him to sleep in the past 5 days, and had also limited his day-to-day activities in the last 5 days. Resident 88's January 2016 Medication Administration Record (MAR) was reviewed. Resident 88's MAR indicated that his pain level was to be monitored every shift. However, the MAR did not indicate what his pain level was, in order to determine if appropriate pain management was occurring. Facility staff did document a pain level on the MAR when a pain medication was administered. The MAR indicated that when resident 88 was administered pain medications, he reported his pain level between a 5 and a 10. Resident 88's February 2016 MAR was reviewed and indicated that from 2/1/16 to the morning of 2/8/16, when resident 88 was administered pain medications, he reported his pain level between a 6 and a 10. MAR progress notes indicated that when a pain medication was administered it was effective, however, many times no follow up pain score was documented, and no indication was made as to how the determination that the pain medication was effective was made. In addition, on 1/10/16, 2/1/16 and 2/7/16, facility staff documented on the MAR progress notes that the pain medication was ineffective, however no progress notes could be located to indicate what facility staff had done about the resident's pain, including contacting resident 88's physician. Review of resident 88's progress notes revealed the following: a) On 1/11/16 - (resident 88) has complained about being awakened for medication stating, 'I don't hurt when I am asleep.' . b) On 1/13/16 - . complains of 9 or 10/10 pain all the time, pain medications barely provide relief outside of taking the edge off. c) On 1/14/16 - resident 88 admitted , in part, for Pain management. d) On 1/15/16 - IDT (InterDisciplinary Team) meeting held yesterday with (resident 88). said pain is still an issue. e) On 1/19/16 - . He has been having break through pain and expressed a desire to have his pain medication closer together. f) On 2/2/16 - resident 88 did not receive wound care for his pressure sores because he was in too much pain. On 2/9/16 an interview was conducted with the DON. The DON stated that she had spoken with the medical director, who stated that she did not believe resident 88 was really experiencing the pain level he was reporting. 3. Resident 89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/2/16 at 9:15 AM, an interview was conducted with resident 89. Resident 89 stated that the facility nurses were not evaluating his pain appropriately. Resident 89 stated that he was at an 8.5 on the pain scale most of the time. Resident 89 stated that when he was in the hospital prior to admission at this facility, he was being offered pain medication such as [MEDICATION NAME]. Resident 89 stated that the only pain medication available to him at the facility was Tylenol, which provided no relief. Resident 89 then stated that he had started to refuse the Tylenol because he felt it was negatively affecting his liver. Resident 89 also stated that because of his pain level, he often refused to participate in physical therapy. Resident 89's medical record was reviewed on 2/2/16. On 1/23/16 facility staff completed a pain tool for resident 89, which indicated that resident 89 was experiencing pain at a 7 on the pain scale. Facility staff documented that resident 89's pain was relieved by [MEDICATION NAME] pain pills. Facility staff documented that resident 89's pain was worsened by walking and moving too much. The pain tool also indicated that resident 89's pain was interfering with his sleep/rest, social activities, physical activity and mobility, and emotions. Resident 89's MAR indicated that his pain level was to be monitored every shift. However, the MAR did not indicate what his pain level was, in order to determine if appropriate pain management was occurring. Review of resident 89's physician orders [REDACTED]. Resident 89's January and February 2016 MARs were reviewed. The MAR indicated that resident 89 did not receive any pain medication on 1/23/16, the day of his admission. The MAR also indicated that when [MEDICATION NAME] was administered, resident 89 reported his pain level between a 6 and an 8. MAR progress notes indicated that when a pain medication was administered it was effective, however, many times no follow up pain score was documented, and no indication was made as to how the determination that the pain medication was effective was made. Review of resident 89's progress notes revealed the following: a) On 1/23/16 - . Resident arrived with no narcotic pain medicine prescriptions, but is adamant about receiving them. MD was telephoned, and refused to provide a pain medication prescription because the resident is not planning on admitting or staying here in the facility. [MEDICATION NAME] was provided for neuro-pain, which he does have an order for [REDACTED]. b) On 1/31/16 - resident 89 admitted , in part, for Pain management. On 2/9/16 an interview was conducted with the DON. The DON stated that she had spoken with the medical director, who stated that she was titrating resident 88's [MEDICATION NAME], and so she did not want to give him a narcotic. The DON stated that the medical director felt like the residents just have an audience with the state and that is why they are complaining of pain. 4. Resident 60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/2/16 at 9:14 AM, an interview was conducted with resident 60. Resident 60 reported she had discomfort or pain with no relief. Resident 60 reported she had pain in her neck and left leg which was not always controlled with pain medication. Resident 60's medical record was reviewed on 2/8/16. On 1/11/16 at 5:11 PM, the licensed nursing staff documented administration of a PRN (as needed) pain medication [MEDICATION NAME] to resident 60. The staff documented resident 60's pain level was 8/10 at the time the [MEDICATION NAME] was administered. On 1/11/16 at 10:48 PM, the licensed nursing staff documented resident 60's follow up pain assessment for the administration of the PRN pain medication [MEDICATION NAME]. The staff documented the pain medication was effective. There was not a pain scale documented for the follow up pain assessment to determine how effective the PRN pain medication was. On 1/12/16 at 5:43 PM, the licensed nursing staff documented administration of a PRN pain medication [MEDICATION NAME] to resident 60. The staff documented resident 60's pain level was 8/10 at the time the [MEDICATION NAME] was administered. On 1/12/16 at 9:01 PM, the licensed nursing staff documented resident 60's follow up pain assessment for the administration of [MEDICATION NAME]. The staff documented resident 60's pain medication was effective and the follow up pain score was 8/10. On 1/14/16 at 9:45 AM, the licensed nursing staff documented administration of a PRN pain medication [MEDICATION NAME] to resident 60. The staff documented resident 60's pain level was 9/10 at the time the [MEDICATION NAME] was administered. On 1/14/16 at 1:51 PM, the licensed nursing staff documented resident 60's follow up pain assessment for the administration of [MEDICATION NAME]. The staff documented resident 60's pain medication was effective and the follow up pain score was 7/10. On 1/15/16 at 8:37 AM, the licensed nursing staff documented administration of a PRN pain medication [MEDICATION NAME] to resident 60. The staff documented resident 60's pain level was 9/10 at the time the [MEDICATION NAME] was administered. On 1/15/16 at 1:44 PM, the licensed nursing staff documented resident 60's follow up pain assessment for the administration of [MEDICATION NAME]. The staff documented resident 60's pain medication was effective and the follow up pain score was 7/10. On 1/16/16 at 7:02 AM, the licensed nursing staff documented administration of a PRN pain medication [MEDICATION NAME] to resident 60. The staff documented resident 60's pain level was 10/10 and Pt (patient) complains of severe pain. On 1/16/16 at 7:09 AM, the licensed nursing staff documented resident 60's follow up pain assessment for the administration of the PRN pain medication [MEDICATION NAME]. The staff documented the pain medication was effective. There was not a pain scale documented for the follow up pain assessment to determine how effective the PRN pain medication was. On 1/17/16 at 3:05 PM, the licensed nursing staff documented administration of a PRN pain medication [MEDICATION NAME] to resident 60. The staff documented resident 60's pain level was 8/10. On 1/17/16 at 5:19 PM, the licensed nursing staff documented resident 60's follow up pain assessment for the administration of the PRN pain medication [MEDICATION NAME]. The staff documented the pain medication was effective. There was not a pain scale documented for the follow up pain assessment to determine how effective the PRN pain medication was. On 1/18/16 at 8:26 AM, the licensed nursing staff documented administration of a PRN pain medication [MEDICATION NAME] to resident 60. The staff documented resident 60's pain level was 9/10. On 1/18/16 at 2:12 PM, the licensed nursing staff documented resident 60's follow up pain assessment for the administration of the PRN pain medication [MEDICATION NAME]. The staff documented the pain medication was effective. There was not a pain scale documented for the follow up pain assessment to determine how effective the PRN pain medication was. On 1/19/16 at 1:25 PM, the licensed nursing staff documented administration of a PRN pain medication [MEDICATION NAME] to resident 60. The staff documented resident 60's pain level was 5/10. On 1/19/16 at 7:02 PM, the licensed nursing staff documented resident 60's follow up pain assessment for the administration of the PRN pain medication [MEDICATION NAME]. The staff documented the pain medication was effective. There was not a pain scale documented for the follow up pain assessment to determine how effective the PRN pain medication was. On 1/21/16 at 7:59 AM, the licensed nursing staff documented administration of a PRN pain medication [MEDICATION NAME] to resident 60. The staff documented resident 60's pain level was 8/10. On 1/21/16 at 7:19 PM, the licensed nursing staff documented resident 60's follow up pain assessment for the administration of the PRN pain medication [MEDICATION NAME]. The staff documented the pain medication was effective. There was not a pain scale documented for the follow up pain assessment to determine how effective the PRN pain medication was. On 1/22/16 at 2:20 PM, the licensed nursing staff documented administration of a PRN pain medication of [MEDICATION NAME] to resident 60. The staff documented resident 60's pain level was 10/10. On 1/22/16 at 4:49 PM, the licensed nursing staff documented resident 60's follow up pain assessment for the administration of the PRN pain medication [MEDICATION NAME]. The staff documented the pain medication was effective and resident 60's pain level was 7/10. On 1/24/16 at 5:52 AM, the licensed nursing staff documented administration of a PRN pain medication [MEDICATION NAME] to resident 60. The staff documented resident 60's pain level was 8/10. On 1/24/16 at 10:45 AM, the licensed nursing staff documented resident 60's follow up pain assessment for the administration of the PRN pain medication [MEDICATION NAME]. The staff documented the pain medication was effective. There was not a pain scale documented for the follow up pain assessment to determine how effective the PRN pain medication was. On 1/26/16 at 2:49 PM, the licensed nursing staff documented administration of a PRN pain medication [MEDICATION NAME] to resident 60. The staff documented resident 60's pain level was 9/10. On 1/26/16 at 3:01 PM, the licensed nursing staff documented resident 60's follow up pain assessment for the administration of the PRN pain medication [MEDICATION NAME]. The staff documented the pain medication was effective. There was not a pain scale documented for the follow up pain assessment to determine how effective the PRN pain medication was. On 1/27/16 at 4:11 PM, the licensed nursing staff documented administration of a PRN pain medication [MEDICATION NAME] to resident 60. The staff documented resident 60's pain level was 8/10. On 1/27/16 at 10:48 PM, the licensed nursing staff documented resident 60's follow up pain assessment for the administration of the PRN pain medication [MEDICATION NAME]. The staff documented the pain medication was effective. There was not a pain scale documented for the follow up pain assessment to determine how effective the PRN pain medication was. On 1/29/16 at 12:25 PM, the licensed nursing staff documented administration of a PRN pain medication [MEDICATION NAME] to resident 60. The staff documented resident 60's pain level was 8/10. On 1/29/16 at 2:21 PM, the licensed nursing staff documented resident 60's follow up pain assessment for the administration of the PRN pain medication [MEDICATION NAME]. The staff documented the pain medication was effective. There was not a pain scale documented for the follow up pain assessment to determine how effective the PRN pain medication was. On 1/30/16 at 11:08 AM, the licensed nursing staff documented administration of a PRN pain medication [MEDICATION NAME] to resident 60. The staff documented resident 60's pain level was 7/10. On 1/30/16 at 2:21 PM, the licensed nursing staff documented resident 60's follow up pain assessment for the administration of the PRN pain medication [MEDICATION NAME]. The staff documented the pain medication was effective. There was not a pain scale documented for the follow up pain assessment to determine how effective the PRN pain medication was. On 1/30/16 at 9:15 PM, the licensed nursing staff documented administration of a PRN pain medication [MEDICATION NAME] to resident 60. The staff documented resident 60's pain level was 10/10. On 1/31/16 at 12:07 AM, the licensed nursing staff documented resident 60's follow up pain assessment for the administration of the PRN pain medication [MEDICATION NAME]. The staff documented the pain medication was effective. There was not a pain scale documented for the follow up pain assessment to determine how effective the PRN pain medication was. On 1/31/16 at 5:37 AM, the licensed nursing staff documented administration of a PRN pain medication [MEDICATION NAME] to resident 60. The staff documented resident 60's pain level was 6/10. On 1/31/16 at 3:16 PM, the licensed nursing staff documented administration of a PRN pain medication [MEDICATION NAME] to resident 60. The staff documented resident 60's pain level was 7/10. On 1/31/16 at 3:16 PM, the licensed nursing staff documented administration of a PRN pain medication [MEDICATION NAME] to resident 60. The staff documented resident 60's pain level was 8/10. On 2/1/16 at 1:34 AM, the licensed nursing staff documented resident 60's follow up pain assessment for the administration of the PRN pain medication [MEDICATION NAME]. The staff documented the pain medication was effective. There was not a pain scale documented for the follow up pain assessment to determine how effective the PRN pain medication was. On 2/1/16 at 4:50 AM, the licensed nursing staff documented administration of a PRN pain medication [MEDICATION NAME] to resident 60. The staff documented resident 60's pain level was 9/10. On 2/1/16 at 9:41 AM, the licensed nursing staff documented resident 60's follow up pain assessment for the administration of the PRN pain medication [MEDICATION NAME]. The staff documented the pain medication was effective and resident 60's pain level was 7/10. On 2/3/16 at 9:07 AM, the licensed nursing staff documented administration of a PRN pain medication [MEDICATION NAME] to resident 60. The staff documented resident 60's pain level was 8/10. On 2/3/16 at 4:16 PM, the licensed nursing staff documented resident 60's follow up pain assessment for the administration of the PRN pain medication [MEDICATION NAME]. The staff documented the pain medication was effective and resident 60's pain level was 7/10. On 2/8/16 at 2:56 PM, the licensed nursing staff documented administration of a PRN pain medication [MEDICATION NAME] to resident 60. The staff documented resident 60's pain level was 7-8/10. On 2/8/16 at 11:20 PM, the licensed nursing staff documented resident 60's follow up pain assessment for the administration of the PRN pain medication [MEDICATION NAME]. The staff documented the pain medication was effective. There was not a pain scale documented for the follow up pain assessment to determine how effective the PRN pain medication was. No documentation could be located to indicate resident 60's physician was notified, or that the pain medication was ever adjusted or increased for improved pain management during the dates listed above. On 2/9/16 at 2:05 PM, an interview was conducted with resident 60. Resident 60 reported her pain level goal was about 5 or 6. Resident 60 reported her medications were not effective enough to control her pain level. On 2/9/16 at 2:30 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 reported each resident was supposed to have a pain goal on their pain assessment which was done on admission and quarterly. RN 1 was unable to locate documentation of a pain goal for resident 60. (Cross refer F279 and F329) POTENTIAL FOR HARM: 5. Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/1/16 at 5:10 PM, an interview was conducted with resident 15. Resident 15 reported that she had discomfort or pain with no relief. Resident 15 described pain as generalized with muscle spasms, which was not controlled with her current pain regimen. Resident 15's medical record was reviewed on 2/2/16. Review of the physician's orders [REDACTED]. a) 12/9/15: [MEDICATION NAME] 5 mg po q 4-6 hours PRN pain. b) 1/26/16: [MEDICATION NAME] 5 mg. Give 5 mg by mouth every six hours as needed for pain c) 12/7/15: [MEDICATION NAME] ([MEDICATION NAME]) tablet 10 mg give 10 mg by mouth three time a day for pain. d) 12/9/15: [MEDICATION NAME] tablet 10 mg by mouth every 8 hours for [DIAGNOSES REDACTED] e) 12/9/15: [MEDICATION NAME] tablet 5 mg. Give 5 mg by mouth every six hours as needed for severe muscle spasms .PRN [MEDICATION NAME] is only to be given for severe spasms, when the scheduled [MEDICATION NAME] 10 mg dose is not effective. Resident 15's December 2015 MAR from 12/2/15 to 12/8/15 revealed that resident 15 received 11 doses of [MEDICATION NAME] 15 mg. The licensed nursing staff documented resident 15's pain level was 5/10 to 10/10 at the time the [MEDICATION NAME] was administered. The licensed staff documented that pain medication was effective. There was not a pain scale documented for the follow up pain assessment to determine how effective the PRN pain medication was. Resident 15's December MAR, from 12/10/15 to 12/31/15 revealed that resident 15 received 65 doses of [MEDICATION NAME] 5 mg. The licensed nursing staff documented resident 15's pain level was 0/10 once; 5/10 three times; 6/10 ten times; 7/10 sixteen times; 8/10 twenty six times; 9/10 three times and 10/10 seven times, at the time the [MEDICATION NAME] was administered. The licensed staff documented that pain medication was effective. There was not a pain scale documented for the follow up pain assessment to determine how effective the PRN pain medication was. Resident 15's January 2016 MAR, from 1/1/16 to 1/26/16 revealed that resident 15 received 72 doses of [MEDICATION NAME] 5 mg. The licensed nursing staff documented resident 15's pain level was 6/10 to 10/10, at the time the [MEDICATION NAME] was administered. The licensed staff documented that pain medication was effective. There was not a pain scale documented for the follow up pain assessment to determine how effective the PRN pain medication was. Resident 15's January 2016 MAR, from 1/26/16 to 1/31/16 revealed that resident 15 received 13 doses of [MEDICATION NAME] 5 mg. The licensed nursing staff documented resident 15's pain level was 5/10 to 10/10, at the time the [MEDICATION NAME] was administered. The licensed staff documented that pain medication was effective. There was not a pain scale documented for the follow up pain assessment to determine how effective the PRN pain medication was. Resident 15's February 2016 MAR, from 2/1/16 to 2/6/16 revealed that resident 15 received 18 doses of [MEDICATION NAME] 5 mg. The licensed nursing staff documented resident 15's pain level was 5/10 once; 7/10 twice; 8/10 thirteen times; 9/10 once; and 10/10 once, at the time the [MEDICATION NAME] was administered. The licensed staff documented that pain medication was effective. There was not a pain scale documented for the follow up pain assessment to determine how effective the PRN pain medication was. Resident 15's January 2016 MAR revealed that resident 15 received the [MEDICATION NAME] 5 mg PRN every six hours, 58 times. The licensed staff documented that pain medication was effective except for one entry that was documented as unknown. There was not a pain scale documented for the follow up pain assessment to determine how effective the PRN medication for pain/[DIAGNOSES REDACTED] was. Resident 15's February MAR, from 2/1/16 to 2/8/16 revealed that resident 15 received the [MEDICATION NAME] 5 mg PRN every six hours, 26 times. The licensed staff documented that the pain medication was effective 24 times and ineffective twice. There was not a pain scale documented for the follow up pain assessment to determine how effective the PRN medication for pain/ [DIAGNOSES REDACTED] was. Review of resident 15's care plan related to pain revealed, The resident has chronic pain r/t (related to) chronic physical disability and [DIAGNOSES REDACTED] with muscle rigidity and spasms emotional distress with anxiety and [MEDICAL CONDITION]. The goals developed included, The resident will verbalize adequate relief of pain or ability to cope with incomplete relieved pain through the review date and The resident will voice a level of comfort of 4/10 through the review date. The interventions developed to achieve the goals included, The resident's pain is alleviated/relieved by [MEDICATION NAME] and [MEDICATION NAME] for spasms Calm and no s/s (signs or symptoms) anxiety will help keep pain levels down. On 1/9/16 at 10:30 AM an interview was conducted with RN 1. RN 1 stated that she did not know why resident 15's pain medication had been decreased and that the resident reported high pain levels most of the time. No documentation could be located to indicate resident 15's pain medication was adjusted for improved pain management during the dates listed above. There was no documentation in the progress notes documenting additional pain levels.

