Every finding on record at Majestic Care of Kent

Based on observation, staff interview, and review of the facility policy and procedure, the facility failed maintain a clean and sanitary resident environment in good repair. This had the potential to affect all residents except 10 residents (#2, #11, #13, #14, #15, #16, #18, #27, #32, and #42) that resided on the memory unit. The facility census was 43. Findings include: 1. Review of Resident #33's medical record revealed the resident was admitted on [DATE] with diagnoses including major depressive disorder, generalized anxiety disorder and chronic obstructive pulmonary disease. Review of Resident #33's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Observation on 07/10/26 at 5:43 A.M. of Resident #33's room revealed the down spouting outside of the resident's room was lying on the ground. During an interview on 07/10/26 at 5:45 A.M., Resident #33 revealed rain came into his room from the window because the down spouting was not repaired. During an interview on 07/10/26 at 9:10 A.M., Director of Maintenance (DOM) #441 confirmed the down spouting outside of Resident #33's window fell off during a windy storm about two months ago, and he has not had a chance to repair it yet. 2. During an observation on 07/10/26 at 9:22 A.M., DOM #441 noted that at the entrance to the dining room near the kitchen, the corner protector was missing from the wall, along with sections of baseboard in the hallway. Inside the dining room, on the back wall where two glass doors lead to the courtyard, two tiles were missing on either side of the left glass door near the floor, exposing wires. On the right glass door, closer to the kitchen, another tile was missing at the bottom left corner, also revealing exposed wires. DOM #441 verified these findings and explained that the floor had recently been installed and the dining room had reopened about one week earlier. He stated the wires were not believed to be live and that the tiles still needed to be placed. To confirm, DOM #441 used a testing device that illuminated red but emitted a beep when a wire was live. When he tested the wires in the areas with the three missing tiles, the wires near the glass door closest to the kitchen beeped, indicating they were live. DOM #441 acknowledged that the exposed wires were live and stated he would have them properly fixed and covered. Observation during the interview on 07/10/26 at 9:49 A.M. with Resident #12 revealed a large black fan blowing on the resident that was full of dust. The ceiling above Resident #12's bed had various areas of chipped and hanging paint pieces. During an observation on 07/10/26 at 9:59 A.M. in Resident #12's room, Housekeeper (HSK) #500 verified that the fan was very dusty and stated that housekeeping would normally clean it. HSK #500 also confirmed the presence of chipped and hanging paint above Resident #12's bed and reported that she had verbally notified DOM #441 of this issue a long while ago. At this time, HSK #500 stated there was a large area of chipped paint that had fallen from Resident #6's ceiling. Observation of Resident #6's ceiling revealed a basketball sized section of missing ceiling paint directly above the resident's bed, exposing a flat white ceiling surface. HSK #500 and Resident #6 both stated they verbally reported this issue to DOM #441 about one week ago. Observation on 07/10/26 at 10:07 A.M. with DOM #441 of Resident #22's bathroom revealed the baseboard under the sink the was missing, and the wall was in disrepair. At this time the observation, DOM #441 verified but could not recall what happened. Follow-up interview on 07/10/26 at 10:25 A.M. with DOM #441 stated he recalled there was a leak in Resident #22's room that was repaired, and he had not been back to repair the wall. DOM #441 stated that was about two weeks ago. DOM #441 stated he was not aware of the chipped and falling paint on the ceilings of Residents #6 and #12's room. Review of the facility policy titled Safe and Homelike Environment, revised 11/07/25, revealed to provide a safe, clean, comfortable, and homelike environment that supports resident independence, enables the use of personal belongings, and ensures the delivery of care and services in a manner that minimizes safety risks and promotes well-being. This deficiency represents non-compliance investigated under Complaint Number 3022593.

Based on record review, observation, interview and review of the United States Pharmacopeia National Formulary Standards, the facility did not ensure medication storage refrigerators were maintained at the proper temperatures for safe medication storage on the 100/200 halls. This had the potential to affect all 28 residents residing on the 100/200 halls (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27 and #28) of 47 residents residing in the facility. The facility census was 47. Findings include:An interview on 05/20/26 at 7:06 A.M. with LPN #135 revealed refrigerator temperatures in the medication room were not being monitored daily or being written in after the fact. LPN #135 stated a digit may be added or changed to make the temperature appear higher than it was. LPN #135 stated the medication refrigerator temperatures were too cold at times to safely store the medications. Observation on 05/20/26 at 7:12 A.M. with Registered Nurse (RN) #175 of the 100/200 hall medication storage refrigerator revealed the internal temperature was at 36 degrees Fahrenheit (F) which was at the low end of acceptable. RN #175 confirmed this refrigerator contained and stored medications for the residents on the 100/200 halls and provided the surveyor the Equipment Temperature Log for the refrigerator for May 2026.Review of the facility document provided by RN #175 titled Equipment Temperature Log for the 100/200 hall medication refrigerator, dated May 2026, revealed directions at the bottom of the log stated refrigerators should temp at 41F or below; equipment not holding food within a safe temperature range will be indicated as do not use until appropriate repairs are made. There were no guidelines on the form regarding the accepted cold holding temperature range for medications in the refrigerator. Temperatures were recorded at freezing levels between 26 to 32 degrees F on 05/01/26, 05/02/26, 05/03/26, 05/04/26, 05/05/26, 05/05/26, 05/09/26 and 05/13/26 with staff initials next to the temperatures.An interview on 05/20/26 at 7:15 A.M. with RN #175 confirmed the temperatures documented on the Equipment Temperature Log dated May 2026.A confidential interview on 05/20/26 with a staff member who wished to remain anonymous revealed medications were not always stored at the proper temperature in the medication refrigerator and temperature logs were incomplete.An interview on 05/21/26 at 8:30 A.M. with the DON revealed she was aware of temperature issues with the medication refrigerator on the 100/200 hall being below 36 degrees at times and she had put in a work order for maintenance within the last month. The DON stated she was monitoring it and again reported it to maintenance to adjust. The DON stated she did not have to move any of the medications.An interview on 05/21/26 at 2:05 P.M. with the Administrator confirmed the temperatures documented on the May 2026 temperature log for the 100/200 hall medication storage refrigerator were at or below 32 degrees F on 05/01/26, 05/02/26, 05/03/26, 05/04/26, 05/05/26, 05/05/26, 05/09/26 and 05/13/26 Review of the United States Pharmacopeia (USP) National Formulary General Notices: Storage Temperature Definitions revealed that USP defines Cold storage as 36 F to 46 F, which represents the accepted professional standard for refrigerated medication storage.This deficiency represents noncompliance investigated under Complaint Number 2987494.

Based on medical record review, interview and review of facility policy, the facility failed to ensure resident weights were monitored according to physician orders. This affected two residents (Residents #12 and #48) of three reviewed for nutrition services. The facility census was 47.Findings include:1.Review of the medical record for Resident #12 revealed an admission date of 03/15/16 with diagnoses including hemiplegia, type two diabetes mellitus, and vascular dementia.Review of the physician order dated 02/28/25 for Resident #12 revealed an order for monthly weights on day shift on the fifth of the month.Review of the clinical weight summary in the medical record for the past five months from 12/25 to 05/26 revealed no monthly weight was recorded for December 2025.Review of the nursing progress notes dated 12/05/25 for Resident #12 revealed staff were unable to obtain weight and would obtain weight the next day. There was no evidence of a second attempt to obtain a weight on Resident #12 in subsequent progress notes for the December weight.Review of the January 2026 Medication Administration Record (MAR) for Resident #12 revealed the weight on 01/05/26 was indicated as not applicable, so no weight measurement was listed on the MAR for the date Resident #12 needed to be weighed per physician order.Review of the weight entered under clinical weight summary section of the medical record for the date of 01/23/26 for Resident #12 revealed a weight entered by the Director of Nursing (DON) at 10:06 A.M. of 147.3 pounds.Review of the clinical weight summary in the medical record for the past five months from 02/26 to 05/26 revealed no monthly weight was recorded for February 2026.Review of the February 2026 MAR for Resident #12 revealed on 02/05/26 a weight of 161.1 pounds was recorded that indicated a weight gain of 13.8 pounds or a significant weight gain of 9.3 percent since the prior weight of 147.3 pounds on 01/23/26. There was no evidence of a re-weight being obtained to confirm the significant weight gain.Review of progress notes dated 02/05/26 through 02/28/26 revealed and there was no progress note recorded to address the weight change for Resident #12.Review of the March 2026 MAR for Resident #12 revealed the weight on 03/05/26 was indicated as not applicable.Review of the weight for Resident #12 entered under the clinical weight summary section of the medical record on 03/03/26 at 10:13 P.M. revealed it was marked as entered in error by the DON and then reentered at 10:24 P.M. by the DON at 10:25 P.M. as 149 pounds weight for Resident #12.Review of the April 2026 MAR for Resident #12 revealed the weight on 04/05/26 was indicated as not applicable.Review of the 04/06/26 weight entered under the clinical weight summary section of the medical record by the DON at 11:09 A.M. revealed a weight of 149 pounds.Review of the 04/19/26 quarterly Minimum Data Set (MDS) 3.0 assessment revealed Resident #12 had intact cognition and required maximum assistance from staff for activities of daily living (ADL).Review of the May 2026 MAR for Resident #12 revealed the weight on 05/05/26 was indicated to see nursing progress note.Review of the progress note dated 05/05/26 for Resident #12 indicated the monthly weight was not obtained.Review of the 05/06/26 weight recorded under the clinical weight summary section in the medical record revealed a weight of 167 pounds which indicated an 18 pound or 12 percent significant weight gain over the past month. There was no evidence that a re-weight was obtained to check for accuracy of the weight or to confirm a significant weight gain.An interview on 05/21/26 at 8:30 A.M. with the DON confirmed if a resident showed a significant weight change from a prior weight, the resident was to receive a reweight within 24 hours. The DON verified residents who were admitted would be weighed weekly for four weeks and then according to physician orders. The DON confirmed Resident #12 did not get weighed according to physician orders and re-weights were not completed when indicated. 2. Review of the closed medical record for Resident #48 revealed an admission date of 12/31/25 and a date of death of [DATE]. Pertinent diagnoses included type two diabetes mellitus, moderate protein-calorie malnutrition, and Alzheimer's dementia. Review of the medical record clinical weight summary for Resident #48 revealed the first recorded weight was completed on 01/05/26 (five days after admission) at 124 pounds then on 02/02/26 and 02/03/26 at 123.0 pounds. Review of the physician orders for Resident #48 dated 02/01/26 revealed monthly weights were ordered. Review of the physician orders for Resident #48 revealed weekly weights were ordered on 03/03/26.Review of the clinical weight summary in the medical record for Resident #48 revealed a weight was recorded on 03/03/26 of 122.5 pounds. Review of the physician note dated 03/05/26 revealed Resident #48's weight is down two pounds in a month, and weekly weights have been requested. Review of the physician note dated 03/09/26 for Resident #48 revealed the physician was awaiting a weekly weight measurement on Resident #48.Review of the significant change MDS 3.0 assessment dated [DATE] revealed Resident #48 had severe cognitive impairment and was dependent upon staff for ADL. Further review of the weights in the medical record for Resident #12 revealed the next recorded weight was 04/02/26 at 120.5 pounds. An interview on 05/21/26 at 8:30 A.M. with the DON confirmed Resident #48 did not get weighed according to physician orders and confirmed the weights as documented. Review of the facility policy titled Weight Monitoring, dated 06/15/25, revealed all residents would be weighed within three days of admission and recorded in the electronic medical record (EMR) by the admitting nurse. Weekly weights would be obtained and recorded in the EMR for four weeks for new admissions to the facility and residents exhibiting significant weight changes or residents determined to be at high nutritional risk. Weekly weights should be taken on a designated day each week. Residents would be re-weighed and verified if a weight change of plus or minus three pounds in a week was noted. Residents would be re-weighed and verified if a weight change of greater than five pounds in a month was noted for an individual over 100 pounds. If the resident declined to be weighed, documentation would be made in progress notes that the weight had not been taken. This deficiency represents non-compliance investigated under Complaint Number 2987494.

Based on observation, record review, interview and review of facility policy, the facility failed to ensure adaptive feeding equipment was provided per physician orders for Resident #12. This affected one (Resident #12) of one resident reviewed for adaptive feeding equipment. The facility identified one resident (Resident #12) as requiring adaptive feeding equipment. The facility census was 47. Findings include:Review of the medical record for Resident #12 revealed an admission date of 03/15/16 with diagnoses including hemiplegia, type two diabetes mellitus, and vascular dementia.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 had intact cognition and required set up for eating. Review of the physician order dated 10/30/25 for Resident #12 revealed a regular diet with a high sided plate and a rocker knife. Review of resident #12's care plan last revised on 04/26/26 revealed Resident #12 had nutrition risk related to diabetes mellitus, hypertension, hemiplegia and mild cognitive impairment. Resident #12 was noted to require a high sided plate and rocker knife with meals. Observation on 05/20/26 at 1:20 P.M. with Registered Dietitian (RD) #178 of Resident #12's meal tray revealed the high sided plate and rocker knife were not provided for the lunch meal. Interview at the time of the observation with Resident #12 revealed he frequently did not get the rocker knife or high sided plate and it made it harder for him to eat his meals. Review of the 12/08/25 revised facility policy called Adaptive Feeding Equipment revealed it was the purpose to ensure that residents/patients who require assistance during meals are assessed for adaptive feeding equipment or restorative dining interventions to promote independence, safety, dignity and adequate nutritional intake. Dietary must be notified of adaptive equipment needs and ensure equipment is placed on tray at each meal. This deficiency represents non-compliance investigated under Complaint Number 2987494.

Based on record review, interview and review of the facility self-reported investigation (SRI) investigation, the facility failed to administer evening medications on 02/21/26 as ordered by the physician to Residents #33, #36, #37, #38, #39, #40, #43, #44, #45, #46, #47, #49, #50, #52, #54, and #57. This affected 16 (Residents #33, #36, #37, #38, #39, #40, #43, #44, #45, #46, #47, #49, #50, #52, #54, and #57) of 24 residents reviewed for medication administration on 02/21/26. The facility census was 53.Findings include:1. Review of the medical record for Resident #33 revealed an admission date of 05/29/25. Diagnoses included cellulitis of left lower limb, hypothyroidism, and obesity.Review of the Medication Administration Record (MAR) for February 2026 revealed Resident #33 did not receive lactobacillus capsule (probiotic), desmopressin acetate (antidiuretic hormone) 0.1 milligrams (mg), levothyroxine (thyroid hormone) 25 micrograms (mcg) 2 tablets, expedite (liquid collagen) 60 milliliters (ml), ProStat (protein supplement) 30 ml, and loratadine (antihistamine) 10 mg on the evening of 02/21/26.2. Review of the medical record for Resident #36 revealed an admission date of 08/11/22. Diagnoses included type two diabetes mellitus, morbid obesity, and depression.Review of the MAR for February 2026 revealed Resident #36 did not receive his colchicine (anti-inflammatory) 0.5 mg on the evening of 02/21/26.3. Review of the medical record for Resident #37 revealed an admission date of 11/15/24. Diagnoses included congestive heart failure, lymphedema, and diabetes insipidus.Review of the MAR from February 2026 revealed Resident #37 did not receive his ezetimibe (cholesterol reducing medication) 10 mg, metformin (medication to treat diabetes) 500 mg, expedite 60 ml, acetaminophen (analgesic) 500 mg two tablets, gabapentin (anticonvulsant and nerve pain medication) 400 mg, and ProStat 30 ml on the evening of 02/21/26.4. Review of the medical record for Resident #38 revealed an admission date of 06/24/24. Diagnoses included chronic obstructive pulmonary disease (COPD), emphysema, and atrial fibrillation.Review of the MAR from February 2026 revealed Resident #38 did not receive his melatonin (hormone to aid in sleep) 5 mg, montelukast (asthma medication) 10 mg, Protonix (stomach acid reducer) 40 mg, trazadone (antidepressant) 50 mg, apixaban (blood thinner) 5 mg, metoprolol tartrate (medication to treat high blood pressure, angina, and heart failure) 50 mg, omega 3 capsule (supplement), Pulmicort (corticosteroid inhaler) two puffs, senna (laxative) 8.6 mg, Combivent (bronchodilator) one puff, Haldol (antipsychotic) 2 mg, and Tylenol (analgesic) 325 mg two tablets, on the evening of 02/21/26.5. Review of the medical record for Resident #39 revealed an admission date of 02/19/26. Diagnoses included necrotizing fasciitis, acute respiratory failure, and diabetes mellitus.Review of the MAR from February 2026 revealed Resident #39 did not receive his atorvastatin calcium (cholesterol reducing medication) 40 mg on the evening of 02/21/26.6. Review of the medical record for Resident #40 revealed an admission date of 03/27/25. Diagnoses included COPD, schizophrenia, and depression.Review of the MAR from February 2026 revealed Resident #40 did not receive his divalproex sodium ER (mood stabilizer) 500 mg, melatonin 3 mg, trazadone 50 mg, Zyprexa (antipsychotic) 20 mg, Seroquel (antipsychotic) 75 mg, Ativan (antianxiety) 0.5 mg, and Ativan 0.5 mg on the evening of 02/21/26.7. Review of the medical record for Resident #43 revealed an admission date of 04/25/24. Diagnoses included Alzheimer's Disease, type two diabetes mellitus, and COPD.Review of the MAR from February 2026 revealed Resident #43 did not receive his atorvastatin calcium 80mg, Flomax (treats benign prostatic hypertrophy) 0.4 mg, gabapentin 100 mg, Keppra (anti-epileptic) 5 ml, magnesium oxide (supplement) 400 mg, memantine (treats Alzheimer's disease) 5 mg, metformin 500 mg, and Prilosec (reduces stomach acid) 20 mg on the evening of 02/21/26.8. Review of the medical record for Resident #44 revealed an admission date of 05/09/24. Diagnoses included dementia, depression, and malignant neoplasm of bone marrow.Review of the MAR from February 2026 revealed Resident #44 did not receive her donepezil (medication to improve cognitive function) 10 mg on the evening of 02/21/26.9. Review of the medical record for Resident #45 revealed an admission date of 05/09/24. Diagnoses included vascular dementia, atrial fibrillation, and hypertension.Review of the MAR from February 2026 revealed Resident #45 did not receive his donepezil 10 mg on the evening of 02/21/26.10. Review of the medical record for Resident #46 revealed an admission date of 04/23/22. Diagnoses included atrial fibrillation, COPD, and senile degeneration of the brain.Review of the MAR from February 2026 revealed Resident #46 did not receive his Remeron (antidepressant) 15 mg, rivaroxaban (anticoagulant) 20 mg, trazadone 25 mg, hydroxyzine (antihistamine) 25 mg, Symbicort (asthma medication) two puffs, and a Magic Cup (nutritional supplement) on the evening of 02/21/26.11. Review of the medical record for Resident #47 revealed an admission date of 02/27/19. Diagnoses included schizophrenia, hypertension, and insomnia.Review of the MAR from February 2026 revealed Resident #47 did not receive her divalproex sodium (mood stabilizer) 125 mg, fluphenazine decanoate (antipsychotic) 25 mg/ml 0.5 ml intramuscular, melatonin 10 mg, quetiapine fumarate (antipsychotic) 50 mg, aspirin (blood thinner) 81 mg, Zyprexa 5 ml, and Ensure Plus 4-ounces (nutritional supplement) on the evening of 02/21/26.12. Review of the medical record for Resident #49 revealed an admission date of 02/20/23. Diagnoses included catatonic schizophrenia, insomnia, and intermittent explosive disorder.Review of the MAR from February 2026 revealed Resident #49 did not receive his melatonin 10 mg, trazadone 75 mg, benztropine mesylate (anticholinergic) 0.5 mg, Keppra 50 0mg, risperidone (antipsychotic) 1 mg, senna 8.6 mg, clonazepam (benzodiazepine) 0.25 mg, and thiamine (supplement) 100 mg on the evening of 02/21/26.13. Review of the medical record for Resident #50 revealed an admission date of 06/20/25. Diagnoses included seizures, visual hallucinations, and dementia.Review of the MAR from February 2026 revealed Resident #50 did not receive his atorvastatin calcium 10 mg, Lantus (insulin) 24 units, Remeron 30 mg, Ativan 0.5 mg, Eliquis 5 mg, Glucerna 8 ounces (nutritional supplement), Keppra 500 mg, metoprolol tartrate 12.5 mg, Humalog (insulin) 4 units, and Seroquel 50 mg on the evening of 02/21/26.14. Review of the medical record for Resident #52 revealed an admission date of 12/31/25. Diagnoses included type two diabetes mellitus, dementia, and overactive bladder.Review of the MAR from February 2026 revealed Resident #52 did not receive her Protonix 40 mg, Ensure Plus 8 ounces, and Remeron 7.5 mg on the evening of 02/21/26.15. Review of the medical record for Resident #54 revealed an admission date of 12/09/23. Diagnoses included Alzheimer's disease, convulsions, and insomnia.Review of the MAR from February 2026 revealed Resident #54 did not receive her melatonin 10 mg and Keppra 500 mg on the evening of 02/21/26.16. Review of the medical record for Resident #57 revealed an admission date of 08/29/24. Diagnoses included Alzheimer's disease, dementia, and anxiety disorder.Review of the MAR from February 2026 revealed Resident #57 did not receive her Buspar 9antianxiety) 5 mg, Ensure Plus 8 ounces, and Ativan 0.5 mg on the evening of 02/21/26.Interview on 03/12/26 at 9:05 A.M. with the Administrator and the Director of Nursing (DON) confirmed on 02/21/26 the Assistant Director of Nursing (ADON) was called in to work the day shift and when her shift ended at 7:00 P.M., her replacement never showed up. The ADON abandoned her shift and called the Administrator and quit her job. The ADON dropped her keys for the medication cart off at the Administrators home. There was still a nurse in the facility during that shift and there were extra keys available in the Administrators' office which the nurse on duty had access to. The nurse working refused to take the keys to the medication cart since they were not signed off to her. The nurse working at the facility that night did not administer nighttime medications to the residents on the 300 and 400 halls. All residents were assessed that night, and pain medications were administered as needed to those residents. The facility started an SRI for the event and assessed all residents affected. No adverse outcomes were found as each resident was assessed by the nurse practitioner, and the pharmacist reviewed all the medications to ensure no concerns. No outcomes were found. Resident #57, on the 300 units, who did have a seizure the next day, but after review of her medical record revealed no diagnoses of seizure disorders, and she was not on any seizure medications.Review of the facility SRI tracking number 2713454 dated 02/21/26 revealed a nurse left the faciity on [DATE] at around 7:30 P.M. taking the medication cart keys and not signing them off to the other nurse. The nurse left because her replacement did not show up, and she quit her job. The nurse dropped her keys off at the Administrators home who promptly returned them the next day. The Administrator informed the nurse in the facility that there were extra keys available to her, but she would not accept them because they were not signed out to her. No residents on the 300 or 400 halls received their nighttime medications as prescribed. The next morning two nurses showed up for their shifts and all residents were assessed and interviewed if able. The residents on the 300 and 400 halls were assessed by the nurse on duty during the night, wound care treatments were provided as ordered, and as needed pain medications were administered. After thorough review of the facility along with collaboration with the physician's assistant and pharmacist no adverse outcomes were identified. All staff were reeducated on the attendance policy, and the Administrator and the DON have been monitoring staffing since the incident.This deficiency represents non-compliance investigated under Master Complaint Number 279187.