Based on observation, interview and record review it was determined that for 1 of 49 sample residents from developing pressure sores while in the facility. Specifically, interventions were not implemented to prevent the development of a pressure sore and interventions were not implemented which resulted in the pressure sore getting worse. Resident identifier: 83. Findings include: Resident 83 was admitted to facility on 12/4/15 with [DIAGNOSES REDACTED]. On 2/1/16 at approximately 4:00 PM, resident 83 was observed to be sitting in her wheelchair. Resident 83 did not have a pressure relieving cushion in place. On 2/3/16 at 2:25 PM, Registered Nurse (RN) 1 was interviewed. RN 1 stated that resident 83 had two pressure ulcers on the back portion of her thighs. RN 1 stated, The wheelchair doesn't fit her properly. Resident 83's medical record was reviewed on 2/2/16. Resident 83's Admission Minimum Data Set (MDS) assessment dated [DATE] was reviewed. The facility staff assessed resident 83 as not having pressure sores but was at risk for developing pressure sores. The facility staff assessed resident 83 as requiring extensive assistance with a one person physical assist for mobility and transfers. A Care Area Assessment (CAA) triggered for pressure sores. The facility staff documented that the care area would be addressed in a care plan. A care plan dated 12/4/15 revealed that resident 83 was at risk for developing skin breakdown due to incontinence and decreased mobility. There were no documented goals or interventions developed to prevent resident 83 from developing skin breakdown. Review of the physician's orders [REDACTED]. a) 12/18/15: OT (Occupational Therapy): seating and positioning eval (evaluation) -Posterior thighs rub on WC (wheelchair) seat- evaluate for cushion and/seating. b) 1/1/16: Daily wound care to sore on back of right thigh. Clean with wound cleaner, apply [MEDICATION NAME] ointment, foam padding and bordered 4x4 bandage. Change daily and PRN (as needed) is (sic) dressing becomes soiled or is accidentally removed until resolved. c) 1/11/16: Wound care: Right thigh inner (excoriation). Remove old dressing-cleanse with normal saline-apply border gauze dressing for protection. Change three times week and prn, every 24 hours as needed'. Review of the therapy evaluations completed revealed that resident 83 had not been evaluated by the OT. On 2/3/15 at 2:40 PM, RN 1 was interviewed. RN 1 stated that resident 83 was not evaluated by the OT. RN 1 stated that the PTA (physical therapy assistant) screened resident 83 and ordered a cushion her wheelchair. On 2/4/16 at approximately 2:45 PM, resident 83's wounds were observed. There were two open wounds on the posterior right thigh consistent with pressure ulcers from the wheelchair. Review of the weekly skin monitoring charting revealed the following: a) 12/21/15: The Interim Director of Nursing (DON) documented that resident 83 had one stage II pressure ulcer on the right posterior thigh that measured 2.0 cm(centimeter) X 1.5 cm. The ADON documented that the pressure ulcer was in-house acquired and that a pressure relieving cushion was being used. b) 12/28/15: The interim DON documented that resident 83 had one stage II pressure ulcer on the right posterior thigh that measured 2.0 cm X 1.5 cm X 0.1 and that a wheelchair cushion was being used. c) 1/3/16 through 1/9/16: The interim DON documented that resident 83 had one stage II pressure ulcer on the right posterior thigh that measured 1.1 cm X 1.0 cm X 0.1 and one stage II pressure ulcer on the inner aspect of the right thigh that measured 0.3 cm X 0.5 cm and that a wheelchair cushion was being used. d) 1/12/16: The interim DON documented that resident 83 had one stage II pressure ulcer on the right posterior thigh that measured 0.75 cm X 1.5 cm and one stage II pressure ulcer on inner aspect of the right thigh that measured 0.5 cm X 0.5 cm and that no pressure relieving device was being used. Additionally, the interim DON documented that no nutritional interventions had been implemented e) 1/21/16: The interim DON documented that resident 83 had one stage II pressure ulcer on the right posterior thigh that measured 1.7 cm X 1.3 cm and one stage II pressure ulcer on inner aspect of the right thigh that measured 0.7 cm X 0.7 cm and that no pressure relieving device was being used. Additionally, the interim DON documented that no nutritional interventions had been implemented. (Note: Both pressure ulcers increased in size.) On 2/10/16 at 10:30 AM, RN 1 was observed while sheremoved the soiled dressings on resident 83's thighs. After removing the old dressing on resident 83's poster right thigh and inner thigh the wounds appeared to be open. RN 1 stated, This is not the right dressing, this wound is larger and is getting worse. RN 1 stated that the wound measured 3 cm in diameter and connected with the other pressure ulcer. Additionally, resident 83 had another pressure ulcer on the left thigh that measured 1 cm in diameter.

Based on interview, observation, and record review it was determined that the facility failed to maintain a quality assessment and assurance committee that develops and implements appropriate plans of action to correct identified quality deficiencies. Specifically, pressure sores developed and worsened in the facility, significant medication errors occurred, residents did not have an adequate pain management system, and residents with behaviors did not have a behavior management plan in place. This failure resulted in a finding of harm for residents (60, 83, 88, 89, and 93). Resident identifiers: 15, 51, 60, 83, 88, 89 and 93. Findings include: 1. The facility quality assessment and assurance committee failed to ensure that residents received the necessary care and services to attain or maintain the highest practical physical, mental and psychosocial well-being. Specifically, residents were not appropriately assessed for pain management effectiveness. The deficient practice for residents 60, 88, 89 and 93 was cited at the scope and severity of a pattern of harm. Resident identifiers: 15, 60, 83, 88, 89 and 93. (Cross refer to F309) 2. The facility quality assessment and assurance committee failed to ensure that interventions were implemented to prevent the development of a pressure sore, and which resulted in the pressure sore getting worse. The deficient practice for resident 83 was cited at the scope and severity of harm. Resident identifier: 83. (Cross refer to F314) 3. The facility quality assessment and assurance committee failed to ensure that residents were free from significant medication errors. Specifically, pain medications and antianxiety medications were not available for administration. The deficient practice for residents 89 and 93 were cited at the level of harm. Resident identifiers: 51, 89 and 93. (Cross refer to F333) 4. The facility quality assessment and assurance committee failed to provide adequate supervision to prevent accidents. Specifically, multiple resident altercations were observed or documented without a subsequent behavior management plan being implemented, thus putting residents at risk for harm. Resident identifers: 12, 52 and 20. (Cross refer to F323) 5. The facility quality assessment and assurance committee failed to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being the residents. Specifically, residents with behaviors that presented a danger to themselves or others were not placed on appropriate behavior management programs. Resident identifiers: 12, 44, 52, 60, 17, 23, 85 and 26. (Cross refer to F250) 6. The facility administration failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain or attain the highest practicable physical, mental, and psychosocial well-being of each resident. The deficient practice was cited during the previous recertification survey of September 2015, as well as an abbreviated complaint survey conducted in December 2015. During both previous surveys harm was cited. (Cross refer to F490)

Based on interview, observation, and record review it was determined that the facility failed to be administered in a manner that enabled it to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, pressure sores developed and worsened in the facility, significant medication errors occurred, residents did not have an adequate pain management system, and residents with behaviors did not have a behavior management plan in place. This failure resulted in a finding of harm for residents (60, 83, 88, 89, and 93). Resident identifiers: 15, 51, 60, 83, 88, 89 and 93. Findings include: 1. The facility administration failed to ensure that residents received the necessary care and services to attain or maintain the highest practical physical, mental and psychosocial well-being. Specifically, residents were not appropriately assessed for pain management effectiveness. The deficient practice for residents 60, 88, 89 and 93 was cited at the scope and severity of a pattern of harm. Resident identifiers: 15, 60, 83, 88, 89 and 93. (Cross refer to F309) 2. The facility administration failed to ensure that interventions were implemented to prevent the development of a pressure sore, and which resulted in the pressure sore getting worse. The deficient practice for resident 83 was cited at the scope and severity of harm. Resident identifier: 83. (Cross refer to F314) 3. The facility administration failed to ensure that residents were free from significant medication errors. Specifically, pain medications and antianxiety medications were not available for administration. The deficient practice for residents 89 and 93 were cited at the level of harm. Resident identifiers: 51, 89 and 93. (Cross refer to F333) 4. The facility administration failed to provide adequate supervision to prevent accidents. Specifically, multiple resident altercations were observed or documented without a subsequent behavior management plan being implemented, thus putting residents at risk for harm. Resident identifers: 12, 52 and 20. (Cross refer to F323) 5. The facility administration failed to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being the residents. Specifically, residents with behaviors that presented a danger to themselves or others were not placed on appropriate behavior management programs. Resident identifiers: 12, 44, 52, 60, 17, 23, 85 and 26. (Cross refer to F250) 6. The facility administration failed to maintain a quality assessment and assurance committee that identified quality of care concerns and implemented plans of action to correct the identified concerns. The deficient practice was cited during the previous recertification survey of September 2015 as well as an abbreviated complaint survey conducted in December 2015. During both previous surveys harm was cited. (Cross refer to F520)

Based on observation, interview and record review, it was determined the facility did not ensure that residents were free from significant medication errors for 3 of 49 sample residents. Specifically, pain medications and antianxiety medications were not available for administration; and a blood thinning medication was not administered as ordered. The deficient practice for residents 89 and 93 were cited at the level of harm. Resident identifiers: 51, 89 and 93. Findings include: 1. Resident 93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/2/16 at 8:50 AM, Licensed Practical Nurse (LPN) 2 stated that resident 93 was admitted yesterday and that his medications had not been delivered from the pharmacy yet and that she would have to pull his medications from the emergency kit. On 2/2/16 at 10:20 AM, resident 93 was standing at the nurses station asking for his pain medication. Resident 93 was told that the pain medication had not been delivered from the pharmacy yet. On 2/2/16 at 10:45 AM, LPN 2 was observed while preparing and administering medications to resident 93. Resident 93 was told that the ordered [MEDICATION NAME] had not been delivered from the pharmacy yet. Resident 93 stated that his pain was at a 10 on a scale of 1-10 and that he was unable to sleep. Resident 93 stated, I need it bad. I'm going through detox and withdraw. Resident 93 stated that he had been without any pain medications for 15-18 hours now. Resident 93 stated, I'm chilled and going through withdraws. Resident 93's medical record was reviewed on 2/8/16. Review of the admission orders [REDACTED]. On 2/1/16 at 3:30 PM, a facility Licensed Practical Nurse (LPN) documented, Resident transferred to facility . New orders for [MEDICATION NAME] and [MEDICATION NAME] this shift. On 2/2/16 at 4:45 AM, a facility Licensed Practical Nurse (LPN) documented, .Resident's medications arrived from pharmacy tonight, with the exception of his [MEDICATION NAME] for pain management. Upon calling pharmacy, this nurse was told that resident's [MEDICATION NAME] order cannot be processed, as it cannot be crushed and given through an NG tube. MD (Medical Doctor) notified and gave new orders for [MEDICATION NAME] and [MEDICATION NAME]. Scripts faxed to pharmacy with a STAT (immediate) delivery request. Resident's reported pain level is a 10/10 at this time. On 2/2/16 at 3:30 AM, an order was received to D/C (discontinue) [MEDICATION NAME]; cannot be crushed. [MEDICATION NAME] 0.5 mg via NG tube 4Xdays (four times a day) for anxiety. [MEDICATION NAME] 10/325 mg via NG tube 4Xday for pain. On 2/2/16 at 10:45 AM, LPN 2 contacted the contracted pharmacy. LPN 2 stated that the pharmacy was unable to fill the [MEDICATION NAME] and [MEDICATION NAME] orders, or give a code to get the [MEDICATION NAME] and [MEDICATION NAME] out of the emergency kit because the physician had not signed the order yet. On 2/2/16 at 2:00 PM, LPN 2 stated that resident 93's [MEDICATION NAME] and [MEDICATION NAME] had arrived from the pharmacy and that she had just administered the medications. (Note: Resident 93 waited over 23 hours the ordered pain medications to be administered.) 2. Resident 51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 51's medical record was reviewed on 2/9/16. a. On 1/20/16, a International Normalized Ratio (INR) was obtained on resident 51. The INR returned low at 1.48 (normal range 2.0 - 3.0). On 1/21/6, a new order was received to increase the [MEDICATION NAME] to 2.5 mg daily. Review of the January 2016 Medication Administration Record [REDACTED]. b. On 1/27/16, an INR was obtained for resident 51. The INR returned low at 1.49. On 1/28/16 a new order was receive to administer [MEDICATION NAME] 2.5 mg daily. (Note: Resident 51 was previously receiving [MEDICATION NAME] 2.5 mg daily.) Review of the January 2016 MAR indicated [REDACTED]. c. On 2/3/16, an INR was obtained for resident 51. The INR returned low at 1.68. On 2/4/16 a new order was received to administer [MEDICATION NAME] 3 mg daily. (Note: The order was received a day after the laboratory value was obtained.) Review of the February 2016 MAR indicated [REDACTED]. On 2/9/16 at approximately 10:00 AM, the facility Director of Nursing (DON) was interviewed. The DON stated that the [MEDICATION NAME] should have been administered the day the order was received. 3. Resident 89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 89's medical record was reviewed on 2/2/16. Review of resident 89's physician orders [REDACTED]. Resident 89's February MAR indicated [REDACTED]. Review of resident 89's progress notes revealed the following: a) On 2/3/16 at 9:51 AM - The [MEDICATION NAME] was not adminstered because the [MEDICATION NAME] is not here, the rx (prescription) is not signed. b) On 2/3/16 at 11:54 AM - The [MEDICATION NAME] was not administered because there was not a signed prescription from the physician. c) On 2/3/16 at 3:41 PM - The [MEDICATION NAME] was not administered because there was not a signed prescription from the physician. d) On 2/6/16 at 12:18 PM - The [MEDICATION NAME] was not administered because Hold pending signed script (prescription). On 2/6/16 at 4:31 PM - The [MEDICATION NAME] was not administered because Hold pending signed script. On 2/9/16 at 1:00 PM an interview was conducted with RN 1. RN 1 stated that she had entered the information for resident 89's [MEDICATION NAME] prescription on 1/31/16, but couldn't do anything because the pharmacy had called multiple times to contact the doctor, but the doctor wasn't responding . we can only do so much. RN 1 presented the bubble pack containing resident 89's [MEDICATION NAME]. The bubble pack indicated that 45 pills were sent, and 4 were gone, indicating that resident 89 was administered three pills on 2/8/16 and one morning dose on 2/9/16. On 2/9/16 an interview was conducted with the facility Director of Nursing (DON). The DON stated that if the nurses were reporting to surveyors that they could not pull [MEDICATION NAME] from the e-kit until the prescription was signed, then that was incorrect information. The DON stated that if the nurses were not being provided the code for the e-kit, then she would contact the pharmacy for clarification. (Cross refer to F501)

Based on interview and record review, it was determined, for 1 of 8 residents, that the facility did not ensure that residents were free of significant medication errors. Specifically, a resident received the wrong dosage of [MEDICATION NAME] resulting in the resident being hospitalized . Resident identifier: 1 Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/3/15 at 8:11 AM, an interview was conducted with Resident 1. Resident 1 stated that he was hospitalized shortly after admission to the facility. Resident 1 was hospitalized for [REDACTED]. A review of Resident 1' s medical record revealed the following orders: On 11/19/15, the facility Medical Director (MD) wrote an order to administer [MEDICATION NAME] Solution 20 mg/ml (milligrams per milliliter). give 5 mg by mouth three times a day for dyspnia/pain. Give 0.25 cc (cubic centimeter). On 12/07/15 the narcotic records for resident 1's [MEDICATION NAME] sulfate were reviewed and revealed that Registered Nurse (RN) 1 documented administering 0.5 cc to resident 1 at 8:00 AM and 2:30 PM. (Note: RN 1 administered twice the ordered dose of [MEDICATION NAME] sulfate.) On 11/20/15 at 8:45 PM, licensed practical nurse (LPN) 5 documented, At 1630 (4:30 PM) nurse entered resident's room to introduce self and provide 1700 (5:00 PM) medications. Resident appeared lethargic, resting supine in bed with eyes closed. Unable to wake resident by speaking to (him), and gently rubbing arm. Resident appeared as though (he) needed rest and was given (his) privacy at this time. (his) skin color appeared normal, respirations clear. At 2000 (8:00 PM) a CNA (certified nursing assistant) alerted the nurse that resident had increased secretions and was still not waking to eat dinner, or responding to verbal stimuli. Resident was then assessed by nurse. Increased secretions noted. Head immediately elevated and oral cleaning done by nurse to clear away secretions. Airway was effectively opened, no suctioning needed. Breathing rate had increased to 26 resps/min (respirations per minute). Oxygen therapy started via nasal cannula @2L (at 2 liters). Resident is normally continent, and had urinated in bed at this point. CNAs assisted with cleaning and changing resident. Physician was immediately called, and responded right away. Orders were received to give 0.8 mg [MEDICATION NAME] IM (intramuscularly) for decreased LOC (level of consciousness) and to call 911 to be sent to ER (emergency room ). Residents vital signs were taken; BP (blood pressure) 98/62, temp (temperature) 98.5, pulse 76, respirations 26. Oxygen saturation levels were attempted on fingers and toes. Unable to obtain SPO2 (oxygen) level before paramedics arrived. Resident has thick fingernail polish. Resident appeared diaphoretic although temperature was trending normal. No noted discoloration or cyanosis in lips. Skin color remained normal throughout. Oral secretions continued until resident left with paramedics. DON (Director of Nursing) notified, family (sister) was notified and spoken to by phone. Physician spoken with (sic) multiple times throughout incident. Paramedics arrived at 2010 (8:10 PM), ten minutes after symptoms had been discovered by nurse. Left facility at 2020 (8:20 PM) via stretcher. Orders entered into MAR (medication administration record). 72 hour alert charting updated for resident's decrease in LOC. (Local Hospital) ER (emergency room ) telephoned by DON to provide report. Physician again notified of resident's transport to hospital. Resident's sister also updated as to location of ER visit. Will continue to monitor health status of resident. On 12/3/15 at 2:46 PM an interview was conducted with the DON. The DON stated around 7:00 PM on 11/20/15 she was notified by RN 1 that Resident 1 had been given too much [MEDICATION NAME]. RN 1 admitted to giving .5 ml of [MEDICATION NAME] instead of .25 ml of [MEDICATION NAME] for the morning and noon dose. LPN 5 then informed the DON that the count was off when they did the count at 6:00 PM. On 12/3/15 at 11:02 AM, RN 1 was interviewed. RN 1 stated resident 1 was dressed and at the nurses station prior to the beginning of her shift on 11/20/15. RN 1 stated that she was notified by the CNAs that resident 1 was lethargic and was not going to eat her lunch on 11/20/15. RN 1 stated that she went to assess resident 1 at approximately 2:00 PM and to administer his [MEDICATION NAME] sulfate as ordered. RN 1 stated that resident 1 was really tired, sat up slightly leaning on his elbows so that she could administer resident 1's [MEDICATION NAME] sulfate then fell straight back and did not verbally respond after that and appeared to sleep soundly. RN 1 stated that she checked on resident 1 again before the end of her shift and stated that resident 1 was just out. RN 1 stated at the end of her shift, at approximately 6:00 PM, she reported resident 1's status to LPN 5. The ER summary report for resident 1 dated 11/23/15 was reviewed. The hospital staff documented, .Diagnoses: [REDACTED]. 7) Toxic metabolic [MEDICAL CONDITION]. The history of present illness from the emergency room revealed: .I spoke with the nurse at Lomond Peak nursing and rehabilitation who stated that today changes (sic) shift there accounting (sic) the [MEDICATION NAME]. 6.5 ML's a (sic) [MEDICATION NAME] were missing. The patient should have received 0.75 cc of [MEDICATION NAME] total for the day, 5 mg 3 times a day, 0.25 ml. The Aid checked on the patient at 1945 (7:45 PM) on rounds and found the patient frothing at the mouth and unresponsive. The night nurse had received report that patient had been sleeping all day. Prior to this the patient had been awake and interactive. When they found the patient unresponsive and frothing at the mouth the (sic) elevated the head of the bed and administered oxygen. The patient had shallow breathing. He was given 0.8 mg of [MEDICATION NAME] without any response. This (sic) 911 was called and the patient was incontinent of urine and diaphoretic. His blood pressure was 119/40 54 his heart rate was 103 his temperature was 99.8.

Based on observation, interview and record review it was determined, for 1 of 8 sample residents, that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the plan of care. Specifically, staff failed to readily identify and follow up on a change of status in resident 1. Resident identifier: 1. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/19/15, the facility Medical Director (MD) wrote an order to administer [MEDICATION NAME] Solution 20 mg/ml (milligrams per milliliter). give 5 mg by mouth three times a day for dyspnia/pain. Give 0.25 cc (cubic centimeter). On 12/07/15 the narcotic records for resident 1's [MEDICATION NAME] sulfate were reviewed and revealed that Registered Nurse (RN) 1 documented administering 0.5 cc to resident 1 at 8:00 AM and 2:30 PM. (Note: RN 1 administered twice the ordered dose of [MEDICATION NAME] sulfate.) On 11/20/15 at 1:59 PM, a facility licensed nurse documented that resident 1's blood pressure was 115/98, significantly lower than resident 1's normal blood pressure of 137-142 systolic and 88-92 diastolic. On 11/20/15, between 5:47 PM and 5:49 PM, a facility nurse documented that resident 1 refused to take his [MEDICATION NAME], and [MEDICATION NAME]. RN 1 documented that resident 1 was sleeping and refused to get up to take his medication. On 11/20/15 at 8:45 PM, licensed practical nurse (LPN) 5 documented, At 1630 (4:30 PM) nurse entered resident's room to introduce self and provide 1700 (5:00 PM) medications. Resident appeared lethargic, resting supine in bed with eyes closed. Unable to wake resident by speaking to (him), and gently rubbing arm. Resident appeared as though (he) needed rest and was given (his) privacy at this time. (his) skin color appeared normal, respirations clear. At 2000 (8:00 PM) a CNA (certified nursing assistant) alerted the nurse that resident had increased secretions and was still not waking to eat dinner, or responding to verbal stimuli. Resident was then assessed by nurse. Increased secretions noted. Head immediately elevated and oral cleaning done by nurse to clear away secretions. Airway was effectively opened, no suctioning needed. Breathing rate had increased to 26 resps/min (respirations per minute). Oxygen therapy started via nasal cannula @2L (at 2 liters). Resident is normally continent, and had urinated in bed at this point. CNAs assisted with cleaning and changing resident. Physician was immediately called, and responded right away. Orders were received to give 0.8 mg [MEDICATION NAME] IM (intramuscularly) for decreased LOC (level of consciousness) and to call 911 to be sent to ER (emergency room ). Residents vital signs were taken; BP (blood pressure) 98/62, temp (temperature) 98.5, pulse 76, respirations 26. Oxygen saturation levels were attempted on fingers and toes. Unable to obtain SPO2 (oxygen) level before paramedics arrived. Resident has thick fingernail polish. Resident appeared diaphoretic although temperature was trending normal. No noted discoloration or cyanosis in lips. Skin color remained normal throughout. Oral secretions continued until resident left with paramedics. DON (Director of Nursing) notified, family (sister) was notified and spoken to by phone. Physician spoken with (sic) multiple times throughout incident. Paramedics arrived at 2010 (8:10 PM), ten minutes after symptoms had been discovered by nurse. Left facility at 2020 (8:20 PM) via stretcher. Orders entered into MAR (medication administration record). 72 hour alert charting updated for resident's decrease in LOC. (Local Hospital) ER (emergency room ) telephoned by DON to provide report. Physician again notified of resident's transport to hospital. Resident's sister also updated as to location of ER visit. Will continue to monitor health status of resident. The ER summary report for resident 1 dated 11/23/15 was reviewed. The hospital staff documented, .Diagnoses: [REDACTED]. 7) Toxic metabolic [MEDICAL CONDITION]. The history of present illness from the emergency room revealed: .I spoke with the nurse at Lomond Peak nursing and rehabilitation who stated that today changes (sic) shift there accounting (sic) the [MEDICATION NAME]. 6.5 ML's a (sic) [MEDICATION NAME] were missing. The patient should have received 0.75 cc of [MEDICATION NAME] total for the day, 5 mg 3 times a day, 0.25 ml. The Aid checked on the patient at 1945 (7:45 PM) on rounds and found the patient frothing at the mouth and unresponsive. The night nurse had received report that patient had been sleeping all day. Prior to this the patient had been awake and interactive. When they found the patient unresponsive and frothing at the mouth the (sic) elevated the head of the bed and administered oxygen. The patient had shallow breathing. He was given 0.8 mg of [MEDICATION NAME] without any response. This (sic) 911 was called and the patient was incontinent of urine and diaphoretic. His blood pressure was 119/40 54 his heart rate was 103 his temperature was 99.8. Review of the Medication Error Report completed on 11/20/15 by the DON indicated that resident 1 received 0.5 ml of [MEDICATION NAME] twice on 11/20/15. To correct the error the PM dose was held and vital signs were ordered for every 2 hours for the next 2 hours. On 12/3/15 at 11:02 AM, RN 1 was interviewed. RN 1 stated resident 1 was dressed and at the nurses station prior to the beginning of her shift on 11/20/15. RN 1 stated that she was notified by the CNAs that resident 1 was lethargic and was not going to eat her lunch on 11/20/15. RN 1 stated that she went to assess resident 1 at approximately 2:00 PM and to administer his [MEDICATION NAME] sulfate as ordered. RN 1 stated that resident 1 was really tired, sat up slightly leaning on his elbows so that she could administer resident 1's [MEDICATION NAME] sulfate then fell straight back and did not verbally respond after that and appeared to sleep soundly. RN 1 stated that she checked on resident 1 again before the end of her shift and stated that resident 1 was just out. RN 1 stated at the end of her shift, at approximately 6:00 PM, she reported resident 1's status to LPN 5. After RN 1 completed giving LPN 5 a verbal report, that she (RN 1) and LPN 5 conducted a narcotic count. RN 1 stated that when when they got to resident 1's [MEDICATION NAME] sulfate, the narcotic count was quite a bit off. RN 1 stated that she was not sure how the narcotic count was off. RN 1 stated that she then became aware that resident 1 had administered too much [MEDICATION NAME] to resident 1. RN 1 stated that resident 1 was reassessed by herself and LPN 5 went to check resident 1 out. RN 1 stated that resident 1 was sleeping soundly, snoring with no signs of respiratory distress. RN 1 stated that she then went home. RN 1 stated that at approximately 7:30 PM, she returned to the facility and informed the DON that she had given too much [MEDICATION NAME] sulfate to resident 1. (Note: RN1 reported the discrepency approximately an hour and a half after discovering the error.) RN 1 stated that the Medical Director (MD) was then notified of the medication error and gave orders to check on resident 1's vital signs every 2 days and to report any deviation of vital signs from resident 1's normal range. RN 1 stated that another narcotic count was conducted with the DON. RN 1 stated that it was then identified that there was a total of 6 ml's of [MEDICATION NAME] sulfate unaccounted for. RN 1 stated that the narcotic count was corrected with the DON and then she (RN 1) went home. RN 1 stated that she was not notified that resident 1 was hospitalized until 11/21/15. On 12/3/15 at 5:02 PM, LPN 5 was interviewed. LPN 5 stated he was the float nurse between 2:00 PM and 6:00 PM. LPN 5 stated that at approximately 4:00 PM, he attempted to administer medications to resident 1. LPN 5 stated that he was unable to wake resident 1 up and reported such to RN 1. At 6:00 PM, LPN 5 received report from RN 1. LPN 5 stated that during the narcotic count, he identified that resident 1's [MEDICATION NAME] sulfate was slightly off. LPN 5 stated that he went to check on resident 1 immediately after receiving report from RN 1. LPN 5 stated that resident 1 was just sleeping and didn't appear to be in any distress. LPN 5 stated that he was not alarmed about resident 1 until RN 1 retuned to the facility. LPN 5 stated that resident 1 was again checked on and resident 1 had excessive secretions from his mouth at which time the MD was notified. LPN 5 stated that orders were received to call 911 and to administer [MEDICATION NAME]. LPN 5 stated that [MEDICATION NAME] was immediately administered to resident 1 and then the emergency medical team (EMT) arrived. LPN 5 stated that the EMTs took over care of resident 1, administered another dose of [MEDICATION NAME] to resident 1, and transported resident 1 to the hospital. On 12/3/15 at 10:26 AM, LPN 3 was interviewed. LPN stated that on 11/20/15 she overheard LPN 5 and RN 1 discussing that resident 1's narcotic count was off. LPN 3 stated that several CNA's expressed their concern about resident not responding and sleeping soundly. LPN 3 stated that one of the CNA's stated, Why is no one doing anything? LPN 3 stated that she assessed resident 1 and found him nonresonsive to verbal and physical stimulae with frothy foam coming out of his mouth. LPN 3 stated that resident 1's blood pressure at that time was 98/62. LPN 3 stated that the MD was notified and gave orders to call 911 immediately and to administer [MEDICATION NAME] to resident 1. On 12/3/15 at 10:53 AM an interview was conducted with CNA 3. CNA 3 stated that resident 1 was always up and about in the facility. CNA 3 stated that he went into resident 1's room to collect his dinner tray. CNA 3 stated that resident 1 was sleeping, breathing heavily, and had foam around his mouth. CNA 3 stated that he reported resident 1's status to LPN3 and LPN 5. CNA 3 stated that he was told by CNA 2 that she (CNA 2) was unable to wake resident 1 earlier to get his dinner order On 12/3/15 at 12:12 PM an interview was conducted with CNA 2. CNA 2 stated that resident 1 had only been in the facility for a few days and that 11/20/15 was her first day working with resident 1. CNA 2 stated that the prior day, she had observed resident 1 independently exploring the facility in his electronic wheelchair. On 11/20/15, CNA 2 recalled that resident 1 had been sleeping all day, but that she (CNA 2) was not familar resident 1's daily routine. CNA 2 stated that she informed two facility nurses that resident 1 was not acting right, but stated that the nurses were not really concerned. CNA 2 stated that she was unable to get resident 1's dinner order because resident 1 kept falling asleep. CNA 2 stated that she believed that resident 1 had not eaten his lunch tray, but she was not certain. CNA 2 stated that on 11/20/15 at approximately 8:00 PM, she informed LPN 5 that resident 1 could not be aroused. On 12/3/15 at 1:30 PM an interview was conducted with CNA 1. CNA 1 stated that resident 1 was normally up in his electronic wheelchair and wandered around the facility throughout the day. CNA stated that on 11/20/15, resident 1 was acting normal, but around 2:00 PM, resident 1 was sleeping. On 12/3/15 at 2:46 PM an interview was conducted with the DON. The DON stated that she was notified about the medication error around 7:00 PM on 11/20/15. RN 1 had returned to the facility after giving her report and leaving. LPN 5 and RN 1 were having a conversation around the medication cart. LPN 5 and RN 1 called the DON over. RN 1 stated that she may have given resident 1 too much [MEDICATION NAME]. The DON reported that when asked to clarify how much, LPN 5 stated that the count was off, and it was off when they did the count at 6:00 PM. (Note: This conversation occurred approximately one and a half hours after the error was identified). The DON confirmed she would have expected her staff to notify her immediately that the count was off. The DON stated that the MD was then called to inform her of the error. LPN 5 reported to the MD that Resident 1 was sleeping, the MD then requested a full set of vitals every 2 hours for 12 hours. The DON recalled that she then corrected the count on the narcotics sheets. The DON recalled that Resident 1' s vitals were within normal limits so she left for the night. About 20 minutes later, the DON received a call that resident 1 could not be aroused. The DON directed nursing staff to call the MD to get an order to send Resident 1 to the ER. The DON was asked about resident 1' s blood pressure reading of 115/98 at 2:00 PM. The DON stated that she was unaware of this blood pressure reading at that time. The DON stated that if she had been aware, since it is different from resident 1' s normal she would have done more of an assessment at that time. On 12/3/15 at 3:21 PM, the MD was interviewed. The MD stated that she was notified that resident 1 was given a double dose of [MEDICATION NAME], 0.5 ml instead of 0.25 ml. The MD stated she did not know there was a 6.25 ml discrepancy, she only knew about the 0.5 ml that RN 1 admits to giving. The MD stated if she had known about the 6.25 ml discrepancy that would have been a different story and she would have immediately sent resident 1 to the ER. The MD stated she was not informed about any changes until around 7 PM. She was unaware of the 2:00 PM blood pressure. When the MD received the call that resident 1 was unresponsive she asked nursing staff to administer [MEDICATION NAME] and call 911.