Based on interview, record review and review of facility policy, the facility failed to provide advanced, written notification of room changes that were signed by the resident and/ or the resident's representative for Residents #16, #30, and #56. This affected three (Residents #16, #30, and #56) of three residents reviewed for room changes.Findings include:1. Review of the medical record for Resident #16 revealed an admission date of 01/20/26. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure, and obesity.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had intact cognition and required extensive assistance for all activities of daily living.Review of the progress note dated 02/11/26 revealed staff talked with Resident #16 and her daughter on 02/10/26 regarding a room move. The family and resident were agreeable.Review of the intra facility room change form dated 02/11/26 revealed Resident #16 was transferring rooms but was not signed by Resident #16 or her representative.2. Review of the medical record for Resident #30 revealed an admission date of 05/23/16. Diagnoses included hypertensive chronic kidney disease, gastroesophageal reflux disease, and obesity.Review of the annual MDS dated [DATE] revealed Resident #30 had moderate cognitive impairment and required extensive assistance with all activities of daily living.Review of the progress note dated 02/10/26 revealed Resident #30 was spoken to regarding a room move. Resident #30 was in agreement and observed throughout the facility telling everyone about the move.Review of the intra facility room change form dated 02/11/26 revealed Resident #30 was moving rooms. The form was not signed by Resident #30 or her representative.3. Review of the medical record for Resident #56 revealed an admission date of 02/08/25 and a discharge date of 02/26/26. Diagnoses included limb girdle muscular dystrophy, neuromuscular bladder, and osteoarthritis.Review of the annual MDS dated [DATE] revealed Resident #56 had intact cognition and required extensive assistance for all activities of daily living.Review of the progress notes revealed no notes observed about a room change on 02/11/26.Review of the facility intra facility room change form dated 02/11/26 revealed Resident #56 was to change rooms, but it was not signed by Resident #56 or her representative.Interview on 03/11/26 at 11:10 A.M. with Social Worker #503 and the Administrator confirmed there were room changes for Residents #16, #30, and #56. They confirmed there was no written notice of the transfer given to the residents or their representatives. They reported Residents #16 and #30 were notified of the room change on 02/10/26, and their rooms were moved on 02/11/26. They provided documentation to support that. No documentation was available for Resident #56, but they reported they spoke with Resident #56 and her brother on 02/10/26, and her room was moved 02/11/26. During that conversation with her brother was when Social Worker #503 was notified to look into transferring Resident #56, and she began that process. The Administrator and Social Worker #503 reported 24-hour notice they felt was appropriate for timely notice.Review of the facility policy Room or Roommate Change, original date 01/02/24, revealed prior to making a room change or roommate assignment, all persons involved in the change assignment, such as residents and their representatives, will be given advance notice of such a change is possible. The notice of a change in room or roommate will be provided in writing; in a language and manner the residents and the representatives understand and will include the reasons why the move or change is required.This deficiency represents non-compliance investigated under Complaint Number 274269.

Based on observation, interviews, and review of facility policy, the facility failed to maintain a safe, clean and sanitary kitchen, and store frozen foods in accordance with professional standards of food safety. This had the potential to affect all 51 residents who received food prepared in the kitchen. The facility census was 51Findings include:Observations on 01/28/26 at 8:35 A.M. during a tour of the kitchen revealed the walk-in freezer revealed one large bag of beef patties, one large bag of chicken breasts, one large bag of breaded chicken tenderloins and one large bag of peppers and onions, all opened and undated. Interview at the time of the observation with Kitchen Aide #506 and Facility [NAME] #531 confirmed the findings and stated all opened frozen foods should be sealed and dated to prevent freezer burn. The dishwasher sanitization area had a large amount of black mold-like substance covering the walls below the rinse shelf where the automatic dishwasher was placed. There was also an open wall area approximately six by six inches with exposed wires which were also covered in a black mold-like substance and a notable amount of dirt and debris on top of the wires and wire casing unit. Interview at the time of the observation with Kitchen Aide #506 verified the findings and stated she was not aware of the black mold-like substance on the walls and under the dishwasher shelf.Interview with Maintenance Director #536 on 01/28/26 at 10:50 A.M. confirmed the black mold-like substance and the dirt and debris on the walls under the dishwasher shelf including the approximately six by six inch hole in the wall that was used for the installation of the new automatic dishwasher unit; however, the wall opening was never closed which exposed it to the black mold-like substance and a notable amount of dirt and debris inside the drywall and on the wiring. Review of the facility policy labeled, Label and Dating, revised 10/06/25, revealed all food items prepared, opened, or stored in the facility kitchen must be clearly labeled and dated to maintain food safety, prevent spoilage, and ensure compliance with state health regulations and local health department requirements.Review of facility policy labeled, Kitchen Sanitation, revised 10/06/25, revealed sanitary conditions were maintained in the storage, preparation, and serving areas at all times. Equipment was to be clean, organized, and free of spills, mold, or build up.This deficiency represents non-compliance investigated under Master Complaint Number 2689815 and Complaint Number 2687104.

Based on record review and interview, the facility failed to have a written transfer agreement with one or more hospitals. This had the potential to affect all 55 residents residing in the facility.Findings include:Review of the hospital-nursing facility transfer agreement dated 12/31/24 revealed the hospital had not signed the agreement, only the facility agent.Interview on 09/03/25 at 8:22 A.M. with the Administrator revealed she was unable to find a signed transfer agreement with a hospital. She stated she was only able to locate the transfer agreement dated 12/31/24 and it was not signed by the hospital.

Based on interview, record review, review of personnel files, review of a self-reported incident (SRI), review of the facility's investigation and review of the facility policy, the facility failed to implement its abuse policy relative to screening staff against the Nurse Aide Registry (NAR) prior to employment as well as timely reporting, thorough investigations and effective education of staff regarding abuse. This affected three personnel files for [NAME] #569, Certified Nursing Assistant (CNA) #561 and Activity Assistant (AA) #585 out of nine files reviewed with the potential to affect all 55 resident in the facility.1.Review of personnel files on 08/28/25 at 9:21 A.M. and 3:34 P.M. with the Administrator and Human Resources (HR) #590 revealed the following areas of concern: a. Review of CNA #561's personnel file revealed a hire date of 08/22/24. There was no check against the NAR to rule out any findings of abuse and neglect until 03/06/25.b. Review of [NAME] #569's personnel file revealed a hire date of 05/28/25. There was no evidence [NAME] #569 was checked against the NAR to rule out any findings of abuse and neglect.c. Review of AA #585's personnel file revealed a hire date of 07/16/25. There was no evidence AA #585 was checked against the NAR to rule out any findings of abuse and neglect. Interview on 08/28/25 at 3:55 P.M. with the Administrator verified staff were to be checked against the NAR prior to working with residents to rule out any findings of abuse and neglect. Review of the facility policy, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation, revised 06/05/25 and effective 07/01/25 revealed the facility would do the following prior to hiring a new employee: a) check the Nurse Aide Registry (and attempt to check other state registries if the individual is known to have worked in another state) for all potential new employees (licensed and unlicensed) and new volunteers to determine if there is a finding of abuse, neglect or misappropriation of property against the individual prior to the use of that individual. 2. Review of Resident #49's medical record revealed an admission date of 03/01/24 and diagnoses including Alzheimer's disease, dysphagia, constipation, generalized anxiety disorder, vascular dementia with behavioral disturbance, psychotic disorder and mood affective disorder. Resident #49 had a legal guardian and was receiving hospice services. Review of Resident #49's quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 had cognitive impairment, displayed physical and verbal behaviors one to three days in the look-back period and was dependent for upper body and lower body dressing. Review of Resident #23's medical record revealed an admission date of 08/11/22 and diagnoses including Asperger's syndrome, morbid obesity, depression, type two diabetes and insomnia. Resident #23 was his own responsible party. Review of Resident #23's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #23 was cognitively intact and did not display behaviors. Resident #23 was dependent for dressing, personal hygiene and dressing and required partial/moderate assistance for rolling. Review of a SRI dated 07/27/25 and submitted to the State Agency (SA) at 4:23 P.M. revealed an allegation of staff to resident neglect involving Certified Nursing Assistant (CNA) #555, Resident #23 and Resident #49. Licensed Practical Nurse (LPN) #536 informed Unit Manager (UM)/LPN #532 that CNA #561 expressed concern that CNA #555 who was working with her had yelled at and shook Resident #49 while dressing him in her presence. CNA #561 also reported that CNA #555 went into Resident #23's room and argued with him. The allegation was not reported to another agency. The facility determined the allegation of neglect to be unsubstantiated as Resident #23 refuted the allegation of verbal abuse and disputed information from CNA #561 could not be verified. Review of a timeline included in the facility's SRI investigation revealed on 07/27/25 (time not given), LPN #536 contacted UM/LPN #532 to report an allegation of abuse that was reported to her by CNA #561. CNA #561 reported that CNA #555 shook Resident #49 and yelled at him while they were dressing the resident (time not given). CNA #561 reported that CNA #555 had yelled out in a mocking manner saying okay, okay, okay which is what Resident #49 was known for repeating as he had limited verbalization due to his Alzheimer's diagnosis. It was reported that both CNAs then went to Resident #23's room (time not given) to assist with care. UM/LPN #532 instructed LPN #536 to ask CNA #555 to leave immediately (time not given) then go into Resident #23's room to ask about the reported allegation. Resident #23 denied concerns with staff, denied any CNA yelling or arguing with him and indicated he felt safe. UM/LPN #532 instructed LPN #536 to complete pain assessments on Resident #23 and Resident #49 and to complete skin assessments on all residents on the 300 and 400 halls. Resident #49's skin assessment was negative. UM/LPN #532 notified the Director of Nursing Services (DNS) and Regional Director of Operations (RDO) of the allegation, an SRI was initiated and an investigation began. Continued review of the facility's timeline revealed on 07/28/25, UM/LPN #532 assessed Resident #23 and Resident #49 who were within normal limits. Social Service Director (SSD) #559 observed and interviewed residents on the 300 and 400 halls with no findings. Continued review of the facility's timeline revealed on 07/29/25, Resident #23 had a care conference and did not voice any concerns or issues. A follow-up interview completed by the Administrator with CNA #555 revealed she was blindsided by the allegations as she had been a CNA at the facility for 14 years. CNA #555 stated she only touched Resident #49's shoulders when putting his shirt on and may have said okay, okay, okay but not in a mocking way but to repeat as that is how Resident #49 communicated. CNA #555 felt the allegations were false and may have been ignited the day before because she had to repeatedly ask where the other CNA was during that shift. SSD #559 met with Resident #23 who was resting. SSD #559 met with Resident #23 again on 07/30/25 who was resting and smiled when he asked how he was feeling.Review of an undated witness statement authored by CNA #561 revealed it was directed towards the facility's previous Human Resource Director (HRD), UM/LPN #532 and the DNS and revealed the following information: I am writing to formally report a situation that I believe violated workplace policies and may have impacted my sense of safety and professionalism on the job. On 07/27/25 (no time given) I witnessed my co-worker [CNA #555] yell and shake a dementia patient [Resident #49] as we were dressing him. Then (no time given) the next patient [Resident #23] [CNA #555] argued with and I stepped in to diffuse the situation. The coworker cooled down but I reported this to two different nurses, UM/LPN #532 and the DNS. I believe it is important to bring this forward in the spirit of maintaining a respectful and accountable but mostly safe workplace. I am willing to cooperate with any investigation or discussion necessary. Please confirm receipt of this message and let me know the next steps. Review of a witness statement dated 07/27/25 and authored by CNA #555 revealed the following information: Today I helped my co-worker with Resident #49 (no time given). Everything went good, she put his pants on and I put his shirt on and got him up in his chair. Additional writing on this statement dated 07/29/25 and signed by the Administrator revealed the following information: I knew the other CNA and did not expect anything. I don't know why she would make accusations. I have spent 14 years working at the facility. There was another accusation in the past made by the resident (not specified) a few months ago. I put his [Resident #49's] shirt on. I did not shake him. I may have said 'okay, okay,' but not to mock him - that's just how he communicates. I have never had a problem with the other CNA. I spent much of the day asking where the CNA was and the nurse (not specified) would say 'no.' And I stated, 'I haven't either.' I don't know, I have worked here a long time and would never abuse a resident. I don't do this job for the Administrator or the DNS, I do it for the person in the bed. Review of a witness statement dated 07/27/25 and authored by Registered Nurse (RN) #518 revealed the following information: I was approached by CNA #561 (time not given) and she told me that she was in the room with CNA #555 changing Resident #49. She said CNA #555 was frustrated and shook Resident #49. She said she is about to be a nurse and that she would have to report it. Review of a witness statement dated 07/27/25 and authored by LPN #536 revealed the following information: CNA #561 came to me while I was walking down the hallway (time not given). CNA #561 stated while her and CNA #555 were in Resident #49's room she witnessed CNA #555 put her hands on Resident #49's shoulders and shake him, mocking him, saying 'okay, okay, okay.' I would like to add that I feel like CNA #561 was upset she was told by this nurse that she was working the 300 hall and the other CNA was working 400 hall by herself. I went in to speak to Resident #23 who stated nothing happened other than CNA #444 was moody and upset because she did not have any linen to do his bed bath. Additional writing present on LPN #536's statement that lacked a date and an author revealed that RN #518 reported to LPN #536 that something happened with CNA #555 between 9:30 A.M. and 10:00 A.M. which was late reporting and CNA #555 did an amazing job and never had issues. Review of a witness statement dated 07/27/25 and authored by LPN #578 denied witnessing abuse of any sort on 07/27/25 or any other days worked previously.Review of a witness statement dated 07/29/25 and authored by SSD #559 revealed she spoke with Resident #23 who was resting in bed and was alert and oriented times three. Resident #23 told SSD #559 that CNA #555 did not verbally abuse him and asked who the other CNA was that had come in and told him another resident had had an incident with CNA #555. Resident #23 stated he did not want to be put into this situation and stated he felt safe at the facility. Review of CNA #555's time punch detail revealed she worked on 07/27/25 from 6:56 A.M. to 3:34 P.M. The next date CNA #555 worked was on 08/05/25. Interview on 08/27/25 at 1:53 P.M. with Resident #23 revealed there was a CNA (not named) that was verbally abusive to him about four months ago and who had a snarky attitude. The CNA would make him wait, then not do what he requested. Resident #23 reported he had not seen the CNA in a while. Observation on 08/28/25 at 12:42 P.M. revealed UM/LPN #532 was interacting with Resident #49 who was seated in a Broda chair on the secured unit. The surveyor asked Resident #49 how lunch was and Resident #49 put his head down and did not respond. Resident #49 was not interviewable due to cognition. Interview on 08/28/25 at 1:45 P.M. with RN #518 revealed on 07/27/25, she was working in the front of the facility on the 200 hall and CNA #555, CNA #561 and LPN #536 were in the back of the facility. Around 2:00 P.M. RN #518 was on her lunch and CNA #561 approached her while she was in her car. CNA #561 stated she thought she had to report something as CNA #555 was in a room with her and grabbed Resident #49 and shook him. RN #518 stated she told CNA #561, 'yes, you need to report that. You need to tell your charge nurse then contact the previous Administrator and if not the DNS.' RN #518 stated LPN #536 had called a member of management staff at some point and they were gathering statements from anyone CNA #555 and CNA #561 spoke to. When asked if she reported the allegation, RN #518 stated she did not tell anyone about the allegation as CNA #561 and LPN #536 were doing that. RN #518 stated CNA #561 was also telling a resident, Resident #11, about the incident and Resident #11 also told CNA #561 she had to report the allegation. When asked if CNA #555 was sent home, RN #518 stated she should have been sent home immediately but was not sure if this occurred. Interview on 08/28/25 at 2:00 P.M. with CNA #573 revealed on 07/27/25, she was working in the front of the facility and recalled CNA #561 said CNA #555 said harsh words to an unknown resident. Around 3:00 P.M. CNA #561 appeared shook and came to her, telling her she reported this to LPN #536 and RN #518 but did not report it right away. CNA #573 stated CNA #561 did not divulge what time the incident occurred at. When asked if she reported the allegation, CNA #573 stated she did not report this to anyone as CNA #561 did what she was supposed to do. CNA #573 also stated CNA #555 did not go home right away on 07/27/25 but should have and this was because the allegation was not reported as it was happening. CNA #573 reported she never was asked to write a statement regarding the allegation even as she was working the date and shift the allegation occurred within. When asked about the facility's abuse protocol, CNA #573 stated staff were to make sure the resident was safe, remove the alleged perpetrator immediately and if after telling the charge nurse nothing was done, the DNS or Administrator were to be contacted. Interview on 08/28/25 at 2:23 P.M. with CNA #565 revealed she worked on 07/27/25 in the front of the facility but denied writing a statement regarding the allegation that occurred on that date and shift. Interview on 08/28/25 at 2:41 P.M. with LPN #578 revealed she had worked all four halls during her time at the facility and denied knowledge of the allegation on 07/27/25 during that date and shift. When asked about the facility's abuse protocol, LPN #578 stated residents should be separated, then the DNS should be contacted and if she weren't available then she would contact the manager on call. Interview on 08/28/25 at 2:56 P.M. with LPN #536 revealed she worked on 07/27/25 in the back of the facility. Around 2:30 P.M. to 3:00 P.M. she went outside to take a smoke break and RN #518 told her CNA #561 was going to tell her that CNA #555 did something to Resident #49. LPN #536 stated she asked RN #518 what was she talking about and RN #518 reported CNA #561 had just come to her, something had happened in the room with CNA #555 and she did not want to tell her. LPN #536 asked RN #518 why CNA #561 did not tell her about this, as she was the nurse on the 300 and 400 halls. LPN #536 went to go talk to CNA #561. CNA #561 told her that she and CNA #555 were in Resident #49's room getting him dressed around 10:00 A.M. and CNA #555 put her hands on his shoulder, shook him and was mocking him. LPN #536 explained that Resident #49 said the same words over and over due to his cognitive decline. CNA #561 also told her CNA #555 argued with Resident #23. LPN #536 stated by this time it was 3:30 P.M. or so and she told CNA #561 to write a statement. LPN #536 stated she and RN #518 spoke to Resident #23, who denied the allegation but stated CNA #555 was upset there was no linen for his shower. LPN #536 stated she contacted UM/LPN #532, who was the nurse on call, before dinner [4:30 P.M. to 5:00 P.M.] to report that RN #518 told her CNA #561 had told her CNA #555 did something to Resident #49. At that point, CNA #555 was already out of the facility as her shift was over at 3:00 P.M. but she had written a statement before leaving. LPN #536 stated they got statements from everyone on 07/27/25 for the 7:00 A.M. to 3:00 P.M. shift. LPN #536 confirmed CNA #555 was not removed immediately from the facility as CNA #561 did not report the allegation timely. When asked about the facility's abuse protocol, LPN #536 stated she would call the Administrator but she did not have the Administrator's number in this case so she called the manager on call. Phone interview on 08/28/25 at 3:17 P.M. with CNA #555 revealed she currently worked the front of the facility and had not worked in the back of the facility for several weeks. When asked why this was, CNA #555 reported she was accused of shaking Resident #49 by another staff member and was told to write a statement before she left at 3:00 P.M. that day [07/27/25]. CNA #555 verified she worked her entire shift on 07/27/25, from 7:00 A.M. to 3:00 P.M. CNA #555 stated she worked with Resident #49 in the morning and then was suspended after her shift that day. When she returned to work on 08/05/25, CNA #555 stated she was scheduled in the front of the facility and was told the allegations were unsubstantiated. When asked about the allegations involving Resident #23 and Resident #49, CNA #555 stated Resident #23 was like a child and called her grandma and denied the allegations. Interview on 08/28/25 at 4:00 P.M. with the Administrator confirmed CNA #555 worked her entire shift on 07/27/25 and did not go home early as the allegation of neglect/abuse was not reported timely. Interview on 08/28/25 at 5:06 P.M. with UM/LPN #532 revealed on 07/27/25 (no time given) LPN #536 called her to tell her CNA #561 came to her with concerns about CNA #555 including grabbing and shaking Resident #49 during care and saying 'okay, okay, okay,' then going into Resident #23's room and gave him attitude. At that time CNA #561 told CNA #555 to exit the room. UM/LPN #532 shared LPN #536 did not mention abuse but told her, I know I need to report this. UM/LPN #532 stated she called the DNS and they explained CNA #555 needed to go home but she had already exited the building at that time. UM/LPN #532 reported Regional Nurse Consultant (RNC) #598 became involved and someone at the corporate level initiated a SRI. UM/LPN #532 stated staff floated across the units at the facility. For the SRI, CNA #561 was the only witness to the allegation and shared CNA #555 was moved to the front of the facility post-allegation as an intervention. Phone interview on 08/29/25 at 10:08 A.M. with CNA #561 revealed on 07/27/25, CNA #555 helped her with Resident #49's care as she dressed from his feet up and CNA #555 dressed him from his head down around 12:30 P.M. When she looked up, CNA #561 was shaking Resident #49 for two minutes as he fought her while she tried to put his shirt on. CNA #561 stated Resident #49 was holding on to CNA #555's arms and was not hitting her and then CNA #555 stated, Oh my God, why the (expletive) can't you just work with me? Why do you have to fight with me? CNA #561 stated she told CNA #555, I need you to breathe, this is not worth your license, and shared CNA #555 replied back, (Expletive) this place, I don't care about this place. CNA #561 was questioned regarding CNA #555's verbal statements as these were not in her written statement which she verified during the interview and stated she informed the DNS of this content while she wrote her statement. After the incident, she walked out of Resident #49's room and CNA #555 stood in front of LPN #536 so she did not feel she could talk to LPN #536. CNA #561 stated she then spoke to RN #518 in the parking lot who told her to report the incident. Later, she overheard CNA #555 cursing at Resident #23 while trying to clean him up and she intervened and told CNA #555 to just go. CNA #561 stated she spoke to Resident #23 who stated he does not like when CNA #555 screams. CNA #561 then stated she reported these incidents to LPN #536 (time not given) and shared CNA #555 did not leave right away but she did not know when CNA #555 actually left. When asked about the facility's abuse protocol, CNA #561 stated she was educated on abuse but not the procedure upon hire and was directed to report abuse issues to the nurse. CNA #561 confirmed she was to report allegations of abuse/neglect immediately and shared she had not been re-educated since the allegations occurred. Interview on 09/02/25 at 8:46 A.M. with the DNS revealed on 07/27/25 after 3:00 P.M. UM/LPN #532 called her and they ended up doing a three-way call with LPN #536. At this time, CNA #555 had already left as it was shift change. During the call, it was shared CNA #555 was rude to Resident #23 and shook Resident #49's shoulder. Someone (not identified) said RN #518 was told first, but then it went to LPN #536 who stated 'I just found out' and had called UM/LPN #532 first. The DNS confirmed RN #518 never called her or reported the allegation to her. The DNS stated she then had to call RNC #598 to get an SRI started as the facility did not have an Administrator during the weekend the allegation occurred. During the interview, the DNS was questioned if the police were contacted regarding the allegation of neglect/abuse and indicated police should be called with SRIs. The DNS was informed at this time there was no evidence the police were contacted with the SRI and she did not disagree. Interviews on 09/02/25 at 9:29 A.M. and 4:40 P.M. with the Administrator revealed she officially started at the facility on 07/29/25 and that is when she became aware of the SRI involving Resident #23 and Resident #49 on 07/27/25. When asked about if the police were involved with the allegation, the Administrator stated they (not specified) asked the residents/responsible parties if they wanted the police contacted and stated UM/LPN #532 had reported to her the responsible parties did not want the police called. When asked about the lack of statements from all staff working on the affected date and shift for the SRI, the Administrator stated they interviewed where the allegation occurred and confirmed statements were not collected from CNA #565 and CNA #573. When asked about the lack of resident statements or skin sweeps on the 100 and 200 halls, as many care staff floated across the whole facility, the Administrator confirmed no residents on the 100 or 200 halls had their skin checked or were interviewed. When asked if personnel files were reviewed as part of the SRI, the Administrator confirmed she did not review personnel files even as the facility policy directed to do so. When asked about the timeline regarding the incident and the reporting of the allegation, the Administrator stated it seemed like it took most of the day for CNA #561 to report the allegation which was not immediate as required. The Administrator verified the overall SRI on 07/27/25 was not thoroughly investigated, did not follow the facility's abuse protocol and multiple facility staff did not report the allegation of abuse/neglect immediately as required. Review of the facility policy, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation, revised 06/05/25 and effective 07/01/25 revealed residents have the right to be free from abuse, neglect, exploitation and misappropriation of resident/patient property. Care team members should immediately report all such allegations to the Administrator and to Department of Health (DOH) in accordance with the procedures in this policy. [The facility would ensure] all care team members would report all incidents and allegations of abuse, neglect, mistreatment, exploitation and misappropriation of resident/patient property, as well as notifying the Administrator, Director of Nursing, or charge nurse immediately upon identification of any new injuries. If a care team member is accused or suspected, the facility should immediately remove the care team member from the facility and schedule pending the outcome of the investigation. All incidents and allegations of abuse, neglect, exploitation, mistreatment and misappropriation of resident/patient property and all injuries of unknown source must be reported immediately to the Administrator/designee and they should be notified in person, via telephone, text message or phone call. Once the Administrator and the Department of Health (DOH) are notified, an investigation of the alleged violation will be conducted. The person investigating the incident should generally take the following actions: Interview the resident/patient, the accused, and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident, came in close contact with the resident the day of the incident (including the other patients/residents, family members) and employees who worked closely with the accused employees and/or alleged victim the day of the incident. If there are no direct witnesses, the interviews may be expanded. Consider interviews with all care team members on the shift or the unit as well as other residents/patients on the unit. If the allegation involves abuse/neglect interview other residents to determine if they may have been affected by the accused care team member. If the accused is a care team member, employment records are reviewed.If the facility suspects that a crime has been committed, it will report that suspicion to law enforcement. If the resident has serious bodily injury, law enforcement must be notified within two hours; without serious bodily injury, law enforcement must be notified within 24 hours.Facility will educate its care team members upon hire and annually thereafter regarding the facility's policy concerning abuse, neglect, exploitation and misappropriation of resident's property and training will include but not be limited to how to report knowledge related to allegations without fear of reprisal. Ensure resident and other residents are protected throughout the investigation.

Based on observation, interview and review of the facility policy, the facility failed to ensure foods were labeled, dated and not retained when expired. This affected 53 residents receiving meals from the kitchen as Residents #2 and #50 were ordered nothing-by-mouth. Facility census was 55.Findings include:Observation on 09/02/25 starting at 10:40 A.M. with Dietary Manager (DM) #552 revealed in the dry store room, there was an unlabeled and undated container full of dry brown rice and two expired bags of bread crumbs with an expiration date of 08/01/25. In the walk-in cooler, there was a bottle of raspberry decorative sauce dated 01/27/25.Interviews with DM #552 verified the above findings at the time of observation. DM #552 stated she was to check food dates daily and her staff were to check dates when they prepared food items.Review of a list of resident diets revealed Resident #2 and #50 received no food by mouth.Review of the policy, Labeling and Dating Guidelines, dated 01/02/24, revealed all opened and leftover items will be labeled with the date of opening/date stored and a discard/use by date. The date the product must be consumed or discarded by may not exceed the manufacturer's use by date. These are guidelines and should not be used in place of good judgement.

Based on record review, facility policy and procedure review and interview, the facility failed to ensure their Quality Assurance and Performance Improvement (QAPI) committee identified and followed through on staff education. This had the potential to affect all 55 residents in the facility. Findings include:Findings include:Review of the facility QAPI minutes and Performance Improvement Plan (PIP) documentation revealed the following plans without continued corrective action, evidence the plan was revised when necessary or changed once identified to be ineffective:Review of the QAPI meeting dated 03/12/25 revealed facility staff met to review concerns for January and February 2025. Online education began in February 2025 with only a 14% staff participation rate. The plan was to provide training, post signs in the breakroom, review during monthly in-services and to have a gift card giveaway. The minutes did not specify what the online education was.Review of the QAPI meeting dated 06/02/25 revealed facility staff met to review concerns for March and April 2025. Online education compliance revealed March 2025 had 17% of staff participation and April 2025 revealed 19% staff participation. The plan was again to post signs in the breakroom, review during monthly in-services and to have a gift card giveaway. The minutes did not specify what the online education was.Review of the QAPI meeting dated 07/17/25 revealed facility staff met to review concerns for May and June 2025. Online education and staff training were not reviewed. Review of the QAPI meeting dated 08/29/25, after concerns of lack of staff education from the survey team, revealed online education was going poorly. During the current annual survey, deficiencies were cited regarding staff education. The minutes did not specify what the online education was.Interview on 09/04/25 at 12:10 P.M. with Regional Nurse Consultant #598 verified there was no QAPI meeting in January 2025. She also verified the facility's Administrator was responsible for implementing and overseeing auditing as well as quality assurance. Regional Nurse Consultant #598 verified the facility had not followed the QAPI plan to ensure staff training improved.Review of the facility policy titled, QAPI Plan, dated 01/02/24, revealed the Quality Assessment and Assurance (QAA) Committee would determine what performance indicators would be monitored and schedule the frequency of monitoring, identify and respond to quality deficiencies throughout the facility, develop and implement corrective action plans to ensure goals and targets were achieves and monitor the effectiveness of its performance improvement activities to ensure improvements were sustained.

Based on personnel file review, interview and review of the facility policy, the facility failed to ensure staff had tuberculosis (TB) testing prior to working. This affected two staff (Licensed Practical Nurse (LPN) #536 and Certified Nursing Assistant (CNA) #561) of nine staff reviewed during the annual survey with the potential to affect all 55 residents.Findings include:Review of LPN #536's personnel file revealed a hire date of 05/05/25. Further review of the personnel file revealed no evidence TB testing was completed prior to or upon employment.Review of CNA #561's personnel file revealed a hire date of 08/22/24. Further review of the personnel file revealed no evidence TB testing was completed prior to or upon employment.Interview on 09/03/25 at 2:46 P.M. with Regional Human Resources (RHR) #600 and Human Resources (HR) #590 verified they could not locate initial TB testing for LPN #536 or CNA #561. RHR #600 stated a two-step TB test was done upon hire for all new employees.Review of the facility policy, Tuberculosis (TB) Prevention and Control, dated 01/02/24 revealed residents and staff are tested for latent TB infection and screened for TB disease.Review of the facility's TB risk assessment dated [DATE] revealed the facility has a TB screening program for nurses, administrators, janitorial staff, maintenance or engineering staff, transportation staff, dietary staff, physical therapists, receptionist and trainees/volunteers. Baseline skin testing was performed with two-step tuberculin skin test (TST) for health-care workers upon employment.

Based on personnel file review and interview the facility failed to ensure Certified Nursing Assistants (CNAs) had 12 hours of training annually as required. This affected one CNA (#561) of two CNA files reviewed with the potential to affect all 55 residents.Findings include:Review of CNA #561's personnel file revealed a date of hire of 08/22/24. Further review of the file revealed no evidence of training hours.Interview on 09/03/25 at 2:46 P.M. with Regional Human Resources (RHR) #600 and Human Resources (HR) #590 verified they could not locate any evidence of training hours for CNA #561. RHR #600 stated for CNAs, they aimed for at least 12 hours annually for training.

Based on observation, interview and facility policy review, the facility failed to maintain resident rooms and bathrooms in a safe and sanitary condition. This affected four residents (Resident #28, #31, #34, and #44) of 55 residents living in the facility. The facility census was 55.Findings include:Interview and observation on 09/02/2025 at 4:41 P.M. with Certified Nursing Assistant (CNA) #555 of Resident #31 room revealed splatters of food on all four walls and the ceiling of room and outlet by bed was unattached from wall with the wires hanging out.Observation on 09/03/25 between 2:47 P.M. through 3:00 P.M. of multiple resident rooms with Housekeeping Supervisor #513 revealed the following:Resident #31 walls and ceiling were dirty with various food and liquid debris from resident throwing his food. Outlet was being fixed by maintenance at this time. Housekeeping Supervisor #513 revealed Resident #31 throws food at the wall and will put feces on the wall. Staff was supposed to clean daily but confirmed staff had not been wiping walls thoroughly.Resident #34 and Resident #44 ceiling had multiple brown splatters, and the privacy curtain ceiling track was partially missing with no privacy curtain. Resident #44 said the stains on the ceiling have been there since he moved into the room. The floorboard was missing to the right of the air-conditioning unit. The bathroom smelled of urine, the rim around the toilet was brown and the floor was sticky. Resident # 34 pillow was stained brown and had no pillow case on it.Resident #28 bathroom tile was heavily stained brown due to the resident peeing on the floor and the room smelled of urine. There was a toilet safety rail above toilet with one piece on the right leg missing, causing railing to be unsteady.Interview on 09/02/25 at 3:00 P.M. with Housekeeping Supervisor #513 revealed he puts request in for items to be fixed and they are not approved. Housekeeping Supervisor #513 revealed he feels that request fall on deaf ears. Surveyor requested the service request but they were not provided.Interview and observation on 09/03/25 at 4:20 P.M. with Regional Director of Nurse Consultants #599 of above rooms and confirmed observations.Review of facilities policy Safe & Homelike Environment dated 01/02/24 revealed Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.

Based on record review and interviews the facility failed to ensure Resident #7, who received hemodialysis (HD) three times a week, was evaluated before and after dialysis treatments. This affected one resident (Resident #7) of one resident received for HD. Facility census was 55.Findings include:Record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included diabetes, chronic kidney disease (CKD) - Stage3, major depressive disorder, generalized anxiety disorder, dependence of renal dialysis, heart disease, gastroesophageal reflux disease (GERD), and Vitamin D deficiency.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, for Resident #7, dated 06/20/25 revealed the resident was cognitively intact. Review of the physician orders for Resident #7, dated 04/21/25, revealed that a pre and post assessment needs to be completed on dialysis days.On 09/03/25 at 5:00 P.M., a review of Dialysis PRE/POST Communication Record- - V 2 from 09/01/25, 09/02/25, and 09/03/25 revealed the assessments were not completed. The incomplete assessments were confirmed on 09/04/25 at 2:06 P.M. with Regional Nurse #599. Review of Dialysis binder for Resident #7 revealed only blank Dialysis forms, no completed forms. The empty binder was confirmed on 09/04/25 at 2:10 P.M. by Regional Nurse #598.Review of facility policy titled Dialysis, updated on 12/12/23, asserted the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility.

Based on record review and interview, the facility failed to ensure authorizations were witnessed for resident funds. This affected one resident (#42) of five residents reviewed for resident funds. Facility census was 55.Findings include:Review of Resident #42's medical record revealed an admission date of 07/19/22 and diagnoses including depression, insomnia, auditory hallucinations, delusional disorders, and psoriasis. Further review of the record revealed Resident #42 had a power of attorney (POA).Review of financial records for Resident #42 revealed an authorization for resident funds signed by the POA on 05/05/25. The authorization lacked any witness signatures on the form.Interview on 09/03/25 at 8:45 A.M. with Business Office Manager (BOM) #523 verified Resident #42 did not have his resident funds authorization witnessed as required. BOM #523 reported the facility did not have a policy regarding resident funds to provide for review at the time of the interview.

Based on record review and interview, the facility failed to ensure final disbursal of a deceased resident's funds was completed in 30 days as required. This affected one resident (#64) of five residents reviewed for resident funds. Facility census was 55.Findings include:Review of Resident #64's closed medical record revealed an admission date of [DATE] and diagnoses including personality disorder, breast cancer, insomnia and mild cognitive impairment. Further review of the record revealed Resident #64 expired in the facility on [DATE].Review of the financial records for Resident #64 revealed she expired on [DATE]. The resident statement indicated the balance of $75.77 was issued as a check on [DATE].During an interview on [DATE] at 8:45 A.M. Business Office Manager (BOM) #523 was informed that Resident #64's final disbursement exceeded the 30-day limit and she did not disagree. BOM #523 stated the receptionist and not herself did the disbursal for Resident #64. BOM #523 also reported the facility did not have a policy regarding resident funds to provide for review at the time of the interview.