Based on interview, observation, and record review it was determined that the facility failed to properly assess and provide supervision to residents who were elopement risks(Residents 18, 67, 89, 95, 96, and 100). The deficient practice identified for resident 18 and 100 was found to have occurred at an Immediate Jeopardy level. The deficient practice identified for residents 67, 89, 95, and 96, was found to have occurred at a no actual harm with a potential for more than minimal harm. Additionally, the facility failed to ensure that hot water temperatures throughout the building did not exceed 120 degrees Fahrenheit that was found to have occurred at a no actual harm with a potential for more than minimal harm. Findings include: A. Resident 18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident 18's medical record was completed on 9/3/15. On 2/19/15 an admission Minimum Data Set (MDS) was completed by facility staff. Facility staff assessed resident 18 as having severe cognitive impairment and wandered daily. Facility staff had not developed a plan of care relating to resident 18's assessed wandering or elopement risk. On 6/26/15 at 10:36 AM, a facility nurse documented that resident 18 was found quite a ways down the street. Facility staff returned resident 18 to the facility. There was no documentation to indicate facility staff assessed resident 18's condition following her elopement. Facility staff did not document an incident report or investigate the circumstances surrounding resident 18's elopement. On 7/19/15 a facility nurse documented that resident 18 was spotted by an off-duty employee. The resident was approximately one mile south of the facility at a busy intersection. Resident 18 was returned to the facility by the employee. There was no documentation to indicate facility staff assessed resident 18's condition following her elopement. Facility staff did not document an incident report or investigate the circumstances surrounding resident 18's elopement. On 9/1/15 at approximately 7:35 PM, a facility nurse documented that resident 18 was returned to the facility by her daughter. The daughter stated that the resident walked to her house. The resident's daughter's home was approximately 1.5 miles south of the facility and was located on a busy six lane highway. The family member stated that resident 18 had cut the wander guard bracelet off. On 9/2/15 at approximately 7:00 AM, an observation was made of resident 18. Resident 18 was observed to be off facility grounds, walking with her walker unattended by facility staff. Resident 18 had walked approximately a half a block from the facility towards a busy highway. On 9/2/15 at 1:03 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 18 was a wander risk and was with it enough that she would try to leave the facility to go home. LPN 1 stated that when resident 18 left the faciity on [DATE], conditions in the facility were busy and chaotic. LPN 1 stated staff were not aware resident 18 had left the facility until the resident was returned by her family. LPN 1 stated that when a resident had a wander guard the resident was not checked on frequently because the staff would rely on the wander guard alarm. LPN 1 stated that, they dropped the ball with this resident. LPN 1 stated that on 9/1/15, resident 18 had cut the wander guard off her wrist with a butter knife during dinner. B. Resident 100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 100's medical record was reviewed on 8/27/15. An Admission Psychiatric Evaluation completed on 8/8/15 by a local behavioral hospital revealed the following information, . He (resident 100) has been at the care center due to his symptoms of dementia. These symptoms have included wandering, aggression towards staff and difficulty at bedtime due to Sundowners . A Wandering Risk Scale assessment form dated 8/21/15 revealed resident 100 received a score of 16 or was a High Risk to Wander. On 8/21/15 at 2:47 AM, a facility nurse documented, Rt. (resident) arrived at facility around 1730 (5:30 PM) accompanied by family . Rt. is alert but disoriented to time, place, and situation. Rt. has been wandering into other resident's rooms, getting in bed with other residents, and refusing to stay in his room. Rt. has been found rummaging through his roommate's things as well. Ambulates without assistance . On 8/21/15 at 2:29 PM, a facility nurse documented, Resident is alert and confused. Graveyard nurse reports that resident was up all night going into other residents rooms and unable to sit still. resident requires frequent redirection . On 8/21/15 at 6:59 PM, a facility nurse documented, This nurse was looking for resident to give him his medication, I was unable to locate him, so STAT (immediate) search of the facility was done, then the facility grounds were searched, the door out of the west court yard was left open. still unable to find resident, (Name of facility Assistant Director of Nursing (ADON)) ADON notified and a search of neighborhood performed. Resident was found in (Name of local grocery store) by staff member. Resident brother called, but there was no answer, a message left to call (name of facility) regarding his brother. Also sister in law called, no answer. Upon residents return to facility a complete body check performed and resident put on q (every) 15 minute watch. On 8/22/15 at 2:19 PM, a facility nurse documented, (Resident 100) is alert to self only. He required prompting, and redirecting at all times during shift. Wanderguard in place to left wrist . On 8/23/15 at 11:05 AM, a facility nurse documented, Resident is not in the building. Staff alerted and did an immediate perimeter check et (and) also rechecking all rooms and bathrooms. After checking 3 times. Called DON (Director of Nursing) and all management to drive around and look for resident. Also our RNA (Restorative Nurse Aide) van driver is out looking for him and is accompanied by another can (sic). Will coordinate all calls here at the nursing station. On 8/23/15 at 11:29 AM, a facility nurse documented, ADON called et said to search (name of local grocery store) and all gas stations close by. Our vandriver (sic) and cna called, et they will do that. Attempted to call clients family number is not in service. On 8/23/15 at 12:18 PM, a facility nurse documented, (Resident 100) returned with facility vandriver (sic). Full assessment done at this time et he has a small skin tear to the left foot pad, inner aspect. et a small skin tear to the top of his pinky toe. Areas cleansed et abx (antibiotic) ointment et dry dressings applied. New orders received to change dsg (dressing) q day et prn (as needed). His elbows are slightly red, with no open areas noted. He denies pain or discomfort at this time. He will have staff accompany him for the rest of the day. On 8/23/15 at 12:29 PM, a facility nurse documented a second note, Resident found at (name of local hardware store). Wandering around the parking lot. The lady who found him is sitting with him. And our rna driver called et is closeby (sic) the area. She will pick him up immediately. On 8/27/15 at 3:09 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that there was not enough staff in the building. CNA 1 stated residents often walked out the front door of the facility and that there was not enough staff to respond to the wander guard system alarms. On 9/2/15 at 11:54 AM, an interview was conducted with CNA 3. CNA 3 stated if a resident was a wander risk staff would check on the resident every 15 minutes. CNA 3 stated not one specific staff member would check on the resident every 15 minutes but that Everyone is supposed to keep an eye out for wander risk residents. CNA 3 also stated residents who were at risk for wandering had WanderGuards on. CNA 3 stated if a resident was missing she would tell the nurse and the nurse would tell the DON. CNA 3 stated all staff members would immediately begin looking for the missing resident. CNA 3 stated she was unsure of how the WanderGuard system was tested to ensure it worked properly. CNA 3 stated she did think staff members would once in while take a resident with a WanderGuard to a door and make sure the door alarmed. On 9/2/15 at 11:57 AM, an interview was conducted with CNA 4. CNA 4 stated residents who were wander risks had a WanderGuard bracelet that they wore. CNA 4 stated the CNA's were supposed to check on residents who were wander risks every 15 to 30 minutes and that if a resident with a Wander Guard bracelet were to get to close to a door an alarm would go off. CNA 4 stated if a resident was missing she would make sure the resident's nurse knew and then facility staff would search for the resident. CNA 4 stated she was unsure how staff ensured the WanderGuard system was operating appropriately. On 9/2/15 at 12:01 PM, an interview was conducted with LPN 2. LPN 2 stated that the wander guard alarm does not always go off. LPN 2 stated that it seemed the wander guard devices were somewhat positional, and that if the device was placed on a resident's ankle the device might not set the alarm off. On 9/2/15 at 1:38 PM, an interview was conducted with the facility Administrator. The Administrator stated that he was aware of staff concerns regarding the wander guard system not alarming. The Administrator stated that the wander guard system was tested by both the facility staff and the company that installed the system. (Note: No documentation was provided to show that the system was tested .) On 9/2/15 at 1:52 PM, an interview was conducted with the facility DON. The DON stated there was .Not a frequent check system for the wander risk residents. The DON stated the WanderGuard was the main system used to ensure high risk residents did not elope from the building. The DON also stated that as soon as a resident was not located on the facility grounds the DON, Administrator, local police department and family should be notified. NOTICE: Notice of Immediate Jeopardy was given verbally to the Administrator on 9/3/15 at 10:40 AM. The Administrator was asked to develop an immediate plan to ensure resident safety related to wandering and elopement of residents. PLAN: On 9/8/15 at 10:10 AM, the Administrator provided the surveyors with a written plan of action to remove the Immediate Jeopardy to residents in the facility. The written plan dated 9/6/15 stated the following: Lomond Peak Nursing & (and) Rehab 524 E 800 N, Ogden UT 801-782-3740 (Long Term Care Manager), We allege that on 9/6/2015 at 8:00 PM we were able to remove the immediate jeopardy on our Elopement Policy, relating to F 323. Additionally, as part of our plan we are discharging the residents that are exit seeking. In addition to discharging residents we have taken the following action to remove the immediate jeopardy: - we have put in place corrective measures including 30 minute checks on and residents that are anticipated to be exit seeking, 24 hrs a day 7 days a week. - we have trained every staff member in the building on our elopement policy, what to watch for to prevent elopements, the importance of monitoring the LOA (Leave of Absence) book to ensure the individuals check out properly and return to the facility on time. - we have implemented a new policy which will now prevent the building from admitting residents that are exit seeking going forward. - we have implemented a new administrative audit tool which is utilized 7 days a week, and acts as a second line of protection for the residents in verifying that these systems stay in place going forward. I have attached a blank copy of the tool being used. - we have attached all signed inservice trainings that were conducted with all employees and audit tools being used. On 9/8/15, the surveyors confirmed the abatement of the Immediate Jeopardy situation as of 9/6/15. Deficient practice with potential for more than minimal harm remained for the risk of injury. Findings include: IMMEDIATE JEOPARDY: 1. Resident 18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/2/15 at approximately 7:00 AM, an observation was made of resident 18. Resident 18 was observed to be off facility grounds, walking with her walker unattended by facility staff. Resident 18 had walked approximately a half a block from the facility towards a busy highway. On 9/2/15 resident 18's medical record was reviewed. A review of resident 18's admission MDS assessment dated [DATE], revealed that resident 18 had wandering behaviors that occurred daily. A review of resident 18's 14 day scheduled MDS assessment dated [DATE], revealed that resident 18 had a Brief Interview for Mental Status (BIMS) score of 6. (Note: A BIMS score from 0-7: severe impairment.) The care plans that were developed for resident 18 were reviewed. Resident 18 did not have a care plan developed for wandering behaviors. Nursing Note entries for resident 18, between 6/26/15 and 9/2/15, included the following documentation: a. On 6/26/15 at 9:26 AM, a facility nurse documented, On charting r/t (related to) wandering. It was reported to this nurse that resident was found down the street quite a ways last night. Resident typically spends time outside but does not leave the property. D/t (due to) pt (patient) speaking Spanish only, staff last night was not able to ask her where she was going but they were able to convince her to return to facility . b. On 7/19/15 at 4:40 AM, a facility nurse documented, An employee not working called facility and stated he spotted resident walking on 2nd and Washington blvd. (boulevard). Staff had to go get her. Resident stated she was going to her daughters house. Resident is on 15 minute checks. No injuries noted. Daughter called and notified. c. On 7/19/15 at 5:50 PM, a facility nurse documented, Res (resident) on alert chartind (sic) r/t elopement. Resident's daughter take to home today. Daughter stated that resident went to her house last night, daughter was not at home at the time. d. On 9/2/15 at 7:10 AM, a facility nurse documented, Resident came walking up the hall with her family. Family states resident had left facility and walked to granddaughters house. Family was bringing her back. Noticed resident didn't have a wander guard on. asked resident what happened to it and she stated she had cut it off with a butter knife she had got from dinner. Resident left after dinner and was brought back by family at 1930 (7:30 PM). Another wandergaurd put on resident. A Wandering Risk Assessment form dated 9/2/15 revealed resident 18 received a score of 11 or was a High Risk for Wandering. (Note: A Wander Risk Assessment was not completed on admission.) On 8/27/15 at 3:09 PM, an interview was conducted with CNA 1. CNA 1 stated that there was not enough staff in the building. CNA 1 stated residents often walked out the front door of the facility and that there was not enough staff to respond to the wander guard system alarms. On 9/2/15 at 11:43 AM, an interview was conducted with DON. The DON stated that there was no formal weekly test with the wander guard system. The DON stated that the facility staff were randomly taking residents to the front door to test the wander guards but there was no documentation of the tests. The DON stated that the wander guard system was installed on 7/17/15. The DON stated that when the wander guard system alarmed at the nurses station the facility staff were to look at the exits for residents. The DON also stated that the resident Wander Risk Assessment form would determine if the resident received a wander guard. On 9/2/15 at 12:01 PM, an interview was conducted with LPN 2. LPN 2 stated that the wander guard alarm does not always go off. LPN 2 stated that it seemed the wander guard devices were somewhat positional, and that if the device was placed on a resident's ankle the device might not set the alarm off. On 9/2/15 at 1:03 PM, an interview was conducted with LPN 1. LPN1 stated that a resident that left the facility grounds was considered a wander risk. LPN 1 stated that resident 18 was a wander risk and resident 18 was with it enough that she would try to leave the facility and go home. LPN 1 stated that the facility staff was busy last night and in the chaos the staff didn't notice resident 18 left the facility. LPN 1 stated that she wasn't sure if resident 18 was on 15 minute checks currently from her last elopement. LPN 1 stated that when a resident has a wander guard the facility staff would not check on the residents frequently. LPN 1 also stated that the facility staff would rely on the wander guard to alarm them if a resident was eloping. LPN 1 stated that they, dropped the ball last night with resident 18. LPN 1 also stated that she wasn't aware that resident 18 was missing from the building and that resident 18 must have only been gone for approximately 30 minutes. LPN 1 further stated that she believed the granddaughter lived on 2nd street because they have found resident 18 in that area before when she had wandered from the building. On 9/2/15 at 1:38 PM, an interview was conducted with the facility Administrator. The Administrator stated that he was aware of staff concerns regarding the wander guard system not alarming. The Administrator stated that the wander guard system was tested by both the facility staff and the company that installed the system. (Note: No documentation was provided to show that the system was tested .) On 9/3/15 at 9:27 AM, an interview was conducted with resident 18's grandson. The grandson stated that he was at home when resident 18 walked from the facility to their home. The grandson stated that resident 18 had walked home from the facility on three other occasions. The grandson stated that they live over a mile from the facility on a busy road. The grandson stated the first time resident 18 walked home from the facility he found her on the front porch and he had just got home from school. The grandson also stated that he was concerned about the distance resident 18 was walking to get to their home and the busy street. The grandson further stated that resident 18 was blind in one eye, hard of hearing, and had occasional confusion. The grandson stated that resident 18 usually wandered out of the building during the facility staff shift change. 