Based on interview, record review, review of a self-reported incident (SRI), review of the facility's investigation and review of the facility policy, the facility failed to report allegations of abuse and neglect immediately as required. This affected two residents (#23 and #49) of three residents reviewed for abuse and neglect. Facility census was 55.Findings include:Review of Resident #49's medical record revealed an admission date of 03/01/24 and diagnoses including Alzheimer's disease, dysphagia, constipation, generalized anxiety disorder, vascular dementia with behavioral disturbance, psychotic disorder and mood affective disorder. Resident #49 had a legal guardian and was receiving hospice services.Review of Resident #49's quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 had cognitive impairment, displayed physical and verbal behaviors one to three days in the look-back period and was dependent for upper body and lower body dressing.Review of Resident #23's medical record revealed an admission date of 08/11/22 and diagnoses including Asperger's syndrome, morbid obesity, depression, type two diabetes and insomnia. Resident #23 was his own responsible party.Review of Resident #23's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #23 was cognitively intact and did not display behaviors. Resident #23 was dependent for dressing, personal hygiene and dressing and required partial/moderate assistance for rolling.Review of a SRI dated 07/27/25 and submitted to the State Agency (SA) at 4:23 P.M. revealed an allegation of staff to resident neglect involving Certified Nursing Assistant (CNA) #555, Resident #23 and Resident #49. Licensed Practical Nurse (LPN) #536 informed the unit manager, UM/LPN #532, that CNA #561 expressed concern that CNA #555 who was working with her had yelled at and shook Resident #49 while dressing him in her presence. CNA #561 also reported that CNA #555 went into Resident #23's room and argued with him. The allegation was not reported to another agency. The facility determined the allegation of neglect to be unsubstantiated as Resident #23 refuted the allegation of verbal abuse and disputed information from CNA #561 could not be verified. Review of a timeline included in the facility's SRI investigation revealed on 07/27/25 (time not given), LPN #536 contacted UM/LPN #532 to report an allegation of abuse that was reported to her by CNA #561. CNA #561 reported that CNA #555 shook Resident #49 and yelled at him while they were dressing the resident (time not given). CNA #561 reported that CNA #555 had yelled out in a mocking manner saying okay, okay, okay which is what Resident #49 was known for repeating as he had limited verbalization due to his Alzheimer's diagnosis. It was reported that both CNAs then went to Resident #23's room (time not given) to assist with care. UM/LPN #532 instructed LPN #536 to ask CNA #555 to leave immediately (time not given) then go into Resident #23's room to ask about the reported allegation. Resident #23 denied concerns with staff, denied any CNA yelling or arguing with him and indicated he felt safe. UM/LPN #532 instructed LPN #536 to complete pain assessments on Resident #23 and Resident #49 and to complete skin assessments on all residents on the 300 and 400 halls. Resident #49's skin assessment was negative. UM/LPN #532 notified the Director of Nursing Services (DNS) and Regional Director of Operations (RDO) of the allegation, an SRI was initiated and an investigation began.Continued review of the facility's timeline revealed on 07/28/25, UM/LPN #532 assessed Resident #23 and Resident #49 who were within normal limits. Social Service Director (SSD) #559 observed and interviewed residents on the 300 and 400 halls with no findings.Continued review of the facility's timeline revealed on 07/29/25, Resident #23 had a care conference and did not voice any concerns or issues. A follow-up interview completed by the Administrator with CNA #555 revealed she was blindsided by the allegations as she had been a CNA at the facility for 14 years. CNA #555 stated she only touched Resident #49's shoulders when putting his shirt on and may have said okay, okay, okay but not in a mocking way but to repeat as that is how Resident #49 communicated. CNA #555 felt the allegations were false and may have been ignited the day before because she had to repeatedly ask where the other CNA [#561] was during that shift. SSD #559 met with Resident #23 who was resting. SSD #559 met with Resident #23 again on 07/30/25 who was resting and smiled when he asked how he was feeling.Review of an undated witness statement authored by CNA #561 revealed it was directed towards the facility's previous Human Resource Director (HRD), UM/LPN #532 and the DNS and revealed the following information: I am writing to formally report a situation that I believe violated workplace policies and may have impacted my sense of safety and professionalism on the job. On 07/27/25 (no time given) I witnessed my co-worker [CNA #555] yell and shake a dementia patient [Resident #49] as we were dressing him. Then (no time given) the next patient [Resident #23] [CNA #555] argued with and I stepped in to diffuse the situation. The coworker cooled down but I reported this to two different nurses, UM/LPN #532 and the DNS. I believe it is important to bring this forward in the spirit of maintaining a respectful and accountable but mostly safe workplace. I am willing to cooperate with any investigation or discussion necessary. Please confirm receipt of this message and let me know the next steps.Review of a witness statement dated 07/27/25 and authored by CNA #555 revealed the following information: Today I help my co-worker with Resident #49 (no time given). Everything went good, she put his pants on and I put his shirt on and got him up in his chair. Additional writing on this statement dated 07/29/25 and signed by the Administrator revealed the following information: I knew the other CNA and did not expect anything. I don't know why she would make accusations. I have spent 14 years working at the facility. There was another accusation in the past made by the resident (not specified) a few months ago. I put his [Resident #49's] shirt on. I did not shake him. I may have said 'okay, okay,' but not to mock him - that's just how he communicates. I have never had a problem with the other CNA. I spent much of the day asking where the CNA was and the nurse (not specified) would say no. And I stated, 'I haven't either.' I don't know, I have worked here a long time and would never abuse a resident. I don't do this job for the Administrator or the DNS, I do it for the person in the bed.Review of a witness statement dated 07/27/25 and authored by Registered Nurse (RN) #518 revealed the following information: I was approached by CNA #561 (time not given) and she told me that she was in the room with CNA #555 changing Resident #49. She said CNA #555 was frustrated and shook Resident #49. She said she is about to be a nurse and that she would have to report it.Review of a witness statement dated 07/27/25 and authored by LPN #536 revealed the following information: CNA #561 came to me while I was walking down the hallway (time not given). CNA #561 stated while her and CNA #555 were in Resident #49's room she witnessed CNA #555 put her hands on Resident #49's shoulders and shake him, mocking him, saying 'okay, okay, okay.' I would like to add that I feel like CNA #561 was upset she was told by this nurse that she was working the 300 hall and the other CNA was working 400 hall by herself. I went in to speak to Resident #23 who stated nothing happened other than CNA #444 was moody and upset because she did not have any linen to do his bed bath. Additional writing present on LPN #536's statement that lacked a date and an author revealed that RN #518 reported to LPN #536 that something happened with CNA #555 between 9:30 A.M. and 10:00 A.M. which was late reporting and CNA #555 did an amazing job and never has issues.Review of a witness statement dated 07/27/25 and authored by LPN #578 denied witnessing abuse of any sort on 07/27/25 or any other days worked previously.Review of a witness statement dated 07/29/25 and authored by SSD #559 revealed she spoke with Resident #23 who was resting in bed and was alert and oriented times three. Resident #23 told SSD #559 that CNA #555 did not verbally abuse him and asked who the other CNA was that had come in and told him another resident had had an incident with CNA #555. Resident #23 stated he did not want to be put into this situation and stated he felt safe at the facility.Review of CNA #555's time punch detail revealed she worked on 07/27/25 from 6:56 A.M. to 3:34 P.M. The next date CNA #555 worked was on 08/05/25.Interview on 08/27/25 at 1:53 P.M. with Resident #23 revealed there was a CNA (not named) that was verbally abusive to him about four months ago and who had a snarky attitude. The CNA would make him wait, then not do what he requested. Resident #23 reported he had not seen the CNA in a while.Observation on 08/28/25 at 12:42 P.M. revealed UM/LPN #532 was interacting with Resident #49 who was seated in a Broda chair on the secured unit. The surveyor asked Resident #49 how lunch was and Resident #49 put his head down and did not respond. Resident #49 was not interviewable due to cognition. Interview on 08/28/25 at 1:45 P.M. with RN #518 revealed on 07/27/25, she was working in the front of the facility on the 200 hall and CNA #555, CNA #561 and LPN #536 were in the back of the facility. Around 2:00 P.M. RN #518 was on her lunch and CNA #561 approached her while she was in her car. CNA #561 stated she thought she had to report something as CNA #555 was in a room with her and grabbed Resident #49 and shook him. RN #518 stated she told CNA #561, 'yes, you need to report that. You need to tell your charge nurse then contact the previous Administrator and if not the DNS.' RN #518 stated LPN #536 had called a member of management staff at some point and they were gathering statements from anyone CNA #555 and CNA #561 spoke to. When asked if she reported the allegation, RN #518 stated she did not tell anyone about the allegation as CNA #561 and LPN #536 were doing that. RN #518 stated CNA #561 was also telling a resident, Resident #11, about the incident and Resident #11 also told CNA #561 she had to report the allegation.Interview on 08/28/25 at 2:00 P.M. with CNA #573 revealed on 07/27/25, she was working in the front of the facility and recalled CNA #561 said CNA #555 said harsh words to an unknown resident. Around 3:00 P.M. CNA #561 appeared shook and came to her, telling her she reported the allegation to LPN #536 and RN #518 but did not report it right away. CNA #573 stated CNA #561 did not divulge what time the incident occurred at. When asked if she reported the allegation, CNA #573 stated she did not report this to anyone as CNA #561 did what she was supposed to do. CNA #573 also stated CNA #555 did not go home right away on 07/27/25 but should have and this was because the allegation was not reported as it was happening. CNA #573 reported she never was asked to write a statement regarding the allegation even as she was working the date and shift the allegation occurred within.Interview on 08/28/25 at 2:56 P.M. with LPN #536 revealed she worked on 07/27/25 in the back of the facility. Around 2:30 P.M. to 3:00 P.M. she went outside to take a smoke break and RN #518 told her CNA #561 was going to tell her that CNA #555 did something to Resident #49. LPN #536 stated she asked RN #518 what was she talking about and RN #518 reported CNA #561 had just come to her, something had happened in the room with CNA #555 and she did not want to tell her. LPN #536 asked RN #518 why CNA #561 did not tell her about this, as she was the nurse on the 300 and 400 halls. LPN #536 went to go talk to CNA #561. CNA #561 told her that she and CNA #555 were in Resident #49's room getting him dressed around 10:00 A.M. and CNA #555 put her hands on his shoulder, shook him and was mocking him. LPN #536 explained that Resident #49 said the same words over and over due to his cognitive decline. CNA #561 also told her CNA #555 argued with Resident #23. LPN #536 stated by this time it was 3:30 P.M. or so and she told CNA #561 to write a statement. LPN #536 stated she and RN #518 spoke to Resident #23, who denied the allegation but stated CNA #555 was upset there was no linen for his shower. LPN #536 stated she contacted UM/LPN #532, who was the nurse on call, before dinner [4:30 P.M. to 5:00 P.M.] to report that RN #518 told her CNA #561 had told her CNA #555 did something to Resident #49. At that point, CNA #555 was already out of the facility as her shift was over at 3:00 P.M. but she had written a statement before leaving. LPN #536 confirmed CNA #555 was not removed immediately from the facility as CNA #561 did not report the allegation timely.Phone interview on 08/28/25 at 3:17 P.M. with CNA #555 revealed she currently worked the front of the facility and had not worked in the back of the facility for several weeks. When asked why this was, CNA #555 reported she was accused of shaking Resident #49 by another staff member and was told to write a statement before she left at 3:00 P.M. that day [07/27/25]. CNA #555 verified she worked her entire shift on 07/27/25, from 7:00 A.M. to 3:00 P.M. CNA #555 stated she worked with Resident #49 in the morning and then was suspended after her shift that day. When she returned to work on 08/05/25, CNA #555 stated she was scheduled in the front of the facility and was told the allegations were unsubstantiated. When asked about the allegations involving Resident #23 and Resident #49, CNA #555 stated Resident #23 was like a child and called her grandma and denied the allegations.Interview on 08/28/25 at 4:00 P.M. with the Administrator confirmed CNA #555 worked her entire shift on 07/27/25 and did not go home early as the allegation of neglect/abuse was not reported timely.Interview on 08/28/25 at 5:06 P.M. with UM/LPN #532 revealed on 07/27/25 (no time given) LPN #536 called her to tell her CNA #561 came to her with concerns about CNA #555 including grabbing and shaking Resident #49 during care and saying 'okay, okay, okay,' then going into Resident #23's room and gave him attitude. At that time CNA #561 told CNA #555 to exit the room. UM/LPN #532 shared LPN #536 did not mention abuse but told her, I know I need to report this. UM/LPN #532 stated she called the DNS and they explained CNA #555 needed to go home but she had already exited the building at that time. UM/LPN #532 reported Regional Nurse Consultant (RNC) #598 became involved and someone at the corporate level initiated a SRI. UM/LPN #532 stated all of the staff floated across the units and CNA #561 was the only witness to the allegation and shared CNA #555 was moved to the front of the facility post-allegation as an intervention.Phone interview on 08/29/25 at 10:08 A.M. with CNA #561 revealed on 07/27/25, CNA #555 helped her with Resident #49's care as she dressed from his feet up and CNA #555 dressed him from his head down around 12:30 P.M. When she looked up, CNA #561 was shaking Resident #49 for two minutes as he fought her while she tried to put his shirt on. CNA #561 stated Resident #49 was holding on to CNA #555's arms and was not hitting her and then CNA #555 stated, Oh my God, why the (expletive) can't you just work with me? Why do you have to fight with me? CNA #561 stated she told CNA #555, I need you to breathe, this is not worth your license, and shared CNA #555 replied back, (Expletive) this place, I don't care about this place. CNA #561 was questioned regarding CNA #555's verbal statements as these were not in her written statement which she verified during the interview and stated she informed the DNS of this content while she wrote her statement. After the incident, she walked out of Resident #49's room and CNA #555 stood in front of LPN #536 so she did not feel she could talk to LPN #536. CNA #561 stated she then spoke to RN #518 in the parking lot who told her to report the incident. Later, she overheard CNA #555 cursing at Resident #23 while trying to clean him up and she intervened and told CNA #555 to just go. CNA #561 stated she spoke to Resident #23 who stated he does not like when CNA #555 screams. CNA #561 then stated she reported these incidents to LPN #536 (time not given) and shared CNA #555 did not leave right away but she did not know when CNA #555 actually left.Interview on 09/02/25 at 8:46 A.M. with the DNS revealed on 07/27/25 after 3:00 P.M. UM/LPN #532 called her and they ended up doing a three-way call with LPN #536. At this time, CNA #555 had already left as it was shift change. During the call, it was shared CNA #555 was rude to Resident #23 and shook Resident #49's shoulder. Someone (not identified) said RN #518 was told first, but then it went to LPN #536 who stated 'I just found out' and had called UM/LPN #532 first. The DNS confirmed RN #518 never called her or reported the allegation to her. The DNS stated she then had to call RNC #598 to get an SRI started as the facility did not have an Administrator during the weekend the allegation occurred.Interview on 09/02/25 at 9:29 A.M. with the Administrator revealed she officially started at the facility on 07/29/25 and that is when she became aware of the SRI involving Resident #23 and Resident #49 on 07/27/25. When asked about the timeline regarding the incident and the reporting of the allegation, the Administrator stated it seemed like it took most of the day for CNA #561 to report the allegation which was not immediate as required.Follow-up interview on 09/02/25 at 4:40 P.M. with the Administrator regarding the SRI on 07/27/25 confirmed multiple facility staff did not report the allegation of abuse/neglect immediately as required.Review of the facility policy, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation, revised 06/05/25 and effective 07/01/25 revealed residents have the right to be free from abuse, neglect, exploitation and misappropriation of resident/patient property. Care team members should immediately report all such allegations to the Administrator and to Department of Health (DOH) in accordance with the procedures in this policy. [The facility would ensure] all care team members would report all incidents and allegations of abuse, neglect, mistreatment, exploitation and misappropriation of resident/patient property, as well as notifying the Administrator, Director of Nursing, or charge nurse immediately upon identification of any new injuries. If a care team member is accused or suspected, the facility should immediately remove the care team member from the facility and schedule pending the outcome of the investigation. All incidents and allegations of abuse, neglect, exploitation, mistreatment and misappropriation of resident/patient property and all injuries of unknown source must be reported immediately to the Administrator/designee and they should be notified in person, via telephone, text message or phone call. If any form of abuse is alleged, the Administrator/designee will notify DOH immediately but no later than two hours after the allegation is made or the serious bodily injury is identified.

Based on interview, record review, review of a self-reported incident (SRI), review of the facility's investigation and review of the facility policy, the facility failed to thoroughly investigate allegations of abuse and neglect. This affected two residents (#23 and #49) of three residents reviewed for abuse and neglect. Facility census was 55.Findings include: Review of Resident #49's medical record revealed an admission date of 03/01/24 and diagnoses including Alzheimer's disease, dysphagia, constipation, generalized anxiety disorder, vascular dementia with behavioral disturbance, psychotic disorder and mood affective disorder. Resident #49 had a legal guardian and was receiving hospice services. Review of Resident #49's quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 had cognitive impairment, displayed physical and verbal behaviors one to three days in the look-back period and was dependent for upper body and lower body dressing. Review of Resident #23's medical record revealed an admission date of 08/11/22 and diagnoses including Asperger's syndrome, morbid obesity, depression, type two diabetes and insomnia. Resident #23 was his own responsible party. Review of Resident #23's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #23 was cognitively intact and did not display behaviors. Resident #23 was dependent for dressing, personal hygiene and dressing and required partial/moderate assistance for rolling. Review of a SRI dated 07/27/25 and submitted to the State Agency (SA) at 4:23 P.M. revealed an allegation of staff to resident neglect involving Certified Nursing Assistant (CNA) #555, Resident #23 and Resident #49. Licensed Practical Nurse (LPN) #536 informed Unit Manager (UM)/LPN #532 that CNA #561 expressed concern that CNA #555 who was working with her had yelled at and shook Resident #49 while dressing him in her presence. CNA #561 also reported that CNA #555 went into Resident #23's room and argued with him. The allegation was not reported to another agency. The facility determined the allegation of neglect to be unsubstantiated as Resident #23 refuted the allegation of verbal abuse and disputed information from CNA #561 could not be verified. Review of a timeline included in the facility's SRI investigation revealed on 07/27/25 (time not given), LPN #536 contacted UM/LPN #532 to report an allegation of abuse that was reported to her by CNA #561. CNA #561 reported that CNA #555 shook Resident #49 and yelled at him while they were dressing the resident (time not given). CNA #561 reported that CNA #555 had yelled out in a mocking manner saying okay, okay, okay which is what Resident #49 was known for repeating as he had limited verbalization due to his Alzheimer's diagnosis. It was reported that both CNAs then went to Resident #23's room (time not given) to assist with care. UM/LPN #532 instructed LPN #536 to ask CNA #555 to leave immediately (time not given) then go into Resident #23's room to ask about the reported allegation. Resident #23 denied concerns with staff, denied any CNA yelling or arguing with him and indicated he felt safe. UM/LPN #532 instructed LPN #536 to complete pain assessments on Resident #23 and Resident #49 and to complete skin assessments on all residents on the 300 and 400 halls. Resident #49's skin assessment was negative. UM/LPN #532 notified the Director of Nursing Services (DNS) and Regional Director of Operations (RDO) of the allegation, an SRI was initiated and an investigation began. Continued review of the facility's timeline revealed on 07/28/25, UM/LPN #532 assessed Resident #23 and Resident #49 who were within normal limits. Social Service Director (SSD) #559 observed and interviewed residents on the 300 and 400 halls with no findings. Continued review of the facility's timeline revealed on 07/29/25, Resident #23 had a care conference and did not voice any concerns or issues. SSD #559 also met with Resident #23 who was resting. SSD #559 met with Resident #23 again on 07/30/25 who was resting and smiled when he asked how he was feeling.Review of an undated witness statement authored by CNA #561 revealed it was directed towards the facility's previous Human Resource Director (HRD), UM/LPN #532 and the DNS and revealed the following information: I am writing to formally report a situation that I believe violated workplace policies and may have impacted my sense of safety and professionalism on the job. On 07/27/25 (no time given) I witnessed my co-worker [CNA #555] yell and shake a dementia patient [Resident #49] as we were dressing him. Then (no time given) the next patient [Resident #23] [CNA #555] argued with and I stepped in to diffuse the situation. The coworker cooled down but I reported this to two different nurses, UM/LPN #532 and the DNS. I believe it is important to bring this forward in the spirit of maintaining a respectful and accountable but mostly safe workplace. I am willing to cooperate with any investigation or discussion necessary. Please confirm receipt of this message and let me know the next steps. Review of a witness statement dated 07/27/25 and authored by CNA #555 revealed the following information: Today I help my co-worker with Resident #49 (no time given). Everything went good, she put his pants on and I put his shirt on and got him up in his chair. Additional writing on this statement dated 07/29/25 and signed by the Administrator revealed the following information: I knew the other CNA and did not expect anything. I don't know why she would make accusations. I have spent 14 years working at the facility. There was another accusation in the past made by the resident (not specified) a few months ago. I put his [Resident #49's] shirt on. I did not shake him. I may have said 'okay, okay,' but not to mock him - that's just how he communicates. I have never had a problem with the other CNA. I spent much of the day asking where the CNA was and the nurse (not specified) would say no. And I stated, 'I haven't either.' I don't know, I have worked here a long time and would never abuse a resident. I don't do this job for the Administrator or the DNS, I do it for the person in the bed. Review of a witness statement dated 07/27/25 and authored by Registered Nurse (RN) #518 revealed the following information: I was approached by CNA #561 (time not given) and she told me that she was in the room with CNA #555 changing Resident #49. She said CNA #555 was frustrated and shook Resident #49. She said she is about to be a nurse and that she would have to report it. Review of a witness statement dated 07/27/25 and authored by LPN #536 revealed the following information: CNA #561 came to me while I was walking down the hallway (time not given). CNA #561 stated while her and CNA #555 were in Resident #49's room she witnessed CNA #555 put her hands on Resident #49's shoulders and shake him, mocking him, saying 'okay, okay, okay.' I would like to add that I feel like CNA #561 was upset she was told by this nurse that she was working the 300 hall and the other CNA was working 400 hall by herself. I went in to speak to Resident #23 who stated nothing happened other than CNA #444 was moody and upset because she did not have any linen to do his bed bath. Additional writing present on LPN #536's statement that lacked a date and an author revealed that RN #518 reported to LPN #536 that something happened with CNA #555 between 9:30 A.M. and 10:00 A.M. which was late reporting and CNA #555 did an amazing job and never has issues. Review of a witness statement dated 07/27/25 and authored by LPN #578 denied witnessing abuse of any sort on 07/27/25 or any other days worked previously.Review of a witness statement dated 07/29/25 and authored by SSD #559 revealed she spoke with Resident #23 who was resting in bed and was alert and oriented times three. Resident #23 told SSD #559 that CNA #555 did not verbally abuse him and asked who the other CNA was that had come in and told him another resident had had an incident with CNA #555. Resident #23 stated he did not want to be put into this situation and stated he felt safe at the facility. Interview on 08/27/25 at 1:53 P.M. with Resident #23 revealed there was a CNA (not named) that was verbally abusive to him about four months ago and who had a snarky attitude. The CNA would make him wait, then not do what he requested. Resident #23 reported he had not seen the CNA in a while. Observation on 08/28/25 at 12:42 P.M. revealed UM/LPN #532 was interacting with Resident #49 who was seated in a Broda chair on the secured unit. The surveyor asked Resident #49 how lunch was and Resident #49 put his head down and did not respond. Resident #49 was not interviewable due to cognition. Interview on 08/28/25 at 1:45 P.M. with RN #518 revealed on 07/27/25, she was working in the front of the facility on the 200 hall and CNA #555, CNA #561 and LPN #536 were in the back of the facility. Around 2:00 P.M. RN #518 was on her lunch and CNA #561 approached her while she was in her car. CNA #561 stated she thought she had to report something as CNA #555 was in a room with her and grabbed Resident #49 and shook him. RN #518 told CNA #561 to report the allegation. RN #518 stated LPN #536 had called a member of management staff at some point on 07/27/25 and they were gathering statements from anyone CNA #555 and CNA #561 spoke to. Interview on 08/28/25 at 2:00 P.M. with CNA #573 revealed on 07/27/25, she was working in the front of the facility and recalled CNA #561 said CNA #555 said harsh words to an unknown resident. Around 3:00 P.M. CNA #561 appeared shook and came to her, telling her she reported this to LPN #536 and RN #518 but did not report it right away. CNA #573 reported she never was asked to write a statement regarding the allegation even as she was working the date and shift the allegation occurred within. Interview on 08/28/25 at 2:23 P.M. with CNA #565 revealed she worked on 07/27/25 in the front of the facility but denied writing a statement regarding the allegation that occurred on that date and shift. Interview on 08/28/25 at 2:41 P.M. with LPN #578 revealed she had worked all four halls during her time at the facility and denied knowledge of the allegation on 07/27/25 during that date and shift. Interview on 08/28/25 at 2:56 P.M. with LPN #536 revealed she worked on 07/27/25 in the back of the facility. Around 2:30 P.M. to 3:00 P.M. she went outside to take a smoke break and RN #518 told her CNA #561 was going to tell her that CNA #555 did something to Resident #49. LPN #536 stated she asked RN #518 what was she talking about and RN #518 reported CNA #561 had just come to her, something had happened in the room with CNA #555 and she did not want to tell her. LPN #536 went to go talk to CNA #561. CNA #561 told her that she and CNA #555 were in Resident #49's room getting him dressed around 10:00 A.M. and CNA #555 put her hands on his shoulder, shook him and was mocking him. LPN #536 explained that Resident #49 said the same words over and over due to his cognitive decline. CNA #561 also told her CNA #555 argued with Resident #23. LPN #536 stated by this time it was 3:30 P.M. or so and she told CNA #561 to write a statement. LPN #536 stated she and RN #518 spoke to Resident #23, who denied the allegation but stated CNA #555 was upset there was no linen for his shower. LPN #536 stated she contacted UM/LPN #532, who was the nurse on call, before dinner [4:30 P.M. to 5:00 P.M.] to report that RN #518 told her CNA #561 had told her CNA #555 did something to Resident #49. At that point, CNA #555 was already out of the facility as her shift was over at 3:00 P.M. but she had written a statement before leaving. LPN #536 stated they got statements from everyone on 07/27/25 for the 7:00 A.M. to 3:00 P.M. shift. Phone interview on 08/28/25 at 3:17 P.M. with CNA #555 revealed she currently worked the front of the facility and had not worked in the back of the facility for several weeks. When asked why this was, CNA #555 reported she was accused of shaking Resident #49 by another staff member on 07/27/25. CNA #555 stated she worked with Resident #49 in the morning and then was suspended after her shift that day. When she returned to work on 08/05/25, CNA #555 stated she was scheduled in the front of the facility and was told the allegations were unsubstantiated. When asked about the allegations involving Resident #23 and Resident #49, CNA #555 denied the allegations. Interview on 08/28/25 at 5:06 P.M. with UM/LPN #532 revealed on 07/27/25 (no time given) LPN #536 called her to tell her CNA #561 came to her with concerns about CNA #555 including grabbing and shaking Resident #49 during care and saying 'okay, okay, okay,' then going into Resident #23's room and gave him attitude. At that time CNA #561 told CNA #555 to exit the room. UM/LPN #532 shared LPN #536 did not mention abuse but told her, I know I need to report this. UM/LPN #532 stated she called the DNS and they explained CNA #555 needed to go home but she had already exited the building at that time. UM/LPN #532 reported Regional Nurse Consultant (RNC) #598 became involved and someone at the corporate level initiated a SRI. UM/LPN #532 stated all of the staff floated across the units at the facility. For the SRI, CNA #561 was the only witness to the allegation and shared CNA #555 was moved to the front of the facility post-allegation as an intervention. Phone interview on 08/29/25 at 10:08 A.M. with CNA #561 revealed on 07/27/25, CNA #555 helped her with Resident #49's care as she dressed from his feet up and CNA #555 dressed him from his head down around 12:30 P.M. When she looked up, CNA #561 was shaking Resident #49 for two minutes as he fought her while she tried to put his shirt on. CNA #561 stated Resident #49 was holding on to CNA #555's arms and was not hitting her and then CNA #555 stated, Oh my God, why the (expletive) can't you just work with me? Why do you have to fight with me? CNA #561 stated she told CNA #555, I need you to breathe, this is not worth your license, and shared CNA #555 replied back, (Expletive) this place, I don't care about this place. CNA #561 was questioned regarding CNA #555's verbal statements as these were not in her written statement which she verified during the interview and stated she informed the DNS of this content while she wrote her statement. After the incident, she walked out of Resident #49's room and CNA #555 stood in front of LPN #536 so she did not feel she could talk to LPN #536. CNA #561 stated she then spoke to RN #518 in the parking lot who told her to report the incident. Later, she overheard CNA #555 cursing at Resident #23 while trying to clean him up and she intervened and told CNA #555 to just go. CNA #561 stated she spoke to Resident #23 who stated he does not like when CNA #555 screams. CNA #561 then stated she reported these incidents to LPN #536 (time not given). Interview on 09/02/25 at 8:46 A.M. with the DNS revealed on 07/27/25 after 3:00 P.M. UM/LPN #532 called her and they ended up doing a three-way call with LPN #536. At this time, CNA #555 had already left as it was shift change. During the call, it was shared CNA #555 was rude to Resident #23 and shook Resident #49's shoulder. Someone (not identified) said RN #518 was told first, but then it went to LPN #536 who stated 'I just found out' and had called UM/LPN #532 first. The DNS stated she then had to call RNC #598 to get an SRI started as the facility did not have an Administrator during the weekend the allegation occurred. During the interview, the DNS was questioned if the police were contacted regarding the allegation of neglect/abuse and indicated police should be called with SRIs. The DNS was informed at this time there was no evidence the police were contacted with the SRI and she did not disagree. Interviews on 09/02/25 at 9:29 A.M. and 4:40 P.M. with the Administrator revealed she officially started at the facility on 07/29/25 and that is when she became aware of the SRI involving Resident #23 and Resident #49 on 07/27/25. When asked about if the police were involved with the allegation, the Administrator stated they (not specified) asked the residents/responsible parties if they wanted the police contacted and stated UM/LPN #532 had reported to her the responsible parties did not want the police called. When asked about the lack of statements from all staff working on the affected date and shift for the SRI, the Administrator stated they interviewed where the allegation occurred and confirmed statements were not collected from CNA #565 and CNA #573. When asked about the lack of resident statements or skin sweeps on the 100 and 200 halls, as many care staff floated across the whole facility, the Administrator confirmed no residents on the 100 or 200 halls had their skin checked or were interviewed regarding the allegation. When asked if personnel files were reviewed as part of the SRI, the Administrator confirmed she did not review personnel files even as the facility policy directed to do so. The Administrator verified the overall SRI on 07/27/25 was not thoroughly investigated as required. Review of the facility policy, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation, revised 06/05/25 and effective 07/01/25 revealed residents have the right to be free from abuse, neglect, exploitation and misappropriation of resident/patient property. Once the Administrator and the Department of Health (DOH) are notified, an investigation of the alleged violation will be conducted. The person investigating the incident should generally take the following actions: Interview the resident/patient, the accused, and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident, came in close contact with the resident the day of the incident (including the other patients/residents, family members) and employees who worked closely with the accused employees and/or alleged victim the day of the incident. If there are no direct witnesses, the interviews may be expanded. Consider interviews with all care team members on the shift or the unit as well as other residents/patients on the unit. If the allegation involves abuse/neglect interview other residents to determine if they may have been affected by the accused care team member. If the accused is a care team member, employment records are reviewed.If the facility suspects that a crime has been committed, it will report that suspicion to law enforcement. If the resident has serious bodily injury, law enforcement must be notified within two hours; without serious bodily injury, law enforcement must be notified within 24 hours.

Based on record review, interview, observation, and mechanical lift policy the facility failed to ensure Resident #30 was safely transferred with a Hoyer (mechanical) lift to prevent a fall. This affected one resident (Resident #30) of four residents reviewed for accidents. The facility census was 55.Findings include:Review of the medical record for Resident #30 revealed an admission date of 08/20/25 with diagnosis that include: urinary tract infection, type 2 diabetes mellitus with diabetic nephropathy, catatonic disorder, dementia without behavioral disturbance, metabolic encephalopathy, dysphagia and altered mental status.Review of Morse Fall Scale dated 08/20/25 revealed Resident #30 was a high risk for falling.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 cognition was moderately impaired and was dependent on staff for transfers from the chair to the bed.Review of Resident #30 medical chart revealed resident had fallen on 08/21/25, 08/30/25, 08/31/25, and 09/03/25.Review of Resident #30's care plan dated 09/02/25 revealed Resident #30 required assistance with activities of daily living impaired mobility, weakness, debility, catatonic and cognition. An intervention dated 08/22/25 with a revised date of 09/02/25 revealed Resident #30 required a mechanical lift for transfers usually a Hoyer lift.Review of the nursing progress note dated 09/03/25 at 1:15 P.M. authored by Licensed Practical Nurse (LPN) #578 revealed she was preparing to assist Certified Nursing Assistant (CNA) #555 on the left side of the bed when CNA #555 moved the hoyer, the front left hook let loose and Resident #30 fell out of the hoyer, hitting her head on the floor. Resident #30 stated her head hurt a little and the resident was able to move all four extremities without limitations. Resident was sent out to the emergency room.Review of Resident #30's computerized tomography (CT Scan) from the hospital dated 09/03/25 at 12:04 P.M revealed no evidence of an acute infarct or other acute parenchymal process. Resident #30's medical record revealed the resident returned to the facility with no noted injuries.Interview on 09/04/25 at 11:31 A.M. with CNA #555 revealed Resident #30 hoyer pad was hooked up to the hoyer lift, she checked to make sure hoyer pad was hooked up to hoyer, and lifted Resident #30 with the hoyer. Resident #30 came out of the sling and went to the floor. CNA #555 revealed Resident #30 does not want to be here and that she thought the resident tried to move the hoyer strap off. CNA #555 does not remember the last time she had training for the hoyer.Interview on 09/04/25 at 12:06 P.M. with LPN #578 revealed she was assisting CNA #555 in Resident #30's room. LPN #578 was on the left side of the bed and Resident #30 and CNA #555 were by the door when the front left hook gave out and Resident #30 did a somersault out of the hoyer lift and bumped her head. LPN #578 did not witness CNA #555 check hooks because she was in the bathroom gathering supplies at the time. LPN #578 checked hoyer pad after the fall and all straps were in working order. LPN #578 revealed she had not been trained on the hoyer during orientation.Review of the facility policy titled, Transfers and Mechanical Lifts Policy dated 01/02/24, revealed bullet 10: two staff members must be utilized when transferring residents with a mechanical lift. Further, bullet 12 revealed: The staff must demonstrate competency in the use of the mechanical lifts prior to use and annually with documentation of that competency placed in their education file.This deficiency represents non-compliance investigated under Complaint Number 1364232.