2. Resident 100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 100's medical record was reviewed on 8/27/15. An Admission Psychiatric Evaluation completed on 8/8/15 by a local behavioral hospital revealed the following information, . He (resident 100) has been at the care center due to his symptoms of dementia. These symptoms have included wandering, aggression towards staff and difficulty at bedtime due to Sundowners . A Wandering Risk Scale assessment form dated 8/21/15 revealed resident 100 received a score of 16 or was a High Risk to Wander. Nursing Note entries for resident 100, between 8/21/15 and 8/25/15, included the following documentation: a. On 8/21/15 at 2:47 AM, a facility nurse documented, Rt. (resident) arrived at facility around 1730 (5:30 PM) accompanied by family . Rt. is alert but disoriented to time, place, and situation. Rt. has been wandering into other resident's rooms, getting in bed with other residents, and refusing to stay in his room. Rt. has been found rummaging through his roommate's things as well. Ambulates without assistance . b. On 8/21/15 at 2:29 PM, a facility nurse documented, Resident is alert and confused. Graveyard nurse reports that resident was up all night going into other residents rooms and unable to sit still. resident requires frequent redirection . c. On 8/21/15 at 6:59 PM, a facility nurse documented, This nurse was looking for resident to give him his medication, I was unable to locate him, so STAT (immediate) search of the facility was done, then the facility grounds were searched, the door out of the west court yard was left open. still unable to find resident, (Name of facility Assistant Director of Nursing (ADON)) ADON notified and a search of neighborhood performed. Resident was found in (Name of local grocery store) by staff member. Resident brother called, but there was no answer, a message left to call (name of facility) regarding his brother. Also sister in law called, no answer. Upon residents return to facility a complete body check performed and resident put on q (every) 15 minute watch. d. On 8/22/15 at 2:19 PM, a facility nurse documented, (Resident 100) is alert to self only. He required prompting, and redirecting at all times during shift. Wanderguard in place to left wrist . e. On 8/23/15 at 11:05 AM, a facility nurse documented, Resident is not in the building. Staff alerted and did an immediate perimeter check et (and) also rechecking all rooms and bathrooms. After checking 3 times. Called DON and all management to drive around and look for resident. Also our RNA (Restorative Nurse Aide) van driver is out looking for him and is accompanied by another can (sic). Will coordinate all calls here at the nursing station. f. On 8/23/15 at 11:29 AM, a facility nurse documented, ADON called et said to search (name of local grocery store) and all gas stations close by. Our vandriver (sic) and cna called, et they will do that. Attempted to call clients family number is not in service. g. On 8/23/15 at 12:18 PM, a facility nurse documented, (Resident 100) returned with facility vandriver (sic). Full assessment done at this time et he has a small skin tear to the left foot pad, inner aspect. et a small skin tear to the top of his pinky toe. Areas cleansed et abx (antibiotic) ointment et dry dressings applied. New orders received to change dsg (dressing) q day et prn (as needed). His elbows are slightly red, with no open areas noted. He denies pain or discomfort at this time. He will have staff accompany him for the rest of the day. h. On 8/23/15 at 12:29 PM, a facility nurse documented a second note, Resident found at (name of local hardware store). Wandering around the parking lot. The lady who found him is sitting with him. And our rna driver called et is closeby (sic) the area. She will pick him up immediately. (Note: No documentation could be found that per facility policy resident 100's physician was notified, that the local police were notified, or that an incident report was created for either of resident 100's elopements which occurred on 8/21/15 and 8/23/15.) On 9/2/15 at 1:52 PM, an interview was conducted with the facility DON. The DON stated resident 100 had eloped from the building on two occasions. The DON stated resident 100 had eloped from the facility on 8/21/15 when the Lawn Keeper did not shut the courtyard gate. The DON stated resident 100 had eloped from the facility on 8/23/15 through the door in the therapy gym. The DON stated facility staff should have followed the elopement policy for both incidents regarding resident 100. The facility Elopements policy was reviewed on 9/2/15 and revealed the following information under the Policy Interpretation and Implementation section: 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. 3. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Notify the Attending Physician; c. Notify the resident's legal representative (sponsor) of the incident; d. Complete and file Report of Incident/Accident; and e. Document the event in the resident's medical record. 4. If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.); d. Provide search teams with resident identification information; and e. Initiate an extensive search of the surrounding area. POTENTIAL FOR HARM: 1. Resident 89 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 9/2/15 resident 89's medical record was reviewed. A review of resident 89's admission MDS assessment dated [DATE], revealed that resident 89 had wandering behaviors that occurred 1-3 days. Resident 89 also had a BIMS score of 12. (Note: A BIMS score from 8 - 12: moderately impaired.) A Wandering Risk Assessment form dated 6/25/15 revealed that resident 89 received a score of 6 or was a Moderate Risk for Wandering. A Wander Risk Scale from dated 6/25/15 revealed that resident 89 received a score of 13 or was a High risk to Wander. Nursing Note entries for resident 89 dated 7/12/15 included the following documentation: a. On 7/12/15 at 2:28 AM, a facility nurse documented, Resident informed at 11 PM that she was walking to the store to get some things. Resident signed herself out. Arrived back to facility at 01 (1:00) AM intoxicated. Resident smelled of alcohol and was slurring her words.Resident stated she was leaving tonight and went to her room. About an hour and a half later resident came to nurses station and apoligized (sic) for the way she acted and stated she was going out for a cigarette. resident out smoking at this time. Will continue to monitor. b. On 7/12/15 at 3:53 AM, a facility nurse documented, Resident went out to smoke 45 minutes ago and has not returned. This nurse went to check on resident and she is no longer outside in smoking area. c. On 7/12/15 at 10:56 AM, a facility nurse documented, Calls have been place (sic) to the daughter every 15-20 minutes since first attempt. (Note: First attempt was at 9:35 AM.) d. On 7/12/15 at 11:24 AM, a facility nurse documented, Call received from (name of family member) who is (resident 89's) daughter. Informed regarding the events of the night.She has been in contact with the police. Informed of all actions taken by the facility since the resident eloped. e. On 7/12/15 at 4:47 PM, a facility nurse documented, Received in report from noc (night) nurse this am that resident went out for a smoke around 0200 (2:00 AM), resident was placed on 15 minute checks. Resident eloped from facility, was last seen at 0230 (2:30 AM). Full search of all rooms of the facility and the grounds surrounding this am from 0715 (7:15 AM) - 0830 (8:30 AM). This nurse with another staff member walked the grounds at the church and field next to the facility from 0800 (8:00 AM) - 0820 (8:20 AM). No sign of resident at either. RNA sent to search neighborhood, (name of local store), and gas station that resident frequents was gone from 1000 (10:00 AM) - 1120 (11:20 AM). This nurse called (local) dispatch to report resident as missing aprox. (approximately) 1000 (10:00 AM). (Name of Officer) responded and made the report. Officer was able to get in touch with res. (residents) daughter (name of daughter) after several attempts had been made by this nurse to notify her of situation. Administrator assisted with searching the surrounding area from 1215 (12:15 PM) - 1420 (2:20 PM). RNA was sent out again at 1400 (2:00 PM) to search the surrounding neighborhood for resident. RNA called this nurse at 1430 (2:30 PM) stating she found resident. RNA reported that she spoke with resident and tried to get her to return to facility. RNA stated that resident refused and took off running from her. This nurse asked RNA to back off but keep eyes on resident. Administrator notified and went to attempt to calm resident and bring her back to facility. Resident refused to return to facility and signed an AMA (Against Medical Advice) form with administrator and RNA as witnesses. RNA and Administrator returned at 1530 (3:30 PM). A Care Plan revised on 7/27/15, revealed a focus of, The resident is an elopement risk/wanderer risk r/t Impaired safety awareness, History of attempts to leave facility unattended. Resident 89's goal was, The resident will not leave facility unattended through the review date. The interventions for resident 89 to achieve the goal was, 1) Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. 2) Wander guard to right wrist at all times. Check placement Q shift and function Q week. On 8/5/15 at 11:13 PM, a facility nurse documented, At approximately 2115 (9:15 PM) this shift, Rt. asked nurse if she could go outside with a friend who was present at the time to look at his car which was having issues. Nurse told resident that would be okay. At approximately 2120 (9:20 PM), staff member called facility saying that she saw rt. out front drinking alcohol with said friend. This nurse notified the admissions department head who went out and confirmed that rt. was drinking alcohol. Admissions notified rt.'s daughter and they both agreed that rt. was to be discharged from the facility at that time. Admissions explained to rt. the situation and rt. agreed to sign AMA form and go with family friend. Rt. took all of her belongings and left the facility at approximately 2200 (10:00 PM) this shift. MD (Medical Director), administrator and case manager notified. (Note: resident 89 was readmitted to the facility on [DATE].) On 9/2/15 at 1:18 PM, an interview was conducted with the facility DON. The DON stated she was made aware of resident 89's 7/12/15 2:30 AM elopement at 9:25 AM on 7/12/15. The DON stated facility staff should have followed the elopement policy and looked for resident 89 immediately. The DON also stated that as soon as resident 89 could not be located the DON, Administrator, local police department and family should have been notified. The DON stated after resident 89 had eloped on 7/12/15 their intervention was to have a WanderGuard system placed in the facility. On 9/2/15 at 1:38 PM, an interview was conducted with the facility Administrator. The Administrator stated he did not remember the exact time he was notified of resident 89's 7/12/15 elopement, but stated It was after six AM. The Administrator stated it was facility policy to search the facility grounds if a resident could not be found. The Administrator then stated if the resident could not be found on facility grounds he (the Administrator), the DON, the

Based on observation, interview and record review, the facility did not ensure that for 3 of 51 sample residents received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, one resident did not receive her prescribed medications resulting in [MEDICAL CONDITION], and one resident did not receive pain medication as ordered, and one resident's pain was not managed resulting in resident being sent to the hospital. Resident identifiers: 19, 57, and 98. Findings include: 1. Resident 57 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 8/27/15 at 3:14 PM, an interview was conducted with resident 57. Resident 57 stated she was upset because she had not been receiving her [MEDICATION NAME] because it was not reordered from the pharmacy on time. Resident 57 then stated she had attempted suicide several times in the past. Resident 57 would not answer whether or not she had a plan to attempt suicide. A nursing note dated 8/27/15 at 4:29 PM, revealed the following information, Resident admits to being hopeless and no one here can help her. Resident is suicidal therefore will be blue sheeted to (name of local hospital) psych (psychiatric) unit for evaluation for her safety per (name of facility Medical Director (MD)). An ED (Emergency Department) Physician Report dated 8/27/15 revealed the following information, This is a [AGE] year-old female who presents from the nursing home after she was making suicidal comments to staff along with pain today, the medical director became so concern (sic) that she ended up blue sheeting her. She is brought in by (local city) police. She states that she has felt suicidal for several years. This is nothing new that has to do with the fact that she is not giving (sic) her pain medication or other medications as she needs for her chronic pain . A Psychiatric Admission Report dated 8/28/15 revealed the following information, This is a patient with whom I am familiar from 2 previous psychiatric hospitalization s under somewhat similar circumstances . Because she was sent over on a blue sheet, it was determined that she needed to come into the psychiatric hospital for a more in-depth evaluation before making that determination. From the patient's point of view, she was upset because there are problems over at (facility name) where she is not getting her medications regularly. She states that the pharmacy will run out of her medications. They will have to order them and she will go a day or 2 without getting her meds (medications). Additionally, sometimes they get her meds late. She states that when she does not get her meds on time, especially the pain pills, but also the [MEDICATION NAME], she starts to feel more dysregulated, and it affects her 'dissociative disorder'. She also acknowledges that as part of having borderline personality disorder, it is very likely that she could escalate and get upset when she is experiencing major stressors . I also wonder if it is possible if the patient had made comments out of frustration with the hope that would help them (facility staff) be more responsive with her requests . A physician order dated 6/9/15 revealed the following information, [MEDICATION NAME] Tablet 5 MG (milligram) Give 5 mg by mouth four times a day for Muscle Spasm. Resident 57's Controlled Drug Record was reviewed and revealed: a. Resident 57 was administered two doses of her ordered [MEDICATION NAME] on 8/25/15. One dose at 5:00 AM and the other dose at 12:00 PM. b. Resident 57 was administered one dose of her ordered [MEDICATION NAME] on 8/26/15 at 6:00 PM. c. Resident 57 was administered two doses of her [MEDICATION NAME] on 8/27/15. One dose at 11:00 AM and a second dose at 5:00 PM. A one time physician order dated 8/26/15 at 12:30 PM, revealed the following information, [MEDICATION NAME] Tablet 5 MG Give 5 mg by mouth one time only for anxiety . (Note: Resident 57 only received half of her ordered doses of [MEDICATION NAME] from 8/25/15 to 8/27/15.) On 9/10/15 at 10:06 AM, an interview was conducted with the facility Director of Nursing (DON). The DON confirmed resident 57 was administered the doses of [MEDICATION NAME] as above. The DON confirmed that resident 57's last dose of [MEDICATION NAME] was administered on 8/25/15 at 12:00 PM. The DON confirmed that resident 57 received the next dose of [MEDICATION NAME] on 8/26/15 at 6:00 PM. The DON confirmed resident 57 missed 4 doses of her scheduled [MEDICATION NAME]. 2. Resident 98 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/1/15 at 2:46 PM, resident 98 was interviewed with his wife present. Resident 98 stated that the facility did not administer his pain medications or antibiotics intravenously as ordered by the physician. Resident 98 stated that the facility stated that they had a problem with the pharmacy. Resident 98 stated that he attempted to contact the hospital that he was discharged from to get an order to administer his pain medications without success. Resident 98 stated that his pain was rated at a 10 (on a scale of 1-10 with 10 being excruciating pain) over the weekend and that he was having a difficult time getting his pain under control. Resident 98's medical record was reviewed on 9/2/15. Review of the admission orders [REDACTED] a. [MEDICATION NAME] ([MEDICATION NAME]) 25 mcg (micrograms) per HR (hour) every 72 hours; b. [MEDICATION NAME] 5 mg 1-2 tablets every 4 hours as needed for breakthrough pain; c. [MEDICATION NAME] 20 mg every 12 hours; and d. [MEDICATION NAME] 2 grams Intravenously (IV) every 4 hours. On 8/26/15 the facility staff completed a Pain Tool assessment for resident 98. Resident 98 complained of pain shock-like pain in the lower back and a deep ache in the right thigh. Resident 98 stated that his pain level was rated at an 8. Resident 98 stated that pain medication helped somewhat, as well as laying down once in a comfortable position and was not moving. On 8/27/15 the facility staff completed a Pain Interview with resident 98. Resident 98 stated that he had pain frequently. Resident 98 stated that the pain made it hard for him to sleep at night and limited his ability to perform his day-to-day activities. Resident 98 stated that his pain was severe. The facility staff assessed resident as having had vocal complaints of pain, non-verbal sounds that indicated resident 98 was in pain (e.g., crying, whining, gasping, moaning, or frowning) , and had facial expressions that indicated resident 98 was in pain (e.g., that hurts, ouch, stop) on a daily basis. Review of the August 2015 and September 2015 Medication Administration Record [REDACTED] a. [MEDICATION NAME] Patch 25 mcg per hr was not available for administration on 8/27/15 as scheduled. On 8/30/15 the facility staff applied two 12 mcg patches instead of the ordered 25 mcg. Additionally, on 9/2/15 one 12 mcg patch was applied instead of the ordered 25 mcg patch. b. [MEDICATION NAME] 2 grams intravenously every 4 hours was only administered at noon on 8/27/15; and was not administered again until 8/28/15 at 10:00 AM instead of the ordered 2 grams IV every 4 hours. (Note: Resident 98 missed a total of nine doses of the [MEDICATION NAME] that was to be administered related to the staphylococcus aureus bacteremia.) c. [MEDICATION NAME] 20 mg twice a day was not available for administration until 8/28/15. (Note: Resident 98 missed a total of 3 doses that was to be administered related to the acute osteo[DIAGNOSES REDACTED] and chronic pain.) d. [MEDICATION NAME] 5 mg 1-2 tablets as needed every 4 hours was not available for administration until 8/27/15 at 8:27 PM. The facility licensed nursing staff documented the following in a Progress Note: a. 8/27/15 at 3:57 PM: .Resident has stayed in bed most of shift.Resident is concerned with back and fearful. Resident spoke with MD (Medical Doctor) this shift. b. 8/27/15 at 11:23 PM: [MEDICATION NAME] ([MEDICATION NAME]) Tablet 5 mg Give 1 tablet by mouth every 4 hours as needed for Pain Give 5-10 mg Q4H (every 4 hours) PRN (as needed) pain (was rated) 10/10 10 mg po (orally) given. c. 8/27/15 at 11:20 PM: [MEDICATION NAME] was ineffective. (Note: There was no documentation by the facility licensed nursing staff about resident 98's pain medication not being available.) On 9/2/15 at 3:48 PM, the facility DON was interviewed. The DON stated that she was not aware that resident 98's medications were not available for administration on 8/26/15 and 8/27/15 or why resident 98's [MEDICATION NAME] was not administered as ordered. Additionally, the DON was not aware that resident 98's [MEDICATION NAME] Patch delivered was the wrong dosage. 3. Resident 19 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 9/2/15 at 1:17 PM, an observation was made of resident 19. Resident 19 was in her room screaming and yelling out. Resident 19 was heard from the hallway. Resident 19 was crying and yelling out that she was in pain and needed help. Resident 19 was observed to yell out and cry until 4:00 PM. On 9/2/15 at 1:20 PM, an interview was conducted with Certified Nurses Assistant (CNA) 4. CNA 4 stated that resident 19 was yelling out because she was in pain. CNA 4 stated that resident 19's nurse was aware that resident 19 was in pain. CNA 4 stated that the nurse had given resident 19 pain medication but the medication was not helping. On 9/2/15 at 1:25 PM, an interview was conducted with CNA 5. CNA 5 stated that resident 19 was yelling out because she was in pain. CNA 5 stated that resident 19 had psychiatric problems and that was why resident 19 was crying and yelling out in pain. On 9/2/15 at 1:30 PM, an interview was conducted with Agency Registered Nurse (ARN) 1. ARN 1 stated that resident 19 appeared to be going through withdrawals. ARN 1 stated that resident 19 was administered pain medication at 12:30 PM. ARN 1 stated that the pain medication was not effective and a message was left for resident 19's doctor. ARN 1 stated that resident 19's doctor had not returned her phone call regarding resident 19's pain. At 4:05 PM, a follow up interview was conducted with ARN 1. ARN 1 stated that resident 19's physician had not returned her call. Resident 19's medical record was reviewed on 9/8/15. Resident 19's physicians orders dated 8/28/15 revealed, [MEDICATION NAME] Tablet 10 MG Give 10 mg by mouth as needed for Muscle Spasm. [MEDICATION NAME] 10 mg PO TID (3 times a day) PRN. There were no other orders for pain medication on the Medication Review Report dated 8/28/15. The [MEDICATION NAME] 5 mg twice a day and the [MEDICATION NAME]-[MEDICATION NAME] Tablet 7.5-325 MG to give 4 hours as needed were discontinued. In addition, the form revealed that resident 19's 800 MG [MEDICATION NAME] was discontinued. Resident 19's August 2015 MAR indicated [REDACTED]. Every shift for pain document pain level on a scale from 1-10. The August 2015 MAR further revealed that resident 19 complained of pain rated at 8-9 from 8/28/15 until 8/31/15. Resident 19's pain prior to readmission from 8/1/15 until 8/17/15 revealed resident 19's pain level was rated at less than a 7. Resident 19 was administered [MEDICATION NAME] 15 mg on 8/28/15 through 8/31/15, one to two times per day. On 8/29/15 after pain medication was administered it was documented the pain medication was ineffective. (Note: There was no physician order for [REDACTED]. Resident 19's September 2015 MAR indicated [REDACTED]. Resident 19's pain was rated at a level of a 10 on 9/1/15 and 9/6/15. On 9/2/15 resident received 15 mg [MEDICATION NAME] at 12:32 PM. The nurse documented resident 19 had pain rated at a 6 and the pain medication was effective. (Note: Resident was observed to be screaming and yelling out that she was in pain on 9/2/15 from 1:17 PM until 4:00 PM.) Resident 19's nurses notes revealed the following: a. On 9/2/15 at 12:32 PM, [MEDICATION NAME] Tablet 15 MG .pain 6/10 signed by the facility Assistant Director of Nursing (ADON) b. On 9/2/15 at 4:23 PM, [MEDICATION NAME] Tablet 15 MG . PRN Administration was : Effective not effective. c. On 9/2/15 at 5:40 PM, Resident crying in room requesting to go to ER (emergency room ), MD notified for pain management. (Local transportation) called for transportation. An Emergency Provider Report dated 9/2/15 at 6:40 PM, revealed that resident 19 was brought into the ER via Emergency Medical Services.Pt (patient) has been staying at a skilled level 2 facility, but reports that someone has taken her off her medications. She normally takes [MEDICATION NAME] and dialudid every 3 hours on rotation, but she has not had her medication for the past 7 days. She complained of generalized pain. The report further revealed, . ED Course: Stable, Pain medicine and anxiety medicines did not help the patient. She received 10 of [MEDICATION NAME] IM (intramuscularly) and already symptoms completely resolved. She was able to relax and sleep comfortably. On 9/8/15 at 1:32 PM, an interview was conducted with resident 19. Resident 19 stated that on 9/2/15 she was going through withdrawals because her pain medication had been discontinued. Resident 19 stated that she had to demand to go to the ER because she was in so much pain. Resident 19 stated that the ER treated her pain and sent her back to the facility. Resident 19 stated that the facility discussed hospice because her pain was uncontrolled and was told hospice would be able to control her pain with medication. On 9/8/15 at 3:09 PM, an interview was conducted with the DON. The DON stated that resident was screaming and yelling out that she was in pain so she was sent to the ER. The DON stated that she was not aware that resident 19 was crying and yelling out for over 5 hours before she was sent to the ER. The DON further stated she did not know that the physician did not call the facility back regarding resident 19's pain. The facility provided a policy titled, Pain Assessment and Management which revealed the following: The purpose of this procedure are (sic) to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. General Guidelines: 1. The pain management program is based on a facility-wide commitment to resident comfort. 2. 'Pain management' is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain; b. Effectively recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying cause of the pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary. 4. It is important to recognize cognitive, cultural, familial, or gender-specific influences on the resident's ability or willingness to verbalize pain. 5. Conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. 6. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Recognizing pain: 1. Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. Possible Behavioral Signs of Pain: a. Verbal expressions such as groaning, crying, screaming; b. Facial expressions such as grimacing, frowning, clenching of the jaw, . c. Change in gait, skin color and vital signs; d. Behavior such as resisting care, irritability, depression, decreased participation in usual activities; e. Limitation in his or her level of activity due to the presence of pain; f. Guarding, rubbing or favoring a particular part of the body; g. Difficulty eating or loss of appetite; h. [MEDICAL CONDITION]; and i. Evidence of depression, anxiety, fear or hopelessness. Possible Physiological Signs of Pain: a. Increased blood pressure; b. [MEDICAL CONDITION] c. Increased respirations; and d. Diaphoresis. 2. Ask the resident if he/she is experiencing pain. Be aware that the resident may avoid the term 'pain' and use other descriptors such as throbbing, aching, hurting, cramping, numbness or tingling. 3. Review the Medication Administration Record [REDACTED]. Assessing Pain: 1. During the comprehensive pain assessment gather the following information as indicated from the resident . a. History of pain and its treatment, including pharmacological and non-pharmacological intervention; b. Characteristics of pain: (1) Intensity of pain (as measured on a standardized pain scale); (2) Descriptors of pain; (3) Pattern of pain (e.g., constant or intermittent); (4) Location and [MEDICAL CONDITION] of pain; (5) Frequency, timing and duration of pain. c. Impact of pain on quality of life; d. Factors that precipitate or exacerbate pain; e. Factors and strategies that reduce pain; and f. Symptoms that accompany pain (e.g., nausea, anxiety). 2. Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. 3. Discuss with the resident (or legal representative) his or her goals for pain management and satisfaction with the current level of pain control. Identifying the Causes of Pain: 1. Review the MDS (Minimum Data Set) and other documentation for indications of the onset or worsening of pain symptoms. Indicators of pain may include MDS items such as sleep cycle, changes in mood, decline in function, weight loss and skin conditions. 2. Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain including:. 3. Review the resident's treatment record or recent nurses' notes to identify any situations or interventions where an increase in resident's pain may be anticipated for example: . 4. In some cases the underlying causes of pain cannot be determined. Defining Goals and Appropriate Interventions: 1. The pain management interventions shall be consistent with the resident's goals for treatment. Such goals will be specifically defined and documented. 2. Pain management interventions shall reflect the sources, type and severity of pain. 3. Pain management interventions shall address the underlying causes of the resident's pain. 4. For those situations where the cause of the resident's pain has not been or cannot be determined, follow current standards of practice for managing pain to help determine appropriate options. Implementing Pain management Strategies: 1. Non-pharmacological interventions may be appropriate alone or in conjunction with medications. Some non-pharmacological interventions include: a. Environmental . b. Physical . c. Exercise. d. Cognitive or Behavioral . 2. Pharmacological interventions. 3. Addiction to narcotic [MEDICATION NAME] is not likely if used appropriately for moderate to severe pain. 4. The physician and staff will establish a treatment regimen based on consideration of the following: a. The resident's medical condition; b. Current medication regimen; c. Nature, severity and cause of the pain; d. Course of the illness; and e. Treatment goals. 5. Strategies that may be employed when establishing the medication regimen include: a. Starting with lower doses and titrating upward as necessary; b. Administering medications around the clock rather than PRN; c. Combining long-acting medications with PRNs for breakthrough pain; d. Combining several [MEDICATION NAME] or [MEDICATION NAME] with other drug classes; and e. Reducing or preventing anticipated adverse consequences of medications. 6. Implement the medication regimen as ordered, carefully documenting the results of the interventions. Monitoring and Modifying Approaches: 1. Re-assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. 2. Monitor the following factors to determine if the resident's pain is being adequately controlled: a. The resident's response to interventions and level of comfort over time; b. The status of the underlying cause(s) of pain, if identified previously; and c. The presence of adverse consequences to treatment. 3. Monitor the resident by performing a basic assessment with enough detail and, as needed, with standardized assessment tools (e.g., approved pain scales, etc.) and relevant criteria for measuring pain management (e.g., target signs and symptoms). 4. If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. If pain symptoms have resolved or there is no longer an indication for pain medication, the multidisciplinary team and physician shall try to discontinue or taper [MEDICATION NAME] medications to the extent possible. Documentation 1. Document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program. 2. Upon completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's medical record. Reporting Report the following information to the physician or practitioner: 1. Significant changes in the level of the resident's pain; 2. Adverse effects from pain medications, . 3. Prolonged, unrelieved pain despite care plan interventions.

Based on interview and record review, it was determined the facility did not provide medically-related social services to attain or maintain the highest practical physical, mental, and psychosocial well-being for 6 of 51 sample residents. Specifically, there were no social services interventions for 6 residents who demonstrated complex behaviors, and the Licensed Clinical Social Worker (LCSW) consultant was not informed of concerns related to residents' psychosocial well-being. Resident identifiers: 19, 57, 70, 89, 91, and 96. Findings include: 1. Resident 57 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 57's medical record was reviewed on 9/9/15. A nursing note dated 8/1/15 revealed the following information, Rt. (resident) being monitored d/t (due to) suicidal ideations earlier today. Rt. was placed on 15 minute checks. Rt. made a safety contract with this nurse that she would not attempt to harm herself for the remainder of this shift. No suicidal ideations were seen or heard on this shift . (Note: No documentation could be found to show social services was involved in the care for resident 57 after having suicidal ideations.) On 8/27/15 at 3:14 PM, an interview was conducted with resident 57. Resident 57 stated she was upset because she had not been receiving her Valium because it was not reordered from the pharmacy on time. Resident 57 then stated she had attempted suicide several times in the past. Resident 57 would not answer whether or not she had a plan to attempt suicide. A nursing note dated 8/27/15 at 4:29 PM, revealed the following information, Resident admits to being hopeless and no one here can help her. resident is suicidal therefore will be blue sheeted to (name of local hospital) psych unit for evaluation for her safety per (name of facility MD (medical Director)). On 9/9/15 at 9:35 AM, an interview was conducted with the Resident Advocate (RA). The RA stated resident 57 was supposed to see a counselor at a local psychiatric treatment center but resident 57 refused to go. The RA stated she had not documented when resident 57 had refused to see her counselor or when she had called to make an appointment for resident 57. The RA stated she had not had any conversations with resident 57's counselor, only the counselor's secretary. The RA stated she had not referred resident 57 to the facility LCSW consultant. The RA then stated she had not referred any of the current residents at the facility to the LCSW. The RA stated she had not referred resident 57 to the LCSW after her suicidal ideations, and then stated she thought the facility Director of Nursing (DON) had referred resident 57 to the LCSW. On 9/9/15 at 10:28 AM, an interview was conducted with the facility DON. The DON stated if a resident experienced suicidal ideation's the staff member should notify the charge nurse who would then notify the physician. The DON stated the resident should not be left alone and should be sent out to a local hospital for a psychological evaluation. The DON confirmed a nurse should not make a contract with a resident who is having suicidal ideations. The DON stated the LCSW consultant was brought in to help when there was a Behaviorally complex resident. The DON confirmed resident 57 would be considered a behaviorally complex resident. On 9/9/15 at 10:47 AM, an interview was conducted with the facility LCSW consultant. The LCSW stated she had not received any referrals from the facility RA regarding resident 57, but did meet with resident 57 for the first time on 9/3/15 when she was notified resident 57 had been sent out to the hospital due to suicidal ideations. The LCSW stated she should be informed anytime a resident experienced suicidal ideations. The LCSW stated it would be inappropriate for the RA to care plan suicidal ideations for a resident, and that the RA had access to a care plan book which would prompt the RA to refer the resident to the LCSW. The LCSW stated she did not have documentation to show that she had been involved in resident 57's care prior to 9/3/15. The LCSW stated she was not told of resident 57's suicidal ideations on 8/1/15. The LCSW also stated resident 57 had been refusing to go to her counselor but stated it was the RA's job to document when resident 57 refused to attend appointments. The LCSW stated although resident 57 had been refusing to go to her outside counselor she had not been in to work with resident 57 until 9/3/15. On 9/10/15 at 9:05 AM, a follow up interview was conducted with the facility RA. The RA stated facility staff did not inform her of resident 57's suicidal ideations on 8/1/15. The RA stated she had not informed the LCSW of resident 57's suicidal ideations on 8/27/15 because she was not aware she was supposed to inform the LCSW when a resident experienced suicidal ideations until this week. 2. Resident 96 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 9/2/15 at 12:42 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that resident 96 was not allowed to go Leave of Absence (LOA) at night. LPN 2 stated that she was told that in report by the night nurse that morning. LPN 2 stated she did not know why resident 96 was not allowed to go LOA. Resident 96's medical record was reviewed on 9/2/15 and 9/9/15. Resident 96 did not have an Minimum Data Set (MDS), wander risk assessment, or care plans. The last nurse's note or facility staff note was 9/1/15. On 9/9/15 at 9:28 AM, an interview was conducted with the RA. The RA stated that she has not been involved in assessing residents to leave LOA. The RA stated that resident 96's payer source was medicare so resident 96 was not allowed to go LOA over night. The RA stated that facility staff had not discussed with resident 96 about not going out overnight. On 9/9/15 at 11:08 AM, an interview was conducted with the facility LCSW. The LCSW stated that she was not contacted regarding resident 96 not being allowed to go LOA at night. The LCSW stated that an evaluation should have been conducted regarding safety concerns in community access. 3. Resident 70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 70's medical record was reviewed on 9/9/15. On 6/1/15, an admission MDS assessment was completed. The facility staff assessed resident 70 as being alert and oriented with no cognitive impairment. Resident 70 was assessed as having verbal behaviors (threatening others, screaming at others or cursing at others) 4-6 times during the assessment period. A care area assessment (CAA) triggered for cognitive loss and behavioral symptoms. The facility staff documented that a care plan would be developed related to the cognitive loss and behavioral symptoms. admission orders [REDACTED] a. Cymbalta 60 mg (milligrams) once a day; b. Saphris 10 mg sublingually once a day; c. Haldol Decanoate 50 mg/ml (milliliter) inject 1 ml intramuscularly once a month; d. Seroquel 25 mg at hour of sleep; e. Clonazepam 0.5 mg twice a day; and f. Divalproex 500 mg twice a day. The care plans developed for resident 70 were reviewed. The following care plans were developed: a. The resident has a behavior problem (SPECIFY) r/t (related to) that was developed on 7/10/15. The goal that was developed was The resident will have fewer episodes of screaming and crying to have her needs met by next review. There were no interventions developed to achieve the goal. b. The resident is/has potential to be verbally aggressive (SPECIFY) r/t that was developed on 7/10/15 The goal that was developed was The resident will verbalize understanding of need to control verbally abusive behavior through the review date. The interventions developed to achieve the goal included: i) Give the resident as many choices as possible about her care and activities and ii) Monitor behaviors (SPECIFY FREQ (frequency)). Document observed behavior and attempted intervention. Review of the Preadmission screening resident review for serious mental illness revealed resident 70's .thinking is quite simplistic and concrete. Information should be presented to her slowly, using simple vocabulary. She does well with routine and has an excellent memory, so consistently (sic) is important for her. She can get upset at times for no reason. As noted above, giving her quiet time rather than trying to talk with her is helpful at these times. Review of the telephone orders for resident 70 revealed: a. 7/1/15: Discontinue Saphris. Start Latuda (at) 20 mg PO (by mouth) QD (daily) for 7 days then increase to 40 mg PO QD. b. 7/15/15: Increase Seroquel to 100 mg PO qHS (at hour of sleep). Also: Seroquel 25 mg PO q (every) AM and 25 mg PO q 2 PM (early afternoon). c. 7/19/15: Haloperidol LAC (lactate) 5 mg/ml IM (intramuscularly), 1 times. Repeat in 1 hr if behavior continues. d. 7/19/15: Increase Klonopin tablet to 1 mg PO two times a day. Review of the progress notes revealed that the facility staff documented the following: a. 7/19/15 at 7:03 PM, Resident was having angry and tearful outbursts. Yelling, screaming and trying to hit the staff timesx4 (sic) this shift. MD (Medical Doctor) on call notified and ordered: HALOPERIDOL 5 MG/ML IM FOR 1 time only. Repeat in 1hr (one hour) PRN (as needed) if behaviors continues. Increase KLONOPIN (CLONAZEPAM)tablet (sic)1 mg, PO, BID (twice a day). Klonopin 1 mg and Haloperidol 5 MG/ML IM (R (right) Deltoid) time X 1 given and behavior discontinued. No further need sat this time. WCTM (will continue to monitor). (Note: There was no documentation of what interventions had been attempted prior to the administration of the Haldol.) b. 7/25/15 at 5:44 PM, This shift resident was very agitated and was yelling from room. Upon assessment resident had call light within reach, sitting upright in chair with no visible problems. Nurse attempted to calm resident down to assist with problems. Resident finally told nurse that the TV (television) needed to be fixed. Nurse attempted to fix TV but it would not work. Nurse told resident to wait a few minutes and that if the resident needed help to push the call light instead of screaming. The resident then attempted to kick the nurse. The nurse told the resident that it was inappropriate and that she would return when the resident was cam. Resident continued to scream and aides assisted resident; resident then attempted to hit aides. Aides told the resident that it was inappropriate and that they would help when she was calm. Resident later then calmed down. WCTM behaviors. c. 8/14/15 at 10:47 AM, Resident was being assisted to the restroom when resident requested to get into bed. Resident was assisted into bed but need (sic) additional staff. Resident was told to wait one minute while assistance came. Resident then start (sic) to scream and trying to hit. Resident was left laying down in bed with call light in reach and told that the aide would return when resident had calmed down. Resident later calmed down and staff assisted resident. Resident's needs are met. WCTM. There was no behavior monitoring to justify the use of the Haldol Decanoate, Latuda, Saphris, Seroquel, or Depakote from the time resident 70 from 5/19/15 through 9/10/15. On 9/9/15 at 1:55 PM, the contracted LCSW was interviewed. The LCSW stated that she had not been contacted regarding resident 70's behaviors. The LCSW stated that she did not know why resident 70's Seroquel and Klonopin had been increased or that she received Haldol intramuscularly. The LCSW stated that the PASRR (preadmission screening resident review) documented that giving her quiet time rather than trying to talk with her is helpful. 