Based on observation, record review, facility policy and procedure review and interview, the facility failed to prevent a potential incident of resident-to-resident sexual abuse for Resident #44. Actual harm occurred on 06/24/23 at 2:45 P.M. when Resident #25 was found lying in bed on top of Resident #44 in a physical manner that was sexual in nature, but which Resident #44 had not consented to. As a result of the incident, Resident #44 voiced pain and fearfulness and was transferred to the hospital for examination. This affected one resident (#44) of six residents reviewed for abuse. The facility census was 49. Findings include: Review of the medical record for Resident #44 revealed an admitted [DATE] with diagnoses including seizures, anemia, myocardial infarction, hypothyroidism, depression, anxiety, and history of a traumatic brain injury due to aneurysm. Review of Resident #44's plan of care, dated 05/22/23 revealed Resident #44 was on antipsychotic medication and medication should be given as ordered. The care plan was silent from any noted behavioral issues or accusatory behaviors until an entry was made on 06/30/23 indicating Resident #44's aunt reported Resident #44 had a history of making false allegations of sexual assault by men and promiscuity. Review of Resident #44's Medicare five-day Minimum Data Set (MDS) 3.0 assessment, dated 06/03/23, revealed Resident #44's Brief Interview for Mental Status (BIMS) assessment indicated she had severely impaired cognition with a BIMS score of zero out of 15. The assessment revealed Resident #44 was dependent on one staff member for bed mobility, transfers, and ambulation. The assessment also noted the resident was able to be understood by others and others were able to understand her. There were times when staff had difficulty understanding Resident #44 due to her only being able to speak in whispered tones. Review of Resident #25's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged from the facility on 07/03/23. Resident #25 had diagnosis including epilepsy, hyperlipidemia, mild intellectual disabilities, other psychoactive substance dependence, cocaine dependence, paranoid schizophrenia, alcohol use, and history of a traumatic brain injury (TBI). Review of Resident #25's annual MDS 3.0 assessment, dated 06/28/23, revealed Resident #25 had intact cognition and was aware of all the decisions he was making. Review of Resident #25's medical record revealed no evidence of sexually inappropriate/sexually abusive behaviors involving the resident prior to 06/24/23. Review of an incident report dated 06/24/23 at 2:45 P.M. authored by Director of Nursing (DON) #308 revealed the charge nurse (Registered Nurse (RN) #324) walked into Resident #44's room to find a male resident (Resident #25) lying on her. The male resident was removed from the room. Resident #44 was clothed in a hospital gown and brief and the male resident was fully clothed in a white t-shirt and blue shorts. Resident #44 was asked by RN #324 what happened and Resident #44 just smiled and continued to have a grin on her face. The RN assessed Resident #44 and found no visible signs of injury and sent her to the local emergency room after contacting the physician. Resident #44's aunt was notified at 4:00 P.M. In the section other info on the document it was noted by DON #308 that Resident #44's aunt reported Resident #44 had a history of being promiscuous when she lived at Mill House. Review of a nursing progress note, dated 06/24/23 at 3:20 P.M. and authored by RN #324, revealed RN #324 found Resident #44 laying in bed with another resident assigned to adjacent hall. Resident assessed; no physical injuries noted. IDT (interdisciplinary team) notified, and resident sent to the emergency room . Review of a document from the local ([NAME]) Fire Department revealed a Pre-Hospital Care Report Summary, dated 06/24/23 at 3:17 P.M. which indicated an emergency call was dispatched to the fire department at 3:09 P.M. for a sexual assault. Staff arrived at the facility at 3:17 P.M. Upon arrival to the facility, Resident #44 was found sitting in a wheelchair at the front desk and was alert to the arrival. Resident #44 was stating a male resident penetrated her vagina with his hands and penis lasting five to 10 minutes before anyone came into the room. Resident #44 complained of genital pain. The report noted the staff had changed the resident out of the original clothing she was wearing. Resident #44 was able to communicate verbally as well as typing on an iPad. She was alert to the event, person and place but not oriented to the time. Review of a Criminal Case Report Summary provided by local law enforcement revealed on 06/24/23 at 3:10 P.M. the police were called to the facility for a resident-to-resident sexual assault. Upon arrival [NAME] paramedics were standing at the nurse's station with Resident #44. The suspect (Resident #25) was in the lobby with the nurse. The [NAME] fire department transferred Resident #44 to the hospital for assessment (sexual assault kit). An interview with RN #324 reported he was making rounds and noticed Resident #44's door was shut, and it concerned him because it was not normal for the resident to have her door shut. When he opened the door, he found Resident #44 laying on her back in bed and Resident #25 laying on top of her. He stated they were laying face to face and Resident #25 had his hands beside Resident #44 on the bed holding himself up. Resident #25 was wearing a white t-shirt and blue shorts which were up around his waist and his genitals were not exposed. Resident #44 was wearing a hospital gown and brief and there was no exposure of her breast or genitals. The brief and gown were in place. RN #324 said he had Resident #25 leave the room and placed Resident #25 on one-to-one observation. Resident #25 looked shocked like he had been doing something he should not have been doing. RN #324 then spoke with Resident #44 who told RN #324 it was not consensual. RN #324 had another nurse come in to assess Resident #44 while he made notifications to supervisors, ambulance and the police. The nurses took Resident #44 out to the nurse's station for one-to-one observation while waiting for the fire department and police to arrive. Additional information on the police report included an interview with State tested Nursing Assistant (STNA) #379 who reported hearing RN #324 yell get the (expletive) off her so she went to see what was going on. STNA #379 then saw Resident #25 walk out of Resident #44's room and adjusting his shorts. STNA #379 said she asked Resident #44 what happened and Resident #44 told her Resident #25 touched her and she did not want him to because she did not know who he was. The police report continued with a statement from STNA #333 who reported being with Resident #25 after the incident. Resident #25 told her he was walking down the hall and Resident #44 motioned for him to come in, patted the bed and told him to lay down. He got on top of her, and they had sex. STNA #333 asked him if he put his penis in her and he replied no they just had sex. STNA #333 said she did not know what he meant by that. The police also collected statements from Resident #44. When asked if she was able to talk about what happened she replied, not really. She affirmed she was touched with the penis and hands in her genital area. When asked by who she was touched she pointed towards the 200 hall and said, by him. It was noted each response was said loudly and not in a whisper which was her usual speaking tone. The police questioned Resident #25 who reported Resident #44 motioned for him to go in her room because she can't talk or nothing and he got on top of her, but they did not have sex. The report noted Resident #25 had diagnosis of mild intellectual disability, paranoid schizophrenia, cognitive communication deficit and traumatic brain injury. Review of a facility self-reported incident (SRI), dated 06/24/23 at 4:23 P.M. and completed 06/30/23 at 3:52 P.M. revealed the facility reported and investigated this incident of resident to resident abuse. Details of the SRI included a nurse finding both residents fully clothed with Resident #25 laying on top of Resident #44 face-to-face in the bed. Resident #44's aunt reported Resident #44, when caught having sex, had a history of claiming sexual assault. The aunt added Resident #44 had a known history of sexual promiscuity and had multiple incidents prior to being admitted to the facility. Resident #25 denied the allegation and Resident #44 just smiled and kept grinning when asked what had happened. Resident #44 was sent to the emergency room as a precaution. Witness statements were obtained from RN #324 who found the residents in bed together. The facility investigation did not contain a witness statement from STNA #379 who spoke with Resident #44 immediately following the incident and who cleaned Resident #44 before going to the emergency room . Therefore, the surveyor found the investigation to be incomplete. Due to alleged sexual assault incident, Resident #25 was placed on one-on-one supervision until he was seen by Physician #386 on Monday 06/26/23. One on One supervision was discontinued on 06/26/23 with no other changes made to the resident's plan of care. Observations made at various times throughout the survey from 06/27/23 through 07/06/23 revealed Resident #44 was a frail woman with very thin upper extremities with limited range of motion and unable to raise her arms very high or for long periods of time. Resident #44 was to receive nothing by mouth (NPO) and utilized a gastrostomy tube (G-Tube) for all meals and medication. She was able to smoke with supervision and with assistance by staff to light her cigarette. She was observed sitting at the nurse's station during most of the observations made, so she was in constant eyesight of staff. Attempts to interview Resident #25 on 06/29/23 at 11:45 A.M. were unsuccessful as the resident refused to talk with the surveyor. Attempts to interview Resident #44's aunt were made on 06/29/23 at 11:59 A.M. and 07/05/23 at 10:00 A.M. which were unsuccessful. On 06/29/23 at 3:30 P.M. Resident #25 was observed sitting in the front lobby by himself and staring at Resident #44 who was sitting by the nurse's station. There were no staff present in the area at that time. Resident #44 appeared to be nervous, with a scared look on her face, and when asked by the surveyor if she felt safe, she stated no because Resident #25 was staring at her and there were no staff around. On 06/29/23 at 4:10 P.M. interview with Resident #44 revealed she was alert and oriented to person, place, time and able to carry on a reciprocal conversation with the surveyor answering both open ended and close ended questions simple to complex. During the interview, Resident #44 stated she was sexually assaulted by Resident #25. She was able to provide Resident #44's name and information regarding the incident that took place on 06/24/23. Resident #44 stated she did not feel safe in the facility if she had to be around Resident #25 without staff present. She stated she was intimidated by Resident #25. Resident #44 stated Resident #25 physically inserted his penis in her, and physically touched her breasts and kissed her. She stated he was in her room too long, she stated he shut the door when he entered the room. She stated he took her brief off enough to insert his penis, and then moved it back when he was done. She also stated she was not washed when the STNA changed her clothing and brief. Resident #44 stated she did not tell or waive for Resident #25 to come in her room, he just came in and shut the door. Resident #44 stated she tried to push him away but does not have the upper body strength to do so and was unable to scream for help due to not being able to speak above a whisper. Interviews conducted throughout the survey from 06/27/23 through 07/07/23 with RN #324 revealed he was working on 06/24/23 and the nurse for Resident #44. He stated he was passing medications to other residents on the 100 hall and when he came back into the hallway, he saw Resident #44's door was shut, which it never was and when he opened the door, he observed Resident #25 laying face to face on top of Resident #44. He admitted to yelling at Resident #25 to Get the (expletive) off of her and leave, Resident #25 was startled and left in a hurry while he was fixing his blue shorts. RN #324 stated he immediately went to the nurse's station and notified the DON, Administrator, Resident #44's family, the physician, and the police. Interview on 07/05/23 at 12:33 P.M., with the local hospital staff Sexual Assault Nurse Examiner (SANE) RN #386 revealed upon arrival to the hospital, Resident #44 was able to consent for the sexual assault exam and stated she was alert and oriented to person, place, time and situation. She was dressed in a hospital gown and had on a brief that was wet with urine, she stated there were no obvious signs of sexual assault, such as cuts, scrapes, or bruising, however she stated Resident #44 named Resident #25 as the alleged perpetrator and she stated he put his penis in her vagina. SANE RN #386 stated Resident #44 said she did not want Resident #25 to do this and was not able to tell him to stop or to push him away due to poor upper body strength and the inability to yell. Interview on 07/05/23 at 2:13 P.M. with STNA #379 revealed on 06/24/23 she was coming out of another resident's room and heard RN #324 yelling for Resident #25 to get off Resident #44. She then saw Resident #25 come out of Resident #44's room and was walking down the hallway adjusting his shorts. STNA #379 stated she then entered Resident #44's room and began to get the resident ready to go to the emergency room . STNA #379 revealed she did not clean her up, she just took the brief which was wet with urine and placed it in a plastic bag and set to the side but did not wash the resident off in any way. The resident was dressed in a new gown and brief. STNA #379 stated Resident #44 said she was ok but did not know Resident #25 and did not want him in her room. STNA #379 stated she asked Resident #44 if Resident #25 touched her down there and she answered yes. STNA #379 stated the brief she removed was moved to the side to expose Resident #44's genital area. As of 07/10/23 the results of the rape kit collected by the SANE RN #386 were not available for review by the State agency surveyor. Review of facility policy titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, dated October 2022, revealed sexual abuse was defined as any non-consensual sexual contact of any type with a resident. This deficiency substantiates Complaint Number OH00144113, OH00144073, and OH00144016.

Based on observation, record review, facility policy and procedure review and interview the facility failed to prevent an incident of neglect involving Resident #10. Actual Harm occurred on 04/26/22 at 7:10 P.M. when Resident #10, who was cognitively impaired, incontinent of bowel and dependent on staff for activities of daily living care was found to have deep tissue pressure ulcers to her bilateral buttocks as a result of having a bed pan placed underneath her for an unknown period of time. This affected one resident (#10) of three residents reviewed for neglect. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a plan of care, dated 12/10/21 revealed Resident #10 had impaired cognition related to a developmental delay. Interventions included the resident required assistance with all decision making and to engage her in simple tasks. Resident #10 had an indwelling urinary catheter and a plan of care related to bowel incontinence. Interventions included to check and change every two hours and to provide perineal care after each incontinent episode. Review of a pressure ulcer risk assessment, dated 04/08/22 revealed Resident #10 was at risk for developing pressure ulcers due to very limited mobility and her skin being very moist. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/09/22 revealed Resident #10 had severe cognitive impairment and memory problems. The assessment revealed the resident required extensive one person physical assistance for bed mobility, total dependence from two persons for transfers and total dependence from one person for dressing, eating, toilet use and personal hygiene. Resident #10 had an indwelling urinary catheter for urine and was always incontinent of bowel. Review of a nursing progress note, dated 04/27/22 at 10:28 P.M. and authored by Registered Nurse #300 revealed Resident #10 was on the bed pan. The note indicated the resident was noted to have a deep tissue injury on 04/26/22 when this nurse and another nurse found her on a bed pan. Review of a wound log, dated 04/27/22 (no time noted) revealed Resident #10 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound bed was observed as red viable tissue with slough and a small amount of serosanguinous exudate. The peri wound area skin was described as fragile. No measurements were noted for the wound. On 05/11/22 at 2:05 P.M. Registered Nurse (RN) #300 was observed providing wound care for Resident #10's bilateral buttocks. Observation of the wounds revealed they were beefy red and the surrounding skin was dry and intact. A small to moderate amount of drainage was noted, with no odors. The surrounding skin was dry and intact. At the time of the observation, interview with RN #300 revealed the wound to the resident's buttocks had developed on 04/26/22 from sitting on a bed pan for too long. Record review revealed no nursing progress note completed on 04/26/22 related to this incident. In addition, review of the delivery records for care, dated 04/26/22 revealed no medications were ordered or administered on 04/26/22 between 3:00 P.M. and 7:00 P.M. The resident was documented to have a bowel movement on this date at 4:31 A.M. and 10:23 P.M., toileting assistance was noted at 4:31 A.M. and 10:24 P.M. and meal documentation was entered at 10:12 P.M. On 05/11/22 at 4:11 P.M. interview with Regional Registered Nurse (RN) #357 revealed she was aware (unable to provide exact date of notification) Resident #10 developed a deep tissue injury on 04/26/22 after being found on the bed pan. RN #357 reported no one was sure how long the resident had been on the bed pan on that date. RN #357 revealed the deep tissue injury eventually evolved into a Stage III pressure ulcer when it opened on 05/04/22. RN #357 revealed no formal investigation was initiated on 04/26/22 when the deep tissue injury was first discovered to determine the circumstances of the incident. On 05/17/22 at 4:43 P.M. interview with RN #300 revealed she had been functioning as the facility wound nurse on 04/26/22. RN #300 revealed sometime after dinner time on this date, Licensed Practical Nurse #307 reported to her Resident #10 had been found on a bed pan and had a wound to her buttocks because of it. RN #300 revealed she proceeded to assess the resident and verified the resident had wounds to her bilateral buttocks as a result of pressure from the bed pan. RN #300 revealed there was no evidence the resident had refused any type of care on this date and it was not known who put the resident on a bed pan or when she had been put on a bed pan. The RN revealed Resident #10 was not known to ask for a bed pan, was incontinent of bowel with staff checking and changing her every two hours. RN #300 also revealed the resident would be physically unable to take herself off a bed pan. During the interview, RN #300 revealed she reported this incident/concern to the Director of Nursing (DON) and regional nurse the next morning (on 04/27/22). On 05/23/22 at 2:53 P.M. interview with State tested Nursing Assistant (STNA) #322 revealed she worked second shift on 04/26/22 beginning at 3:00 P.M. and was assigned to care for Resident #10. The STNA revealed Resident #10 was always incontinent of bowel and never used or asked for the bed pan. The STNA denied putting Resident #10 on the bed pan on this date or providing any care at all to the resident between 3:00 P.M. and 7:00 P.M. The STNA revealed on 04/26/22 following the incident with the bed pan (at 7:10 P.M.), LPN #307 questioned her if she known Resident #10 was on a bed pan or if she had put her there to which she denied. On 05/23/22 at 10:10 A.M. interview with STNA #340 revealed she worked day shift beginning at 7:00 A.M. on 04/26/22 and was assigned to care for Resident #10. During the interview, the STNA revealed the resident never used the bed pan, would not ask for a bed pan and denied putting the resident on a bed pan on her shift. On 05/24/22 at 11:04 A.M. during an interview with the DON, the DON revealed he was unsure what the issue was with Resident #10 and her deep tissue injury. The DON initially reported he was not told of the incident but then indicated he did not recall when he was told about the incident. During the interview, the DON confirmed the facility completed no formal investigation, including interviews with staff or obtaining staff statements to determine the circumstances of the incident. There was no evidence the facility investigated to identify who placed Resident #10 on the bed pan, what time the resident was placed on the bed pan, why the resident was placed on the bed pan or why staff failed to identify the resident was on a bed pan until 04/26/22 at 7:10 P.M. when the oncoming nurse went in the resident's room. The DON also verified the incident was not reported to the State agency as an incident of neglect. On 05/24/22 at 12:01 P.M. interview with LPN #307 revealed she worked on 04/26/22 beginning at 7:00 P.M. LPN #307 revealed she was familiar with Resident #10 and frequently checked on this resident first at the beginning of her shift. The LPN denied receiving any information in report regarding the resident and any issues or use of the bed pan. LPN #307 revealed she entered Resident #10's room around 7:10 P.M. and immediately identified the resident was on a bed pan. The LPN revealed the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN revealed the resident did not normally use a bed pan and at the time she entered the room the resident was not having any type of behaviors/was not resistive to her removing the bed pan at that time. LPN #307 revealed she immediately notified RN #300, the wound care nurse and the resident's skin was assessed. The resident's left and right buttocks were deep purple and bruised appearing in color. During the interview, LPN #307 denied making any type of nursing progress note entry related to the incident. The LPN revealed she did not know how long the resident had been on the bed pan or who put her on the bed pan. She stated she questioned STNA #322, who was assigned to Resident #10's care for second shift to see if she had put her on a bed pan to which STNA #322 denied. The LPN confirmed the incident had occurred on 04/26/22 and could not explain why the nursing progress notes and wound assessment were dated 04/27/22. On 05/24/22 at 2:00 P.M. interview with the Administrator revealed she was not aware Resident #10 had developed a deep tissue injury to her buttocks from a bed pan until 05/11/22 (during the complaint investigation). She confirmed the facility did not complete an investigation into the incident to determine the circumstances of the incident and did not report the incident to the State agency as an incident of neglect. Review of facility policy abuse, neglect, and exploitation, revised June 2019 revealed neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This deficiency substantiates Complaint Number OH 461.

Based on record review, review of nursing staff schedules, review of the facility assessment, review of the facility staffing policy and procedure, review of facility medication error reports, review of a facility self-reported incident (SRI), staff interviews and interview with Medical Director #578 the facility failed to maintain sufficient levels of licensed nursing staff to meet the total care needs of all facility residents. This resulted in Immediate Jeopardy beginning on 03/05/22 at approximately 8:30 P.M. when no licensed nurse (licensed practical nurse (LPN) or registered nurse (RN)) was on duty to provide for the routine care, monitoring, medication administration, assessments, response to urgent resident needs and/or treatments for all 52 residents residing in the facility. The facility remained without a licensed nurse from 03/05/22 at 8:30 P.M. until 03/06/22 at 7:00 A.M. and then was again without a licensed nurse on 03/07/22 from 1:00 A.M. to 7:00 A.M. The lack of licensed nurse in the facility to provide nursing care resulted in actual or the potential for actual harm for residents related to the lack of administration of medications, wound care, supervision, enteral nutrition administration and/or treatment/management of chronic and/or acute disease processes/diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This had the potential to affect all 52 residents. On 03/09/22 at 11:10 A.M. the Administrator, Regional Clinical Support Nurse #579, and the Interim Director of Nursing (IDON) were notified Immediate Jeopardy began on 03/05/22 at 8:30 P.M. when the facility failed to ensure a licensed nurse was on duty and present in the facility to provide for the routine care, monitoring, medication administration, assessments, response to urgent resident needs and treatments for all 52 residents residing in the facility. There was no licensed nurse on duty from 03/05/22 at 8:30 P.M. until 03/06/22 at 7:00 A.M. and again on 03/07/22 at 1:00 A.M. until 7:00 A.M. leaving residents without access to a licensed nurse to meet their total care needs. The Immediate Jeopardy was removed on 03/09/22 when the facility implemented the following corrective actions: · On 03/08/22 the facility identified all residents had the potential to be affected related to the lack of licensed nurse on duty and in the facility. · Beginning 03/08/22 the facility indicated they would attempt to schedule an additional licensed nurse for each 12-hour shift. · On 03/08/22 at 12:27 P.M. Medical Director #578 was notified by Regional Clinical Support Nurse #579 regarding the staffing concern from 03/05/22 for 7:00 P.M. to 7:00 A.M. and from 03/07/22 from 1:00 A.M. to 7:00 A.M. including resident missed medications, treatments, enteral feedings and blood glucose checks. · On 03/08/22 the Administrator was educated by Regional Clinical Support Nurse #579 regarding communication via an immediate phone call to the Regional Support Team regarding any open nurse shift positions due to call-offs that are unable to be filled in a timely manner, nurse no shows, etc to meet the care needs of the residents including medication administration. · On 03/08/22 the Administrator, Human Resource #580 and Scheduler/STNA #539 were educated by Regional Clinical Support Nurse #579 regarding conducting staffing meetings two times daily to review any call-offs and ensure adequate coverage is obtained as needed to meet the care needs of the residents including medication administration. · On 03/08/22 at 2:02 P.M. all 18 facility nurses were educated via blast text through OnShift regarding the importance of safe staffing to foster safe resident care, proper procedure for nurse call-offs, and to immediately notify the Interim DON if an oncoming nurse does not report to work as scheduled and there is no coverage. Nurses were asked to please reply to the message to ensure they received and understood the education. · On 03/08/22 at 5:15 P.M. all 18 State tested Nursing Assistant (STNA) staff were educated via blast text through OnShift regarding if there is not a nurse in the building to immediately notify the Administrator, and then the Interim DON if there isn't an immediate response from the Administrator. STNAs were asked to please reply to the message to ensure they received and understood the education. · On 03/08/22 at 6:55 P.M. the Interim DON's phone number was posted at all nursing stations. · On 03/08/22 the facility implemented a plan to hold a staffing meeting with the Administrator, HR Director #580 and Scheduler/STNA #539 in attendance to review scheduled nursing staff for the day to ensure there was always a licensed nursing staff member on duty to meet the care needs of the residents including medication administration. The daily posted staffing would be reviewed during the meeting to ensure an adequate number of nurses were scheduled for the day. The staffing meeting would occur two times daily Monday through Friday for four weeks and then randomly thereafter. Ad hoc education will be given for any non-compliance. · Beginning 03/08/22 the facility implemented a plan for the Interim DON/designee to verify via a telephone call to facility on the off shift (7:00 P.M. to 7:00 A.M. (nights and weekends) all scheduled nurses had arrived for their scheduled shifts to ensure there was always licensed staff in the facility to meet the care needs of the residents including medication administration. This will occur daily for four weeks and then randomly thereafter. Ad hoc education will be given for any non-compliance. · Between 03/09/22 and 03/10/22 the facility completed medication error reports for each resident. · On 03/09/22 the facility Interdisciplinary (IDT) team, including the Activity Director, Admission Director, Nurse Scheduler, Administrator, Receptionist, Maintenance Director, and Therapy Director completed Ambassador rounds for all residents to conduct psycho-social wellness checks with no negative outcomes identified at that time. · On 03/09/22 at 8:42 A.M. Human Resource Director #580 made telephone contact with 35 nurse and STNA staff members who did not respond in OnShift to the text blasts from 03/08/22 at 2:02 P.M. and 5:15 P.M. and verbally educated them on those texts to complete the education. · On 03/09/22 at 7:30 P.M. all 36 nursing (RN, LPN and STNA) staff members were educated via telephone contact and in person by Human Resources Director #580 and Scheduler/STNA #539 on staffing guidelines regarding sufficient nursing staff required on each shift to meet the needs of the residents in the facility with notification to the IDON, ADON, and nursing scheduler for assistance if unable to schedule sufficient staff. The staff were also educated regarding the facility's proper call-off procedure. · On 03/09/22 one on one education was provided by Regional Clinical Support Nurse #579 to Licensed Practical Nurse (LPN) #507 who was the only nurse on duty on 03/05/22 at 7:00 P.M. and 03/07/22 at 1:00 A.M. who left the facility without having adequate coverage regarding her obligation to ensure adequate licensed nursing staff always remain in the facility to meet the care needs of the residents including administration of medications. · On 03/09/22 the facility implemented a plan for the IDON and/or Regional Support team to cover open nurse shifts until a DON was in place to meet the care needs of the residents including medication administration. · Results of all audits will be reviewed in QAPI for tracking and trending purposes. Although the Immediate Jeopardy was removed on 03/09/22, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Review of the facility staffing schedules, assignments sheets and punch detail revealed on 03/05/22 from 7:00 A.M. to 7:00 P.M. there were two nurses, LPN #507 and LPN #576 on duty for the entire 12 hour shift and one nurse LPN #506 on duty for 8 hours from 7:00 A.M. to 3:00 P.M. to provide care for the 52 residents residing in the nursing facility. Review of a nurse/STNA schedule for 03/05/22 as well as the attendance punch records for 03/05/22, revealed LPN #507 punched in at 8:30 A.M. and punched out at 8:30 P.M. The facility schedule reflected on 03/05/22 there were two nurses, facility LPN #577 and agency LPN #581, scheduled for the shift beginning at 7:00 P.M. However, interview and record review revealed facility LPN #577 never arrived for his shift. Agency LPN #581 arrived at 7:00 P.M. but left at 7:26 P.M. because she did not want to be the only nurse in the facility. The facility schedule reflected on 03/06/22 there were two nurses, facility LPN #507 and facility LPN #505 scheduled for the entire 12 hour shift from 7:00 A.M. to 7:00 P.M. Facility LPN #577 and agency LPN #582 were scheduled for the shift beginning at 7:00 P.M. Interview and record review revealed LPN #577 never arrived to start the 7:00 P.M. shift. Agency LPN #582 arrived at 7:00 P.M. but was unable to punch in or gain access to the facility electronic medical record (EMR) system with her agency badge and password. LPN #582 got frustrated because she could not do anything, called her agency, and left the facility at approximately 7:30 P.M. Review of the facility attendance punch records indicated LPN #505 remained in the facility until 03/07/22 at 12:00 A.M. and LPN #507 remained in the facility on 03/07/22 until 1:00 A.M. However, no nurse(s) arrived to replace them. And LPN #507 left the facility after working 18 hours. Review of a facility self-reported incident (SRI), tracking number 0 created on 03/10/22 a 3:52 P.M. revealed the facility reported an allegation of neglect/mistreatment to the State agency. The SRI revealed during the evening of 03/05/22 from 8:30 P.M. to 7:00 A.M. (03/06/22) and 03/07/22 from 1:00 A.M. to 7:00 A.M. the facility did not have a nurse in the building. The facility identified 52 residents affected by the incident. A narrative summary of the incident revealed a staff nurse called off prompting the agency nurse to leave the facility. The SRI noted as a result of the incident, on 03/08/22 the facility medical director and physicians were notified of the staffing concerns from 03/05/22 at 8:30 P.M. to 03/06/22 at 7:00 A.M. and from 03/07/22 from 1:00 A.M. to 7:00 A.M. including missed medications, wound treatments, enteral (tube feedings) and blood glucose checks. In addition, resident responsible parties were also notified of the missed medications and blood glucose checks. Record review revealed Medication/Treatment Incident Reports were completed on 03/10/22 for all 52 residents in the facility as a result of there being no nurse in the facility on 03/05/22 from 8:30 P.M. to 7:00 A.M. or on 03/07/22 from 1:00 A.M. to 7:00 A.M. The reports indicated all 52 residents in the facility during that time failed to receive their prescribed medications. The reports further indicated each resident's physician as well as the Medical Director were notified of the incident on 03/08/22 and responsible parties were notified on 03/09/22. On 03/08/22 at 3:02 P.M. interview with STNA #520 revealed she worked at the facility on 03/05/22 from 11:00 P.M. to 03/06/22 at 7:00 A.M. and on 03/06/22 from 11:00 P.M. to 7:00 A.M. STNA #520 revealed when she arrived to work at 11:00 P.M. on 03/05/22 quite a few of the residents were asking for pain medication. STNA #520 revealed the same thing happened on Sunday, 03/06/22. STNA #520 revealed there was no licensed nurse working in the facility and she and two other aides, STNA #566 and STNA #574 were working to keep all the residents' safe, clean and dry and to prevent any falls. STNA #520 indicated she contacted both the Administrator and Scheduler #539 multiple times on 03/05/22 from 11:00 P.M. until 12:00 A.M. The scheduler responded and indicated they knew about the staffing situation, and they were making phone calls. At the end of her shift on 03/06/22 at 7:00 A.M. STNA #520 revealed she left written messages regarding the staffing situation in the mailboxes of the Administrator and Scheduler. STNA #520 revealed the Administrator and Scheduler called her for a conference call on Monday, 03/07/22 to discuss the staffing situation and asked her to be patient and understanding regarding the staffing and they were working on it and it would not be an overnight fix. On 03/08/22 at 3:23 P.M. interview with STNA #566 revealed when she arrived to work on 03/05/22 at 11:00 P.M., residents were complaining they did not receive their medications, some residents were complaining of pain and some residents were panicking because there was no nurse in the facility. STNA #566 also stated Sunday night (03/06/22) was the same and the residents only got their first round of night meds (prior to 1:00 A.M. on 03/07/22). STNA #566 stated she did not know what to do. She stated the medication cart keys were locked in the medication carts and in the morning on 03/07/22 the 7:00 A.M. nurses, who arrived on duty could not open the carts to get the keys and had to get someone to open the medication carts. On 03/09/22 at 1:16 P.M. interview with STNA #518 revealed she worked the 3:00 P.M. to 11:00 P.M. shift on 03/05/22 and 03/06/22. STNA #518 revealed there was no nurse in the facility on 03/05/22 after 8:30 P.M. and she was aware there was no nurse in the facility on 03/07/22 after 1:00 A.M. She stated she personally spoke with the scheduler on 03/05/22 at approximately 7:30 P.M. and was told they were working on getting a nurse and to do the best they could. STNA #518 revealed the situation was the same on 03/06/22 when no nurses arrived for the 7:00 P.M. shift but LPN #505 and LPN #507 stayed over until 12:00 A.M. and 1:00 A.M., respectively. LPN #507 came and found her at 11:00 P.M. and indicated her replacement had shown up at approximately 7:00 P.M. but left almost immediately after discovering she would be the only nurse. On 03/09/22 at 1:36 P.M. interview with STNA #575 revealed during shift change at 7:00 P.M. on 03/06/22, an agency nurse (LPN #581) showed up but she had no log-in information for the facility electronic medical record system. STNA #575 indicated the nurse called the agency and then left because there was nothing she could do. The facility nurse, LPN #507 was sick and dizzy and called the Administrator on 03/05/22 at 8:30 P.M. STNA #575 revealed LPN #507 did not receive a return call (from the Administrator) and eventually locked up the narcotic keys and left. STNA #575 revealed we took care of the residents and put them to bed. She stated some were requesting their medications, but we were STNAs and could not do anything but take care of them. On 03/09/22 at 2:05 P.M. interview with LPN #576 revealed she was an agency nurse who was scheduled to work on 03/05/22 from 7:00 A.M. to 7:30 P.M. at the facility. She stated she had worked at the facility in the past and this was the second or third time she had experienced staffing problems. She indicated she was assigned two halls when she arrived at the facility at 7:00 A.M., the 300 Hall (secured dementia unit) and the 400 Hall with two STNAs to assist her. LPN #576 indicated on 03/05/22 the relief nurse LPN #577 called off at 5:14 P.M. and the agency relief nurse LPN #581 arrived at 7:00 P.M. but indicated that she was not staying because she did not want to be the only nurse in the facility. LPN #576 revealed she called the Administrator at 7:15 P.M. regarding LPN #581's staffing concerns and again at 7:26 P.M. when LPN #581 decided she was not staying because it was unsafe, and she left. LPN #576 indicated she counted the narcotics in the medication carts with LPN #507 and left the facility at 8:00 P.M. LPN #507 was still in the facility when she left. LPN #576 indicated on 03/05/22 when she left the facility, there was only one nurse, LPN #507 along with three STNAs (#520, #566 and #574) remaining in the facility. On 03/09/22 at 3:40 P.M. interview with Scheduler/STNA #539 revealed she had worked at the facility since July 2021. She stated she schedules staffing for the facility a month out and posts the entire month at least two weeks before, usually on the 18th of the month. She posts the schedule so if staff want to pick up extra shifts, they know what shifts are available. She also sends out mass texts via the On Shift System for facility staff and enters information into staffing agency portals or emails them directly to let them know of the availability of shifts and facility staffing needs. Scheduler/STNA #539 revealed she typically staffs three nurses for the 7:00 A.M. to 7:00 P.M. shift and two nurses for the 7:00 P.M. to 7:00 A.M. shift and tries to get a medication pass nurse for 7:00 P.M. to 11:00 P.M. and then drops to two nurses at 11:00 P.M. Schedule/STNA #539 revealed when she received the call off notification from LPN #577, she immediately started making attempts to replace him with another licensed nurse. She stated she contacted the Administrator and was working with her using On Shift, texting people, offering bonuses but got a lot of no. She stated she also posted to all of the agencies and still got no response. Scheduler/STNA #539 indicated she continued to try to get staffing for the facility and went to bed with the phone still making phone calls and worrying about the STNAs left to work in the facility with no licensed nurse as well as the residents. On 03/10/22 at 12:58 A.M. interview with LPN #507 revealed she was scheduled to work at the facility on 03/05/22 from 7:00 A.M. to 7:30 P.M. with another staff nurse (LPN #506) scheduled from 7:00 A.M. to 3:00 P.M. and an agency nurse (LPN #576) scheduled for the 7:00 A.M. to 7:30 P.M. shift. LPN #507 indicated LPN #506 left at 3:00 P.M. and she assumed care for the residents on the 100 hall and 200 hall by herself, which was difficult for one nurse. Agency LPN #576 was assigned to care for residents on the 300 Hall and the secured dementia unit. At 7:00 P.M., both LPN #507 and Agency LPN #576 were waiting for their relief staff to arrive. LPN #507 indicated she was sick and barely making it to the end of the shift. She had a headache, vomiting, diarrhea and was dizzy. LPN #507 revealed she sent messages to the scheduler (regarding staffing) with no response. She also called the Administrator at approximately 7:30 P.M. and told her she was sick and couldn't stay. The Administrator's response was, can you hang in for a little longer- about an hour? LPN #507 revealed Agency LPN #576 left at 7:30 P.M. and she (LPN #507) stayed until 8:30 P.M. as the only nurse in the facility and was trying to hang on. LPN #507 revealed at that time no one had told her an oncoming nurse had called off. LPN #507 indicated she stayed for another hour (until approximately 8:00 P.M.-8:30 P.M.), and no one came. LPN #507 stated she sent four messages to the scheduler with no response. LPN #507 revealed she locked the keys in the medication room and placed the medication room key in the office and told the Administrator where they were in a hidden location. During the interview, LPN #507 revealed she returned to the facility on [DATE] at 7:00 A.M. and worked until 03/07/22 at 1:00 A.M. (although she was scheduled to leave on 03/06/22 at 7:30 P.M.). LPN #507 revealed it was like [NAME]-[NAME] all over again. Facility LPN #577 who was scheduled to come in on 03/06/22 at 7:00 P.M. did not show up and she was told he had quit. An agency nurse, LPN #582 did arrive to the facility at 11:00 P.M. but did not stay because she had no access to anything, was unable to scan her badge to administer medications and stated she was not staying because she felt it was unsafe. 2. Record review revealed Resident #105 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No care plan had been developed relative to Resident #105's altered skin integrity was initiated. Review of a nursing progress note, dated 03/04/22 at 6:18 P.M. revealed a wound vac was not available at the time and an abdominal dressing was in place from hospital. No drainage noted. On 03/09/22 at 2:23 P.M. interview with STNA #574 revealed she arrived to work at 10:55 P.M. on 03/05/22 for the 11:00 P.M. to 7:00 A.M. shift and was informed there was no nurse working in the facility. STNA #574 revealed at approximately 3:00 A.M. Resident #105 was in no apparent distress and it appeared her abdominal dressing was intact. At approximately 4:30 A.M., as STNA #574 was making rounds, she noted Resident #105 had blood on her gown and her abdominal dressing was on the floor. She conferred with the other STNAs to determine if 911 should be called or if they should attempt to contact the resident's physician. STNA #574 revealed she contacted Resident #105's physician, Medical Director #578 at approximately 5:00 A.M. and informed him the resident had removed her dressing and there was blood on her gown. Medical Director #578 advised STNA #574 to put multiple abdominal pad dressings on the wound and use the resident's abdominal binder to secure the pads. STNA #574 revealed Medical Director #578 told her the resident would be fine until a nurse arrived in a couple of hours. STNA #574 stated she again asked Medical Director #578 if he was sure, and he responded yes and disconnected the telephone call. STNA #578 revealed she placed multiple abdominal dressing pads over Resident #105's wound and used the resident's abdominal binder to secure the dressings in place as directed by the physician. On 03/08/22 at 2:21 P.M. interview with Medical Director #578 revealed he had received a telephone call from an STNA (STNA #574) at the facility at approximately 5:00 A.M. the morning of 03/06/22 indicating Resident #105 had removed her abdominal dressing and was bleeding. Medical Director #578 revealed he directed STNA #574 to replace the dressing with abdominal pads and secure the pads with the resident's abdominal binder. He stated he reassured STNA #574 it would be okay until a nurse arrived to assess the wound. 3. Record review revealed Resident #140 was admitted to the facility's secured dementia unit on 06/26/18 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A plan of care relative to Resident #140's elopement risk and exit-seeking behavior was initiated upon admission and updated on 04/07/20. Interventions included to encourage Resident #140 to apply Wanderguard, check placement every shift and at bedtime, encourage resident to stay in common areas, assess for hunger, thirst, ambulation or toileting needs when found attempting to exit, complete elopement risk assessment quarterly and as need and provide diversionary activities. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/02/22 revealed Resident #140 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 99. The resident exhibited inattention and disorganized thinking and required limited assistance from one staff person for some activities of daily living and was independent with locomotion on and off the unit using a wheelchair. Review of the quarterly Elopement Risk Evaluation, dated 01/07/22 revealed Resident #140 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The evaluation revealed the resident's wandering behavior was likely to affect the safety or well-being of self/others and likely to affect the privacy of others. On 03/08/22 at 12:02 P.M. Resident #140 was observed maneuvering in his wheelchair towards the exit doors asking have you seen my wife? Resident #140 was redirected away from the exit doors when the Wanderguard alarmed. There was one STNA assigned to the secured dementia unit at that time and a nurse assigned to both the secured dementia unit as well as the 400 hall. The secured dementia unit had a census of 13 on 03/08/22. On 03/09/22 at 2:05 P.M. interview with LPN #576 revealed she was an agency nurse who was scheduled to work on 03/05/22 from 7:00 A.M. to 03/06/22 at 7:30 P.M. at the facility. She indicated she was assigned two halls when she arrived at the facility at 7:00 A.M., the 300 Hall (secured dementia unit) and the 400 Hall with two STNAs to assist her. She stated STNA #511 was scheduled to leave early at 11:00 A.M. which left only one STNA available to assist with resident care. LPN #576 revealed one resident (Resident #140) on the dementia unit was an elopement risk and continually made attempts to leave the dementia unit. LPN #576 indicated it was very difficult to divide her attention between giving Resident #104 (a resident with complex medical issues and [CONDITION(S)]) the attention his condition warranted and at the same time ensuring Resident #140 on the dementia unit did not elope, especially with the lack of help from the remaining STNA assigned to assist her. LPN #576 indicated Resident #140 at one time pushed on the secured dementia unit exit doors long enough for them to open after a short period of time and he was able to get onto the hallway outside of the secured unit. LPN #576 revealed during her shift, she contacted the nurse practitioner to update her on Resident #104's condition and was given an order to send Resident #104 to the hospital. LPN #576 revealed Resident #140 continued his elopement attempts throughout the entire shift. 4. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 9:00 P.M. The resident also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M., 06:00 A.M. 12:00 P.M. and 6:00 P.M. Review of the March 2022 administration record revealed Resident #122 did not receive her enteral feeding as ordered on 03/05/22 at 9:00 P.M. or water flushes as ordered on 03/06/22 at 12:00 A.M. or 6:00 A.M. or on 03/07/22 at 6:00 A.M. 5. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An order to check for enteral feed residuals every four hours (schedule included 5:00 A.M. and 9:00 P.M.) and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M. 5:00 A.M. and 9:00 P.M.). The resident also had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the March 2022 administration record revealed the resident did not receive the enteral feeding, water flushes or monitoring on 03/05/22 from 8:00 P.M. to 03/06/22 7:00 A.M. or on 03/07/22 from 1:00 A.M. to 7:00 A.M. 6. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M., 5:00 A.M., 9:00 A.M., 1:00 P.M., 5:00 P.M., and 9:00 P.M. The resident also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the March 2022 administration records MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. to 03/06/22 at 7:00 A.M. or 03/07/22 from 1:00 A.M. to 7:00 A.M. This included the administration of [MEDICATION(S)] 1.5 Cal Liquid 300 ml and 120 ml free water flush via j tube at 9:00 P.M. on 03/05/22 and 1:00 A.M. and 5:00 A.M. on 03/06/22. 7. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of MAR for March 2022 indicated Resident #102 did not receive her scheduled enteral tube feeding, water flushes, [CONDITION(S)] care, gastrostomy tube care or monitoring as ordered from 03/05/22 at 8:00 P.M. to 03/06/22 at 7:00 A.M. or 03/07/22 from 1:00 A.M. to 7:00 A.M. This included ensuring the [MEDICATION(S)] 1.5 was running continuously, 230 ml water flushes every six hours at 12:00 A.M. and 06:00 A.M. on 03/06/22 and on 12:00 A.M. and 6:00 A.M. on 03/07/22. Review of the March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. 8. The following staff and resident interviews also identified concerns related to the facility staffing from 03/05/22 at 8:30 P.M. until 03/06/22 at 7:00 A.M. and again on 03/07/22 from 1:00 A.M. to 7:00 A.M. a. On 03/08/22 at 3:02 P.M. interview with STNA #520 revealed she worked at the facility on 03/05/22 from 11:00 P.M. to 03/06/22 at 7:00 A.M. and on 03/06/22 from 11:00 P.M. to 03/07/22 at 7:00 A.M. STNA #520 revealed when she arrived at work on 03/05/22 at 11:00 P.M. Resident #122 was crying in pain and needed pain medication. STNA #520 indicated Resident #122 was one of many residents complaining of pain and the STNA felt bad because there was no nurse working and she could not administer medications to the residents. STNA #520 revealed she tried to offer other interventions for pain that were ineffective, and Resident #122 was in pain throughout the whole night on 03/06/22 and 03/07/22. On 03/21/22 at 1:55 P.M. the surveyor attempted to interview Resident #122. The resident was unable to communicate in sentences/conversation but nodded her head yes and no. Resident #122 indicated she was in pain throughout the night when she did not get her pain medication on the above dates. She was unable to verbalize anything specific to the pain but nodded yes to generalized pain. Resident #122 also nodded yes to being anxious about having no nurse in the facility and acknowledged it had not occurred again since those dates. b. On 03/08/22 at 11:48 A.M. interview with Resident #108 revealed she did not receive any medications or her pain medication on Saturday (03/05/22) night because there was no nurse. The resident reported she was having pain which she described as being intolerable. The resident revealed she repeatedly asked STNA #566 that night if the nurse was there to give her pain medication. On 03/08/22 at 3:23 P.M. interview with STNA #566 revealed when she arrived to work on 03/05/22 at 11:00 P.M., Resident #108 immediately voiced complaints of pain and stated she did not receive her bedtime medications or pain medications (Tylenol Extra Strength). STNA #566 indicated Resident #108 was in pain throughout the whole night (03/05/22 to 03/06/22) but there was no nurse working in the facility to administer pain medications to the resident. On 03/21/22 at 2:05 P.M. during a follow up interview with Resident #108 the resident again voiced concerns she discovered there were no nurses in the facility when she went to the nurses' station to check on her medications. Resident #108 revealed she became very frustrated and anxious because she did not get her anxiety