4. Resident 19 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 19's medical record was reviewed on 9/2/15. An admission MDS dated [DATE] revealed that resident 19 did not have any behavior or mood problems. On 9/2/15 at 1:17 PM, an observation was made of resident 19. Resident 19 was observed to be yelling and crying out. Resident 19 was observed to be yelling that she was in pain. Resident 19 was heard yelling and crying from down the hall. On 9/2/14 at 3:31 PM, an interview was conducted with Agency Registered Nurse (ARN) 1. ARN 1 stated that resident 19 appeared to be going through withdrawals from pain medications being discontinued. ARN 1 stated that resident 19 was administered pain medication at 12:30 PM. On 9/2/15 at 1:20 PM, an interview was conducted with Certified Nurse Assistant (CNA) 4. CNA 4 stated that resident 19 was in pain and the nurse had provided pain medications. CNA 4 stated that resident 19 cried out in pain because it was a behavior. On 9/2/15 at 1:25 PM, an interview was conducted with CNA 5. CNA 5 stated that resident 19 was yelling and crying because she was in pain. CNA 5 stated that resident 19 had psychological problems and that was the reason she was crying and yelling out. On 9/8/15 at 1:32 PM, an interview was conducted with resident 19. Resident 19 stated that she was going through withdrawals because her pain medication had been discontinued. Resident 19 stated that she demanded to go to emergency room (ER) because she was in so much pain on 9/2/15. Resident 19 stated that in August the facility staff took her tweezers when she left her room. Resident 19 stated that she used her tweezers to pluck her eye lashes that were in grown on the side of her eye. Resident 19 stated that the facility sent her to the hospital because she took her tweezers back that they took from her. On 9/9/15 at 8:52 AM, an interview was conducted with the DON. The DON stated that resident 19's physician said that crying in pain was a behavior and to not treat the pain. The DON stated that the LCSW and RA had not been notified of the pain behavior. On 9/9/15 at 9:32 AM, an interview was conducted with the RA. The RA stated that resident 19 had complained about pain after pain medications were administered. The RA stated that she had not referred resident 19 to the LCSW. On 9/9/15 at 10:15 AM, a follow-up interview was conducted with the RA. The RA stated that over the weekend prior to 8/19/15, resident 19 had been pulling out her eye lashes and causing herself to bleed. The RA stated that the doctor told staff to take away the tweezers. The RA stated that on 8/19/15, resident 19 went into the RAs office and demanded her tweezers back. The RA stated that the Assistant Director of Nursing (ADON) discussed with resident 19 that she was hurting herself with her tweezers. The RA stated that resident 19 took a pair of scissors from the ADON office and ran back to her room. The RA stated that resident 19's physician ordered for her to be sent to the hospital. Resident 19 was re-admitted to the facility on [DATE] from a psychiatric hospital. On 9/9/15 at 11:08 AM, an interview was conducted with the LCSW and RA. The LCSW stated that she would have expected to be contacted upon re-admission after an incident. The LCSW stated that she would have expected to be contacted regarding a behavior plan for her pain. The LCSW stated that a care plan should have been initiated. 5. Resident 91 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/9/15 resident 91's medical record was reviewed. A review of resident 91's admission MDS assessment dated [DATE], revealed that resident 91 had psychosis which included hallucinations and delusions. Resident 91 experienced behavioral symptoms that occurred 1 to 3 days and verbal behavioral symptoms that occurred 4 to 6 days, but less than daily. Resident 91 also exhibited wandering behaviors that occurred 1 to 3 days. Resident 91's CAA Summary triggered for resident 91 to have a care plan related to behavioral symptoms. (Note: Resident 91 did not have a care plan developed for behavioral symptoms.) A Psychosocial Note dated 8/17/15 revealed, . is combative when confused. She demonstrates anger through hitting and trying to escape the facility. She yells help over and over and says she doesn't walk ot (sic) yalk (sic) as she pushes her wheel chair away in an effort to escape. She is an escape risk and may physically hurt others. She clearly exhibits behavior that will be disruptive to other residents. Special Needs/Concerns/Recommendations: 1- .is capable of harming others if only mildly but it is a concern to be addressed in the care plan. 2- .possess as an escape risk when angry and confused. she places herself in jeopardy if she should somehow find a way to leave the facility. This issue should be addressed in the care plan. On 8/31/15 through 9/3/15 resident 91 was observed multiple times exhibiting exit seeking behaviors. The facility staff were observed redirecting resident 91 from the front door of the facility. A Health Status Note dated 8/30/15 revealed, Rt (resident) is a high fall risk. Very restless throughout day despite PRN anxiety meds (medications). Attempts to ambulate w (with)/out assistance over and over.Rt must be watched closely, tab alarm in-place . On 9/10/15 at 11:14 AM, an interview was conducted with the RA. The RA stated that she was not aware that resident 91 had behaviors. The RA stated that she was aware of resident 91's exit seeking behaviors. 6. Resident 89 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 9/2/15 resident 89's medical record was reviewed. A review of resident 89's admission MDS assessment dated [DATE], revealed that resident 89 had wandering behaviors that occurred 1 to 3 days. Resident 89 also had a Brief Interview for Mental Status (BIMS) score of 12. (Note: A BIMS score from 8 to 12: moderately impaired.) Resident 89 also had physical behavioral symptoms that occurred 1 to 3 days. A Care Plan revised on 7/27/15, revealed a focus of, The resident is an elopement risk/wanderer risk r/t Impaired safety awareness, History of attempts to leave facility unattended. Resident 89's goal was, The resident will not leave facility unattended through the review date. The Interventions for resident 89 to achieve the goal was, 1) Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. 2) Wander guard to right wrist at all times. Check placement Q (every) shift and function Q week. A Wandering Risk Assessment form dated 6/25/15 revealed resident 89 received a score of 6 or was a Moderate Risk for Wandering. A Wander Risk Scale form dated 6/25/15 revealed resident 89 received a score of 13 or was a High risk to Wander. A Psychosocial Note dated 6/30/15 revealed, Resident admitted on [DATE] from home. Resident was living with daughter. Resident is long term. Per nurse resident is alert and oriented x (times) 4. Resident is able to voice her needs and wants. Resident is adjusting to facility. Nursing Note entries for resident 89 dated 7/12/15 included the following documentation: a. On 7/12/15 at 2:28 AM, a facility nurse documented, Resident informed at 11 PM that she was walking to the store to get some things. Resident signed herself out. Arrived back to facility at 01 (1:00) AM intoxicated. Resident smelled of alcohol and was slurring her words.Resident stated she was leaving tonight and went to her room. About an hour and a half later resident came to nurses station and apoligized (sic) for the way she acted and stated she was going out for a cigarette. resident out smoking at this time. Will continue to monitor. b. On 7/12/15 at 3:53 AM, a facility nurse documented, Resident went out to smoke 45 minutes ago and has not returned. This nurse went to check on resident and she is no longer outside in smoking area. c. On 7/12/15 at 10:56 AM, a facility nurse documented, Calls have been place to the daughter every 15-20 minutes since first attempt. (Note: First attempt was at 9:35 AM.) d. On 7/12/15 at 11:24 AM, a facility nurse documented, Call received from (name of family member) who is (resident 89's) daughter. Informed regarding the events of the night.She has been in contact with the police. Informed of all actions taken by the facility since the resident eloped. e. On 7/12/15 at 4:47 PM, a facility nurse documented, Received in report from noc nurse this am that resident went out for a smoke around 0200 (2:00 AM), resident was placed on 15 minute checks. Resident eloped from facility, was last seen at 0230 (2:30 AM). Full search of all rooms of the facility and the grounds surrounding this am from 0715 (7:15 AM) - 0830 (8:30 AM). This nurse with another staff member walked the grounds at the church and field next to the facility from 0800 (8:00 AM) - 0820 (8:20 AM). No sign of resident at either. RNA sent to search neighborhood, (name of local store), and gas station that resident frequents was gone from 1000 (10:00 AM) - 1120 (11:20 AM). This nurse called (local) dispatch to report resident as missing aprox. (approximately) 1000 (10:00 AM). (Name of Officer) responded and made the report. Officer was able to get in touch with res. (resident's) daughter (name of daughter) after several attempts had been made by this nurse to notify her of situation. Administrator assisted with searching the surrounding area from 1215 (12:15 PM) - 1420 (2:20 PM). RNA was sent out again at 1400 (2:00 PM) to search the surrounding neighborhood for resident. RNA called this nurse at 1430 (2:30 PM) stating she found resident. RNA reported that she spoke with resident and tried to get her to return to facility. RNA stated that resident refused and took off running from her. This nurse asked RNA to back off but keep eyes on resident. Administrator notified and went to attempt to calm resident and bring her back to facility. Resident refused to return to facility and signed an AMA (Against Medical Advice) form with administrator and RNA as witnesses. RNA and Administrator returned at 1530 (3:30 PM). On 8/5/15 at 11:13 PM, a facility nurse documented, At approximately 2115 (9:15 PM) this shift, Rt. asked nurse if she could go outside with a friend who was present at the time to look at his car which was having issues. Nurse told resident that would be okay. At approximately 2120 (9:20 PM), staff member called facility saying that she saw rt. out front drinking alcohol with said friend. This nurse notified the admissions department head who went out and confirmed that rt. was drinking alcohol. Admissions notified rt.'s daughter and they both agreed that rt. was to be discharged from the facility at that time. Admissions explained to rt. the situation and rt. agreed to sign AMA form and go with family friend. Rt. took all of her belongings and left the facility at approximately 2200 (10:00 PM) this shift. MD (Medical Director), administrator and case manager notified. (Note: resident 89 was readmitted to the facility on [DATE].) A Psychosocial note dated 8/24/15 revealed, . left AMA before a Psychosocial could be completed. An interview was completed. Resident was combative and angry and insulting. She did not comply with request to be interviewed. Several attempts were made to reach her. (Note: Resident 89 left AMA from the facility on 8/5/15).

Based on observation, interview and record review it was determined that the facility did not ensure that each resident (1) maintained acceptable parameters of nutritional status, such as body weight, protein levels, unless the resident's clinical condition demonstrated that it was not possible; and (2) received a therapeutic diet when there was a nutritional problem. Specifically, 8 of 51 residents experienced weight loss and/or decreased laboratory values with no interventions. In addition, residents were not receiving the diets as ordered by the physician. Resident 93 will be cited at a harm level and the other residents cited at no actual harm with potential for more than minimal harm. Resident identifiers: 1, 15, 17, 31, 32, 58, and 70. Findings include: 1. Resident 93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/27/15 at 11:45 AM, an interview was conducted with resident 93. Resident 93 stated that the food was terrible. Resident 93 stated that he could not eat most of the food. Resident 93 stated staff members had not offered him high calorie foods or a supplement. Resident 93 stated that he had lost weight since admission and was, Skin and bones. Resident 93's medical record was reviewed on 8/27/15 and 9/8/15. Resident 93's weights in the electronic medical record were documented as the following: (Note: All weights were in pounds.) a. 7/29/15: 134.2 b. 8/5/15: 133.4 c. 8/12/15: 133 d. 8/19/15: 118.6 e. 8/26/15: 116.8 f. 9/4/15: 114.6 (Note: Resident 93's weight decreased 12.9% from 7/29/15 to 8/26/15. According the Minimum Data Set (MDS) 5% weight loss in 1 month was considered a significant weight loss.) A physicians telephone order dated 7/29/15 reveled, Add double portions of protein at each meal. On 8/27/15 at approximately 8:00 AM, an observation was made of the facility kitchen. The kitchen staff were observed to be placing food on plates for residents. The kitchen staff were observed to send resident 93 a single breakfast sandwich with sausage, gravy, and egg on a croissant. In addition, resident 93 was served cereal and a half of banana on the tray. The kitchen staff did not provide extra meat. On 8/27/15 at 8:40 AM, an interview was conducted with the facility Dietary Manager (DM) 2. The DM 2 stated that there were no alternative food items for breakfast. On 8/27/15 at approximately 11:50 AM, an observation was made of the facility kitchen. The kitchen staff were observed to be placing food on the plates for residents for lunch. Resident 93 was observed to receive a single piece of meat, pasta, mixed vegetables, strawberry and banana cup, and a roll. Resident 93's plate was not fortified or additional meat provided. An interview was immediately conducted with Cook 1. Cook 1 stated there were no fortified food items. Cook 1 further stated that there were no alternative foods available. Resident 93's laboratory result form dated 7/22/15, revealed a low [MEDICATION NAME] level of 2.8 g/DL (grams per deciliter). (Note: The normal laboratory value for [MEDICATION NAME] was 3.5-5.0.) A Dietary Profile dated 7/20/15 revealed, (Resident 93) is alert (and) oriented, able to express wants and needs. He feeds himself independently and tolerates regular diet with no s/s (signs or symptoms) of difficulties. He is a smoker and frequent drinker - consuming 1-12 beers daily. He is on hospice r/t (related to) liver Ca (cancer) with poor prognosis. Will honor preferences as able. An admission Nutritional Assessment dated 7/24/15 revealed, R (resident) (at) increased risk (secondary to) med (medical) hx (history), underweight. alb ([MEDICATION NAME]), likely r/t liver disease. He is on snacks TID (three times per day). Also recommend fortify diet and 60 ml (milliliters) med pass BID (twice a day) to help meet needs for weight gain. A Nutrition/Dietary Note signed by the facility Dietary Manager dated 7/24/15 revealed, (Resident 93) admitted to facility with DX (diagnosis) of alcoholic liver damage, [MEDICAL CONDITION], prutic (sic) disorder, chronic pain and hospice care r/t [MEDICAL CONDITION] with poor prognosis. He is alert and oriented, able to express wants and needs. He tolerates regular texture diet with no s/s chewing or swallowing difficulties and chooses to eat his meals in his room. He receives snacks TID to encourage increased kcal (calories) intake. His overall intake is fair, avg (average) 50-75(percent) q (every) meal. Pt (patient) CBW (current body weight) of 134.8 is low for pt and puts his BMI (body mass index) at 18. Pt is unsure of usual weight since decline, additionally wt (weight) has fluctuated r/t BLE (bilateral lower extremity) [MEDICAL CONDITION] and ascities (sic). Pt is a frequent smoker and drinks 6-packs (plus) of beer daily. Will refer to RD (Registered Dietitian) to clarify nutritional needs. Resident 93's Medication Administration Record [REDACTED]. On 9/1/15 at 10:01 AM, a follow-up interview was conducted with resident 93. Resident 93 stated he had requested food items from the alternative menu several times and had not been receiving them. Resident 93 stated he was only eating toast for breakfast, and if available a roll for lunch because he had not received the food he had ordered from the alternative menu. Resident 93 stated, I am going to starve to death before [MEDICAL CONDITION] kills me. Resident 93 then stated, I am going to start taking my [MEDICATION NAME] three times a day so I don't care. On 8/27/15 at approximately 2:30 PM, an interview was conducted with the facility Director of Nursing (DON). The DON stated that resident 93 had not been administered Medpass as recommended by the facility RD. The DON stated she did not know why the Medpass had not been ordered and administered to resident 93. On 9/1/15 at approximately 1:30 PM, an interview was conducted with RD 2. RD 2 stated she talked with resident 93. RD 2 stated that resident 93 stated he was not receiving alternative menu items which he had ordered. RD 2 stated that resident 93 was at high nutritional risk and needed high calorie interventions. 2. Resident 58 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 58's medical record was reviewed on 8/27/15 and 9/8/15. Resident 58's weight from the electronic medical record revealed: (Note: All weights are in pounds.) a. 4/1/15 118.6 b. 5/6/15 116 c. 6/3/15 117.6 d. 7/8/15 113.8 e. 8/5/15 108.4 f. 9/4/15 103.4 (Note: Resident 58 lost 12.8 % over 6 months, 9.1 % over 3 months and 4.6 % over 1 month.) A Nutrition/Dietary Note dated 7/2/15 revealed, Pt review during skin and weight meeting. Noted in chart. PT has had significant weight loss over the past week. Pt MedPass will be increased to 120 QID (four times a day) and she will receive 4oz (ounce) fortified pudding QD (every day). Will continue current interventions and continue to monitor. The note was signed by the facility Dietary Manager. A Nutrition/Dietary Note dated 7/13/15 revealed, Pt with significant weight loss over the past week. current interventions: fortified pureed diet, magic cup TID, and med pass (sic). Pt MedPass will be increased to 120 QD and she will receive 4 oz fortified pudding QD. Will continue current interventions and cotinue (sic) to monitor. A physicians telephone order dated 7/8/15 revealed, Give med pass (sic) 120 ml po QD, 4 oz fortified pudding po QD, D/C (discontinue) current med pass (sic) order. There were no additional dietary interventions documented. On 8/27/15 at approximately 8:30 AM, an observation was made of resident 58. Resident 58 was observed to receive a breakfast plate with pureed foods. Resident 58 had a #16 scoop of pureed eggs, #30 scoop of pureed sausage, #10 scoop of oatmeal, and a #16 scoop for the croissant. There was no magic cup as prescribed by the physician for breakfast. The Therapeutic Spreadsheets for 8/27/15 for the breakfast meal revealed the following portion/scoop sizes to be served to residents receiving a pureed diet: a. Pureed egg/cheese croissant was a #6 scoop b. Hot cereal was a 4 ounce ladle c. Pureed hashbrowns was a #8 scoop (Note: Resident 58's portion sizes were smaller than the therapeutic menu sizes required to meet dietary needs. The larger number the scoop size correlates to a smaller portion size. In addition, resident 58 did not receive the pureed hashbrowns.) On 8/27/15 at 8:35 AM, an interview was conducted with Cook 1. Cook 1 confirmed the above scoop sizes were used for all residents receiving pureed diets. Cook 1 stated that residents with pureed foods get tired of potatoes so she did not prepare the pureed hashbrowns. Cook 1 stated she did not substitute another food in place of the hashbrowns. Cook 1 stated she did not know what scoop sizes to use to serve resident meals. On 8/27/15 at 8:40 AM, an interview was conducted with Dietary Manager (DM) 2. DM 2 stated that the facility was out of magic cups. DM 2 stated that there were no alternative menu items made for breakfast. DM 2 stated that the food order had been delivered the day before. DM 2 stated she did not know why the facility was out of magic cups. On 8/27/15 at 8:50 AM, an interview was conducted with the facility Registered Dietician (RD). The RD stated that she was not aware that the portion sizes were not according the the menus. The RD stated that it was shocking that the pureed portion sizes were so small. The RD stated that it was not acceptable. On 8/27/15 at 10:36 AM, an observation was made of the snack cart. Resident 58 was observed to receive cottage cheese for her snack. (Note: Resident 58's physician ordered fortified pudding for a snack.) On 8/27/15 at 11:00 AM, an interview was conducted with Dietary Aide (DA) 1. DA 1 stated that there was no fortified pudding to send for snacks. DA 1 stated that she did not know how to make the fortified pudding. DA 1 stated that the DM had not instructed her on how to make the fortified pudding. 3. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's medical record was reviewed on 9/8/15. Resident 1's current diet order dated 5/19/15 revealed, Fortified diet, Regular texture, Regular consistency. Resident 1's care plan dated 7/1/15 revealed the following problem, Nutrition - (Resident 1) is at nutritional risk r/t inability to feed himself independently secondary [MEDICAL CONDITION] with [MEDICAL CONDITION], contractures, and impaired vision. Resident 1's goals revealed, Nutrition status will be maintained over the next 90 days. Weight will remain stable. The interventions developed for resident 1 to obtain the goal were, (1) Assess (Resident 1's) dietary preferences at least on a quarterly basis. (2) Weigh (resident 1) per facility protocol and make appropriate interventions. Notify physician of significant changes. (3) Ensure fluids are within residents reach. (4) Provide (resident 1) with snacks per order. (5).(6)obtain labs as ordered. (7).(8) . (9). (10) Diet SNP (special nutrition program), regular. (11) Magic cup lunch (and) dinner. (12) .(13) 90 ml Medpass TID. Resident 1's laboratory values dated 5/21/15 revealed an [MEDICATION NAME] level of 3.4 G/DL with total protein 6.0 G/DL. (Note: Normal [MEDICATION NAME] value was 3.5-5.0 and Total Protein value was 6.3-8.2.) Resident 1's previous laboratory value dated 3/2/15 revealed an [MEDICATION NAME] level of 3.6 which was within normal limits according to the laboratory result form. A Nutrition/Dietary Note dated 5/29/15 revealed, R (resident) w/ (with) h/o (history of) [MEDICAL CONDITIONS], GER ([MEDICAL CONDITION] reflux),[MEDICAL CONDITION](hypertension), fair po intake. UBW (usual body weight) 140 (pounds). current supps (supplements): 1000 units Vit (Vitamin) D magic cup w/ lunch and dinner. Med pass (sic) dc'd with resultant (sic) weight loss. Diet order: reg (regular), fortified, large portions. recommend restart 90 ml med pass TID. (Note: There was no information that addressed resident 1's low [MEDICATION NAME] level.) A Nutrition/Dietary Note dated 7/2/15 revealed, Pt reviewed during skin and weight meeting. Pt not regularly accepting magic cup intervention. Will d/c magic cups and increased med pass (sic) to 120 cc (cubic centimeters) Q day. The note was signed by the facility DM. A Nutrition/Dietary Note dated 7/13/15 revealed, R refusing magic cup. weight remains less that UBW. Med pass (sic) increased for 90 TID to 120 ml TID. Conti (continue) to monitor and intervene prn (as needed). The note was signed by the facility RD. On 8/27/15 at 8:35 AM, an interview was conducted with Cook 1. Cook 1 stated she did not know what to send for a fortified diet. Cook 1 stated that there were no fortified foods served with breakfast. On 8/27/15 at 8:36 AM, an interview was conducted with DA 1. DA 1 stated that the residents that required a fortified diet received whole milk with each meal. On 8/27/15 from 11:50-12:30 PM, an observation was made of the facility trayline for lunch. The trayline was observed to have a piece of meat, spaghetti noodles with no sauce, blend of vegetables, roll, and a mixture of strawberries and bananas on the side. An interview was conducted with Cook 1. Cook 1 stated that she put butter on the rolls for residents who had a fortified diet. Cook 1 stated that all residents on a regular and mechanical soft diet received rolls with butter. 4. Resident 31 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 8/27/15 from 8:35 until 9:15 AM, an observation was made of resident 31. Resident 31 was observed to be offered assistance by the Activities Coordinator (AC). The AC handed resident 31 a fork with french toast. Resident 31 was observed to feed herself the french toast. Resident 31 was observed to chew the french toast for 11 minutes. Resident 31 was observed to make eating motions with the fork from the plate to her mouth. Resident 31 was unable to get food on the fork but continued to motion the empty fork towards her mouth. Resident 31 was not observed to receive any fortified foods. Resident 31 was observed to have french toast, 2 full slices of bacon and fruit loops. Resident 31's medical record was reviewed on 8/27/15. Resident 31's weights in the electronic medical record were: (Note: All weights were in pounds.) a. 5/27/15 124 b. 7/29/15 115.6 c. 8/26/15 114.2 (Note: Resident 31 lost 7.9% in 3 months.) Resident 31's physicians orders revealed the following diet orders: a. Medpass 2.0 120 mls TID b. Fortified diet, mechanical soft texture, regular consistency Resident 31's laboratory result sheet dated 4/8/15 revealed that her [MEDICATION NAME] was 3.3 G/DL and Total Protein was 5.9 G/DL which were both low according to the laboratory result form. A Nutrition/Dietary Note dated 6/10/15 revealed, R weight is trending down. She is currently on house supp (supplement) w (with)/ meals, fortified diet, prostat 30 ml QD. recommend 90 ml med pass (sic) TID. (Note: Resident 31 did not receive a house supplement with her breakfast or lunch meal on 8/27/15.) A Quarterly Nutritional Assessment signed 7/6/15 by the facility RD revealed, Pt diet is fortified to encourage increased kcal intake and m/s (mechanical soft) texture r/t chewing difficulties. Pt accepts supplements 100(percent). She requires assistance to eat her meal. Although currently stable at 118 (pounds) with BMI of 18, Pt wt is trending down with over all decline. Pt is on hospice. recommend increase med pass (sic) to 120 ml TID. Resident 31's care plan dated 7/13/15 revealed, Focus: The resident has nutritional problem or potential nutritional problems r/t dementia. Hx of [MEDICAL CONDITION], and visual impairment. (Resident 31) wears dentures and requires assistance at meals. The goal for resident 31 was, The resident will maintain adequate nutritional status as evidenced by maintaining weight within 5 (percent) of CBW. Interventions included, (Resident 31) may be offered alternative meal items if not satisfied with her meal. (Resident 31) will be offered soup and 1/2 sandwich at dinner, .(Resident 31) will eat in the assisted dining room to receive increased supervision and necessary assistance. Provide snacks and supplements as ordered. (Resident 31) receives mighty shake QD, 90cc Medpass TID and snacks BID. Provide, serve diet as ordered. Monitor intake and record q meal. (Resident 31) receives Fortified, Mechanical Soft diet. Resident 31's meal card delivered with her meal was observed and revealed that resident 31 was to receive, Mech (mechanical) soft/Grnd (ground) Fortified. The meal card further revealed, Likes French Toast, Bacon, Fruit Loops. The meal card revealed, serve food in bowls. On 8/31/15 at approximately 10:30 AM, an interview was conducted with resident 31's family member. Resident 31's family member stated that resident 31 needed her food in bowls and assistance with eating. Resident 31's family member stated that resident 31 does not receive her food in bowls. Resident 31's family member stated that resident 31 does not receive the foods the family requested for her. 5. Resident 32 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 32's medical record was reviewed on 8/27/15 and 9/9/15. Resident 32's physician order [REDACTED]. Resident 32's laboratory result dated 4/2/15 revealed an [MEDICATION NAME] level of 3.4 G/DL which was low according to the laboratory result form. Resident 32's weights in the electronic medical record revealed: (Note: All weights were in pounds.) a. 3/25/15 190.8 b. 4/22/15 191.4 c. 5/27/15 190.2 d. 6/24/15 187 e. 8/19/15 177.2 f. 9/4/15 178.4 (Note: Resident 32's weight loss was not significant but had a trending weight loss.) On 8/27/15 during the breakfast and lunch trayline an observation was conducted. There were no observed trays with double meat. In addition, reduced concentrated sweets diet orders were not provided different items. On 9/9/15 at 3:20 PM, an interview was conducted with resident 32. Resident 32 stated that she dislikes double portions of meat. Resident 32 stated that she did not like her meat ground up. Resident 32 further stated that she did not receive the alternative foods she had requested. Resident 32 further stated that no one had discussed her weight loss with her or changing her meat to a ground texture. On 9/9/15 at 2:50 PM, an interview was conducted with Cook 1 and Cook 2. Cook 1 and Cook 2 stated that there was a modified diabetic diet, reduced concentrated sweets diet and a carbohydrate controlled diet. Cook 2 stated that all the diets were different. Cook 1 and Cook 2 stated that they have not been educated about what to serve to the different diabetic diets. Cook 2 stated she had been employed at the facility for a year and a half. (Note: There was no documentation regarding resident 32's weight loss. In addition, there was no nutritional care plan in resident 32's medical record regarding nutrition.) 6. Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 17's medical record was reviewed on 8/27/15 and 9/9/15. A physician order [REDACTED]. A nutrition care plan dated 2/4/14 revealed that, (Resident 17) is at nutritional risk secondary to inability to feed herself independently, need for mechanically altered diet secondary to dysphagia and dementia. Resident 17's developed goal was, Nutrition status will be maintained over the next 90 days. Weight will remain stable. Resident 17's interventions developed to achieve the goal were, Provide (resident 17) with assistance with meals as needed, If (resident 17) is not satisfied with her meal please offer her an alternative. Weigh (resident 17) per facility protocol and make appropriate interventions. Notify physician of significant changes . NAS (No added salt), SNP, pureed diet with nectar thick liquids, (resident 17) eats in assisted diningroom (sic), Medpass 60 cc po TID, provide (resident 17) with meals and snacks per orders, ensure fluids are within resident reach, . Resident 17's laboratory results were reviewed and revealed that on 3/4/15 the [MEDICATION NAME] was 3.5 G/DL which was within normal limits. Resident 17's total protein was 6.2 G/DL which was low. On 8/7/15 her [MEDICATION NAME] was 3.2 G/DL which was low and her total protein level was 5.6 G/DL which was low. (Note: Resident 17's laboratory values had decreased from 3/4/15 to 8/17/15.) A Nutrition/Dietary Note dated 7/8/15 revealed, Pt reviewed during skin and weight meeting, noted in chart. The note was signed by the facility Dietary Manager. A quarterly Nutritional Assessment dated 6/24/15 revealed that, R with fair po intake. On fortified diet and med pass (sic). Weight is stable on current nutrition interventions (sic). Cont to monitor and intervene prn. The assessment was not signed by the facility Registered Dietician. On 8/27/15 at approximately 8:00 AM, an observation was made of the facility trayline. Cook 1 was observed to plate a #30 scoop of pureed sausage, #10 scoop of oatmeal, and a #16 scoop for the pureed bread. Cook 1 stated that resident 17 did not like eggs. Cook 1 was observed to send resident 17's tray with no protein substitute. On 9/9/15 at 2:51 PM, an interview was conducted with DM 1. DM 1 stated that the diets provided and diet orders did not match. DM 1 confirmed the kitchen staff were not serving fortified or diabetic diets. 7. Resident 70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/1/15, an admission Minimum Data Set (MDS) assessment was completed. The facility staff assessed resident 70 as being alert and oriented with no cognitive impairment. Resident 70 was as having a Body Mass Index (BMI) level that was elevated. A care area assessment (CAA) triggered for nutritional status. The facility staff documented that a care plan would be developed related to resident 70's nutritional status. The care plans developed for resident 70 were reviewed. There was not a care plan that had been developed related to resident 70's nutritional status. A physician's telephone order with no date revealed, Add double meat portions to all meals. A Nutrition/Dietary Note dated 6/8/15 reveled, R has low [MEDICATION NAME] level. Elevated BMI (at) 48.2. Will sent large portions protein foods, cont to monitor and intervene prn. The note was signed by the facility RD. On 8/27/15, observations were made during the breakfast and lunch trayline in the facility kitchen. There were no double meat or large meat portions provided by the Dietary Staff. 8. Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/8/15 resident 15's medical record was reviewed. A review of the dietary order dated 4/27/15, revealed that resident 15 was receiving a mechanical soft controlled carbohydrates diet with high protein snacks BID. Resident 15's weights in the electronic medical record were: (Note: All weights are in pounds.) a. 5/27/15: 220.4 b. 6/10/15: 220.3 c. 6/17/15: 222.4 d. 7/01/15: 224.6 e. 7/08/15: 225.2 f. 7/15/15: 231.4 g. 8/19/15: 197.6 h. 9/04/15: 194.4 (Note: Resident 15 lost 14.6% of her total body weight in one month, with a total weight loss of 10.3% since 5/27/15.) A Nutritional Assessment was not completed for resident 15. A care plan dated 7/1/15 for resident 15's nutrition was located in resident 15's medical record. Resident 15's care plan had not been revised to include resident 15's weight loss or additional interventions to prevent weight loss. (Note: No care plans were developed prior to 7/1/15.) On 9/10/15 at 9:00 AM, an interview was conducted with the DON. The DON confirmed that resident 15 has experienced weight loss with no nutritional assessment.

Based on observation, interview and record review, it was determined the facility did not have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident. Specifically, residents had eloped from the facility, residents who needed assistance with dining did not receive it, medications were given over four hours late, non-facility staff provided one on one supervision, and call lights were not answered in a timely manner. Resident identifiers: 31, 36, 39, 45, 58, 72, 73, 93, and 97. Findings include: 1. On 8/31/15 upon admission to the facility the following medication administration times were given to the survey team: AM medication pass 6:00 AM - 10:00 AM Noon medication pass 11:00 AM - 1:30 PM PM medication pass 4:00 PM - 8:00 PM HS (hour of sleep) medication pass 11:00 PM On 9/1/15 at 10:33 AM, an observation was made of Agency Registered Nurse (ARN 2) passing medications. ARN 2 stated she was still passing morning medications medications and had twelve residents who still needed their morning medications. On 9/1/15 at 11:16 AM, a follow up interview was conducted with ARN 2. ARN 2 stated she was still passing morning medications to residents. ARN 2 stated some resident's medications were scheduled to be given at 7:00 AM, but she was running really behind on passing resident medications. ARN 2 stated she had talked with Licensed Practical Nurse (LPN) 3 several times and LPN 3 knew she was behind on passing resident medications. ARN 2 stated facility staff had not offered to help her pass medications even though she was behind. On 9/1/15 at 11:18 AM, an interview was conducted with LPN 3. LPN 3 stated she had talked with ARN 2 several times but ARN 2 did not mention how behind she was on passing resident medications. LPN 3 stated she was aware ARN 2 was still passing medications. A. Resident 36 was admitted to the facility 4/10/14 with [DIAGNOSES REDACTED]. On 9/1/15 resident 36's medical record was reviewed, and the following physician order [REDACTED]. On 9/1/15 resident 36's September 2015 Medication Administration Record [REDACTED]. B. Resident 73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/1/15 resident 73's medical record was reviewed, and the following physician orders [REDACTED].> i. 7/27/15, [MEDICATION NAME] Capsule 100 MG Give 100 mg by mouth two times a day. ii. 7/27/15, [MEDICATION NAME] Tablet 325 MG Give 325 mg by mouth two times a day. iii. 7/27/15, [MEDICATION NAME] Chloride Tablet Give 5 mg by mouth two times a day. iv. 7/27/15, Quetiapine [MEDICATION NAME] Tablet Give 150 mg by mouth two times a day. v. 7/27/15, [MEDICATION NAME] Capsule 100 MG Give 100 mg by mouth three times a day. On 9/1/15 resident 73's September 2015 MAR indicated [REDACTED]. (Note: Both of resident 73's second daily doses of Quetiapine [MEDICATION NAME] and [MEDICATION NAME] were scheduled to be given during the noon medication pass.) C. Resident 58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/1/15 resident 58's medical record was reviewed, and the following physician orders [REDACTED].> i. 6/9/15, [MEDICATION NAME] Tablet 0.5 MG Give 0.25 mg by mouth two times a day. ii. 6/10/15, [MEDICATION NAME] Capsule 50 MG Give 50 mg orally three times a day. iii. 6/10/15, [MEDICATION NAME] Tablet 50 MG give 50 mg by mouth three times a day. On 9/1/15 resident 58's September 2015 MAR indicated [REDACTED]. (Note: Resident 58's second daily dose of [MEDICATION NAME] on 9/1/15 was scheduled for the noon medication pass.) D. Resident 45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/1/15 resident 45's medical record was reviewed, and the following physician order [REDACTED]. On 9/1/15 resident 45's September 2015 MAR indicated [REDACTED]. E. Resident 31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/1/15 resident 31's medical record was reviewed, and the following physician orders [REDACTED].> i. 6/9/15, [MEDICATION NAME] Capsule 100 MG give 100 mg by mouth two times a day. ii. 6/9/15, Senna Tablet 8.6 MG Give 8.6 mg by mouth two times a day. On 9/1/15 resident 31's September 2015 MAR indicated [REDACTED]. 3. On 8/31/15 at 8:48 AM, an observation was made of the call light for room [ROOM NUMBER] alarming. At 8:58 AM, the call light for room [ROOM NUMBER] was answered by the facility Director of Nursing (DON). (Note: The call light alarmed for 10 minutes before faciltiy staff answered it.) On 9/3/15 at 7:51 AM, an observation was made of the call light alarming for room [ROOM NUMBER]. At 8:17 AM, the call light for room [ROOM NUMBER] was answered. (Note: The call light alarmed for 26 minutes before facility staff answered it.) 4. On 8/31/15 at 9:57 AM, an interview was conducted with resident 93. Resident 93 stated the facility was Ridiculously understaffed. On 8/31/15 at 10:47 AM, an interview was conducted with resident 72. Resident 72 stated sometimes she had to push her call light so her roommate would get help, but that they had to wait Almost an hour for staff to answer the call light. Resident 72 stated, We shouldn't have to wait almost an hour On 8/31/15 at 2:13 PM, an interview was conducted with resident 39. Resident 39 stated there was not enough staff in the building. Resident 39 stated, They (facility staff) are late on my meds (medications) and sometimes even miss my medications. Resident 39 stated when he had pulled his call light for assistance he had waited for 30 minutes for staff to answer his call light. On 8/27/15 at approximately 2:30 PM, an interview was conducted with Certified Nurses Assistant (CNA) 1. CNA 1 stated that there was not enough staff to care for the residents as required. CNA 1 stated that there had been elopements because there was not enough staff to respond to the door alarms. CNA 1 stated that residents were falling because there was not enough staff to respond to safety alarms and call lights. On 9/2/14 at 3:31 PM, an interview was conducted with Agency Registered Nurse (ARN) 1. ARN 1 stated that there was not enough staff and residents were falling. ARN 1 stated that call lights were alarming for extended periods of time with no response because there was not enough staff. On 9/2/15 at 1:18 PM, an interview was conducted with the facility DON. The DON stated her first full week in the facility was the week of 8/24/15, she stated the previous Assistant Director of Nursing was in charge and was to report to me. The DON stated the previous DON's last day was 8/3/15. 4. On 8/31/15 at 1:15 PM, an Administrator from a sister facility was providing one-on-one supervision of resident 97 throughout the afternoon. On 9/2/15 at 11:20 AM, a Registered Nurse (RN) from a sister facility was assigned to provide one-on-one cares for resident 97. The RN asked the state surveyors who the resident was that she was assigned to care for. (Cross refer to F309, F311, F312, F323, F325, F333, and F362)