Based on record review, review of nursing staff schedules, review of the facility Abuse, Neglect and Misappropriation policy and procedure, review of facility medication error reports, review of a facility self-reported incident (SRI), staff interviews and interview with Medical Director #578 the facility failed to prevent a situation of neglect when there were no licensed nursing staff on duty in the facility to meet the total care needs of all facility residents. This resulted in Immediate Jeopardy beginning on 03/05/22 at approximately 8:30 P.M. when no licensed nurse (licensed practical nurse (LPN) or registered nurse (RN)) was on duty to provide for the routine care, monitoring, medication administration, assessments, response to urgent resident needs and/or treatments for all 52 residents residing in the facility. The facility remained without a licensed nurse from 03/05/22 at 8:30 P.M. until 03/06/22 at 7:00 A.M. and then was again without a licensed nurse on 03/07/22 from 1:00 A.M. to 7:00 A.M. The lack of licensed nurse in the facility to provide nursing care resulted in a situation of neglect and actual or the potential for actual harm for residents related to the lack of administration of medications, wound care, supervision, enteral nutrition administration and/or treatment/management of chronic and/or acute disease processes/diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This had the potential to affect all 52 residents. On 03/09/22 at 11:10 A.M. the Administrator, Regional Clinical Support Nurse #579, and the Interim Director of Nursing (IDON) were notified Immediate Jeopardy began on 03/05/22 at 8:30 P.M. when the facility failed to ensure a licensed nurse was on duty and present in the facility to provide for the routine care, monitoring, medication administration, assessments, response to urgent resident needs and treatments for all 52 residents residing in the facility. There was no licensed nurse on duty from 03/05/22 at 8:30 P.M. until 03/06/22 at 7:00 A.M. and again on 03/07/22 at 1:00 A.M. until 7:00 A.M. leaving residents without access to a licensed nurse to meet their total care needs. The Immediate Jeopardy was removed on 03/09/22 when the facility implemented the following corrective actions: · On 03/08/22 the facility identified all residents had the potential to be affected related to the lack of licensed nurse on duty and in the facility. · Beginning 03/08/22 the facility indicated they would attempt to schedule an additional licensed nurse for each 12-hour shift. · On 03/08/22 at 12:27 P.M. Medical Director #578 was notified by Regional Clinical Support Nurse #579 regarding the staffing concern from 03/05/22 for 7:00 P.M. to 7:00 A.M. and from 03/07/22 from 1:00 A.M. to 7:00 A.M. including resident missed medications, treatments, enteral feedings and blood glucose checks. · On 03/08/22 the Administrator was educated by Regional Clinical Support Nurse #579 regarding communication via an immediate phone call to the Regional Support Team regarding any open nurse shift positions due to call-offs that are unable to be filled in a timely manner, nurse no shows, etc to meet the care needs of the residents including medication administration. · On 03/08/22 the Administrator, Human Resource #580 and Scheduler/STNA #539 were educated by Regional Clinical Support Nurse #579 regarding conducting staffing meetings two times daily to review any call-offs and ensure adequate coverage is obtained as needed to meet the care needs of the residents including medication administration. · On 03/08/22 at 2:02 P.M. all 18 facility nurses were educated via blast text through OnShift regarding the importance of safe staffing to foster safe resident care, proper procedure for nurse call-offs, and to immediately notify the Interim DON if an oncoming nurse does not report to work as scheduled and there is no coverage. Nurses were asked to please reply to the message to ensure they received and understood the education. · On 03/08/22 at 5:15 P.M. all 18 State tested Nursing Assistant (STNA) staff were educated via blast text through OnShift regarding if there is not a nurse in the building to immediately notify the Administrator, and then the Interim DON if there isn't an immediate response from the Administrator. STNAs were asked to please reply to the message to ensure they received and understood the education. · On 03/08/22 at 6:55 P.M. the Interim DON's phone number was posted at all nursing stations. · On 03/08/22 the facility implemented a plan to hold a staffing meeting with the Administrator, HR Director #580 and Scheduler/STNA #539 in attendance to review scheduled nursing staff for the day to ensure there was always a licensed nursing staff member on duty to meet the care needs of the residents including medication administration. The daily posted staffing would be reviewed during the meeting to ensure an adequate number of nurses were scheduled for the day. The staffing meeting would occur two times daily Monday through Friday for four weeks and then randomly thereafter. Ad hoc education will be given for any non-compliance. · Beginning 03/08/22 the facility implemented a plan for the Interim DON/designee to verify via a telephone call to facility on the off shift (7:00 P.M. to 7:00 A.M. (nights and weekends) all scheduled nurses had arrived for their scheduled shifts to ensure there was always licensed staff in the facility to meet the care needs of the residents including medication administration. This will occur daily for four weeks and then randomly thereafter. Ad hoc education will be given for any non-compliance. · Between 03/09/22 and 03/10/22 the facility completed medication error reports for each resident. · On 03/09/22 the facility Interdisciplinary (IDT) team, including the Activity Director, Admission Director, Nurse Scheduler, Administrator, Receptionist, Maintenance Director, and Therapy Director completed Ambassador rounds for all residents to conduct psycho-social wellness checks with no negative outcomes identified at that time. · On 03/09/22 at 8:42 A.M. Human Resource Director #580 made telephone contact with 35 nurse and STNA staff members who did not respond in OnShift to the text blasts from 03/08/22 at 2:02 P.M. and 5:15 P.M. and verbally educated them on those texts to complete the education. · On 03/09/22 at 7:30 P.M. all 36 nursing (RN, LPN and STNA) staff members were educated via telephone contact and in person by Human Resources Director #580 and Scheduler/STNA #539 on staffing guidelines regarding sufficient nursing staff required on each shift to meet the needs of the residents in the facility with notification to the IDON, ADON, and nursing scheduler for assistance if unable to schedule sufficient staff. The staff were also educated regarding the facility's proper call-off procedure. · On 03/09/22 one on one education was provided by Regional Clinical Support Nurse #579 to Licensed Practical Nurse (LPN) #507 who was the only nurse on duty on 03/05/22 at 7:00 P.M. and 03/07/22 at 1:00 A.M. who left the facility without having adequate coverage regarding her obligation to ensure adequate licensed nursing staff always remain in the facility to meet the care needs of the residents including administration of medications. · On 03/09/22 the facility implemented a plan for the IDON and/or Regional Support team to cover open nurse shifts until a DON was in place to meet the care needs of the residents including medication administration. · Results of all audits will be reviewed in QAPI for tracking and trending purposes. Although the Immediate Jeopardy was removed on 03/09/22, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Review of the facility staffing schedules, assignments sheets and punch detail revealed on 03/05/22 from 7:00 A.M. to 7:00 P.M. there were two nurses, LPN #507 and LPN #576 on duty for the entire 12 hour shift and one nurse LPN #506 on duty for 8 hours from 7:00 A.M. to 3:00 P.M. to provide care for the 52 residents residing in the nursing facility. Review of a nurse/STNA schedule for 03/05/22 as well as the attendance punch records for 03/05/22, revealed LPN #507 punched in at 8:30 A.M. and punched out at 8:30 P.M. The facility schedule reflected on 03/05/22 there were two nurses, facility LPN #577 and agency LPN #581, scheduled for the shift beginning at 7:00 P.M. However, interview and record review revealed facility LPN #577 never arrived for his shift. Agency LPN #581 arrived at 7:00 P.M. but left at 7:26 P.M. because she did not want to be the only nurse in the facility. The facility schedule reflected on 03/06/22 there were two nurses, facility LPN #507 and facility LPN #505 scheduled for the entire 12 hour shift from 7:00 A.M. to 7:00 P.M. Facility LPN #577 and agency LPN #582 were scheduled for the shift beginning at 7:00 P.M. Interview and record review revealed LPN #577 never arrived to start the 7:00 P.M. shift. Agency LPN #582 arrived at 7:00 P.M. but was unable to punch in or gain access to the facility electronic medical record (EMR) system with her agency badge and password. LPN #582 got frustrated because she could not do anything, called her agency, and left the facility at approximately 7:30 P.M. Review of the facility attendance punch records indicated LPN #505 remained in the facility until 03/07/22 at 12:00 A.M. and LPN #507 remained in the facility on 03/07/22 until 1:00 A.M. However, no nurse(s) arrived to replace them. And LPN #507 left the facility after working 18 hours. Review of a facility self-reported incident (SRI), tracking number 0 created on 03/10/22 a 3:52 P.M. revealed the facility reported an allegation of neglect/mistreatment to the State agency. The SRI revealed during the evening of 03/05/22 from 8:30 P.M. to 7:00 A.M. (03/06/22) and 03/07/22 from 1:00 A.M. to 7:00 A.M. the facility did not have a nurse in the building. The facility identified 52 residents affected by the incident. A narrative summary of the incident revealed a staff nurse called off prompting the agency nurse to leave the facility. The SRI noted as a result of the incident, on 03/08/22 the facility medical director and physicians were notified of the staffing concerns from 03/05/22 at 8:30 P.M. to 03/06/22 at 7:00 A.M. and from 03/07/22 from 1:00 A.M. to 7:00 A.M. including missed medications, wound treatments, enteral (tube feedings) and blood glucose checks. In addition, resident responsible parties were also notified of the missed medications and blood glucose checks. The facility substantiated the allegation of neglect. Record review revealed Medication/Treatment Incident Reports were completed on 03/10/22 for all 52 residents in the facility as a result of there being no nurse in the facility on 03/05/22 from 8:30 P.M. to 7:00 A.M. or on 03/07/22 from 1:00 A.M. to 7:00 A.M. The reports indicated all 52 residents in the facility during that time failed to receive their prescribed medications. The reports further indicated each resident's physician as well as the Medical Director were notified of the incident on 03/08/22 and responsible parties were notified on 03/09/22. On 03/08/22 at 3:02 P.M. interview with STNA #520 revealed she worked at the facility on 03/05/22 from 11:00 P.M. to 03/06/22 at 7:00 A.M. and on 03/06/22 from 11:00 P.M. to 7:00 A.M. STNA #520 revealed when she arrived to work at 11:00 P.M. on 03/05/22 quite a few of the residents were asking for pain medication. STNA #520 revealed the same thing happened on Sunday, 03/06/22. STNA #520 revealed there was no licensed nurse working in the facility and she and two other aides, STNA #566 and STNA #574 were working to keep all the residents' safe, clean and dry and to prevent any falls. STNA #520 indicated she contacted both the Administrator and Scheduler #539 multiple times on 03/05/22 from 11:00 P.M. until 12:00 A.M. The scheduler responded and indicated they knew about the staffing situation, and they were making phone calls. At the end of her shift on 03/06/22 at 7:00 A.M. STNA #520 revealed she left written messages regarding the staffing situation in the mailboxes of the Administrator and Scheduler. STNA #520 revealed the Administrator and Scheduler called her for a conference call on Monday, 03/07/22 to discuss the staffing situation and asked her to be patient and understanding regarding the staffing and they were working on it and it would not be an overnight fix. On 03/08/22 at 3:23 P.M. interview with STNA #566 revealed when she arrived to work on 03/05/22 at 11:00 P.M., residents were complaining they did not receive their medications, some residents were complaining of pain and some residents were panicking because there was no nurse in the facility. STNA #566 also stated Sunday night (03/06/22) was the same and the residents only got their first round of night meds (prior to 1:00 A.M. on 03/07/22). STNA #566 stated she did not know what to do. She stated the medication cart keys were locked in the medication carts and in the morning on 03/07/22 the 7:00 A.M. nurses, who arrived on duty could not open the carts to get the keys and had to get someone to open the medication carts. On 03/09/22 at 1:16 P.M. interview with STNA #518 revealed she worked the 3:00 P.M. to 11:00 P.M. shift on 03/05/22 and 03/06/22. STNA #518 revealed there was no nurse in the facility on 03/05/22 after 8:30 P.M. and she was aware there was no nurse in the facility on 03/07/22 after 1:00 A.M. She stated she personally spoke with the scheduler on 03/05/22 at approximately 7:30 P.M. and was told they were working on getting a nurse and to do the best they could. STNA #518 revealed the situation was the same on 03/06/22 when no nurses arrived for the 7:00 P.M. shift but LPN #505 and LPN #507 stayed over until 12:00 A.M. and 1:00 A.M., respectively. LPN #507 came and found her at 11:00 P.M. and indicated her replacement had shown up at approximately 7:00 P.M. but left almost immediately after discovering she would be the only nurse. On 03/09/22 at 1:36 P.M. interview with STNA #575 revealed during shift change at 7:00 P.M. on 03/06/22, an agency nurse (LPN #581) showed up but she had no log-in information for the facility electronic medical record system. STNA #575 indicated the nurse called the agency and then left because there was nothing she could do. The facility nurse, LPN #507 was sick and dizzy and called the Administrator on 03/05/22 at 8:30 P.M. STNA #575 revealed LPN #507 did not receive a return call (from the Administrator) and eventually locked up the narcotic keys and left. STNA #575 revealed we took care of the residents and put them to bed. She stated some were requesting their medications, but we were STNAs and could not do anything but take care of them. On 03/09/22 at 2:05 P.M. interview with LPN #576 revealed she was an agency nurse who was scheduled to work on 03/05/22 from 7:00 A.M. to 7:30 P.M. at the facility. She stated she had worked at the facility in the past and this was the second or third time she had experienced staffing problems. She indicated she was assigned two halls when she arrived at the facility at 7:00 A.M., the 300 Hall (secured dementia unit) and the 400 Hall with two STNAs to assist her. LPN #576 indicated on 03/05/22 the relief nurse LPN #577 called off at 5:14 P.M. and the agency relief nurse LPN #581 arrived at 7:00 P.M. but indicated that she was not staying because she did not want to be the only nurse in the facility. LPN #576 revealed she called the Administrator at 7:15 P.M. regarding LPN #581's staffing concerns and again at 7:26 P.M. when LPN #581 decided she was not staying because it was unsafe, and she left. LPN #576 indicated she counted the narcotics in the medication carts with LPN #507 and left the facility at 8:00 P.M. LPN #507 was still in the facility when she left. LPN #576 indicated on 03/05/22 when she left the facility, there was only one nurse, LPN #507 along with three STNAs (#520, #566 and #574) remaining in the facility. On 03/09/22 at 3:40 P.M. interview with Scheduler/STNA #539 revealed she had worked at the facility since July 2021. She stated she schedules staffing for the facility a month out and posts the entire month at least two weeks before, usually on the 18th of the month. She posts the schedule so if staff want to pick up extra shifts, they know what shifts are available. She also sends out mass texts via the On Shift System for facility staff and enters information into staffing agency portals or emails them directly to let them know of the availability of shifts and facility staffing needs. Scheduler/STNA #539 revealed she typically staffs three nurses for the 7:00 A.M. to 7:00 P.M. shift and two nurses for the 7:00 P.M. to 7:00 A.M. shift and tries to get a medication pass nurse for 7:00 P.M. to 11:00 P.M. and then drops to two nurses at 11:00 P.M. Schedule/STNA #539 revealed when she received the call off notification from LPN #577, she immediately started making attempts to replace him with another licensed nurse. She stated she contacted the Administrator and was working with her using On Shift, texting people, offering bonuses but got a lot of no. She stated she also posted to all of the agencies and still got no response. Scheduler/STNA #539 indicated she continued to try to get staffing for the facility and went to bed with the phone still making phone calls and worrying about the STNAs left to work in the facility with no licensed nurse as well as the residents. On 03/10/22 at 12:58 A.M. interview with LPN #507 revealed she was scheduled to work at the facility on 03/05/22 from 7:00 A.M. to 7:30 P.M. with another staff nurse (LPN #506) scheduled from 7:00 A.M. to 3:00 P.M. and an agency nurse (LPN #576) scheduled for the 7:00 A.M. to 7:30 P.M. shift. LPN #507 indicated LPN #506 left at 3:00 P.M. and she assumed care for the residents on the 100 hall and 200 hall by herself, which was difficult for one nurse. Agency LPN #576 was assigned to care for residents on the 300 Hall and the secured dementia unit. At 7:00 P.M., both LPN #507 and Agency LPN #576 were waiting for their relief staff to arrive. LPN #507 indicated she was sick and barely making it to the end of the shift. She had a headache, vomiting, diarrhea and was dizzy. LPN #507 revealed she sent messages to the scheduler (regarding staffing) with no response. She also called the Administrator at approximately 7:30 P.M. and told her she was sick and couldn't stay. The Administrator's response was, can you hang in for a little longer- about an hour? LPN #507 revealed Agency LPN #576 left at 7:30 P.M. and she (LPN #507) stayed until 8:30 P.M. as the only nurse in the facility and was trying to hang on. LPN #507 revealed at that time no one had told her an oncoming nurse had called off. LPN #507 indicated she stayed for another hour (until approximately 8:00 P.M.-8:30 P.M.), and no one came. LPN #507 stated she sent four messages to the scheduler with no response. LPN #507 revealed she locked the keys in the medication room and placed the medication room key in the office and told the Administrator where they were in a hidden location. During the interview, LPN #507 revealed she returned to the facility on [DATE] at 7:00 A.M. and worked until 03/07/22 at 1:00 A.M. (although she was scheduled to leave on 03/06/22 at 7:30 P.M.). LPN #507 revealed it was like [NAME]-[NAME] all over again. Facility LPN #577 who was scheduled to come in on 03/06/22 at 7:00 P.M. did not show up and she was told he had quit. An agency nurse, LPN #582 did arrive to the facility at 11:00 P.M. but did not stay because she had no access to anything, was unable to scan her badge to administer medications and stated she was not staying because she felt it was unsafe. 2. Review of resident medical records for residents sampled during the investigation revealed residents had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . None of this care was provided as ordered for any facility residents from 03/05/22 at 8:30 P.M. to 03/06/22 at 7:00 A.M. or on 03/07/22 from 1:00 A.M. to 7:00 A.M. when there was no licensed nurse working and in the facility. a. Resident #105 who was a new admission on 03/04/22 with orders for post operative care for an abdominal surgical wound was observed by STNA staff on 03/06/22 to have a complication. There was no nurse in the facility to assess or provide nursing care to the resident at the time of the incident. On 03/09/22 at 2:23 P.M. interview with STNA #574 revealed she arrived to work at 10:55 P.M. on 03/05/22 for the 11:00 P.M. to 7:00 A.M. shift and was informed there was no nurse working in the facility. STNA #574 revealed at approximately 3:00 A.M. Resident #105 was in no apparent distress and it appeared her abdominal dressing was intact. At approximately 4:30 A.M., as STNA #574 was making rounds, she noted Resident #105 had blood on her gown and her abdominal dressing was on the floor. She conferred with the other STNAs to determine if 911 should be called or if they should attempt to contact the resident's physician. STNA #574 revealed she contacted Resident #105's physician, Medical Director #578 at approximately 5:00 A.M. and informed him the resident had removed her dressing and there was blood on her gown. Medical Director #578 advised STNA #574 to put multiple abdominal pad dressings on the wound and use the resident's abdominal binder to secure the pads. STNA #574 revealed Medical Director #578 told her the resident would be fine until a nurse arrived in a couple of hours. STNA #574 stated she again asked Medical Director #578 if he was sure, and he responded yes and disconnected the telephone call. STNA #578 revealed she placed multiple abdominal dressing pads over Resident #105's wound and used the resident's abdominal binder to secure the dressings in place as directed by the physician. On 03/08/22 at 2:21 P.M. interview with Medical Director #578 revealed he had received a telephone call from an STNA (STNA #574) at the facility at approximately 5:00 A.M. the morning of 03/06/22 indicating Resident #105 had removed her abdominal dressing and was bleeding. Medical Director #578 revealed he directed STNA #574 to replace the dressing with abdominal pads and secure the pads with the resident's abdominal binder. He stated he reassured STNA #574 it would be okay until a nurse arrived to assess the wound. b. Resident #122, Resident #130, Resident #133 and Resident #102 had orders for enteral tube feedings and water flushes and were not provided these services/nutritional supplementation on 03/05/22 from 8:30 P.M. through 03/06/22 at 7:00 A.M. or from 03/07/22 at 1:00 A.M. to 7:00 A.M. 3. The following staff and resident interviews also demonstrate concerns related to facility staffing contributing to the incidents of neglect for the residents from 03/05/22 at 8:30 P.M. until 03/06/22 at 7:00 A.M. and again on 03/07/22 from 1:00 A.M. to 7:00 A.M. when there was no licensed nurse in the facility. a. On 03/08/22 at 3:02 P.M. interview with STNA #520 revealed she worked at the facility on 03/05/22 from 11:00 P.M. to 03/06/22 at 7:00 A.M. and on 03/06/22 from 11:00 P.M. to 03/07/22 at 7:00 A.M. STNA #520 revealed when she arrived at work on 03/05/22 at 11:00 P.M. Resident #122 was crying in pain and needed pain medication. STNA #520 indicated Resident #122 was one of many residents complaining of pain and the STNA felt bad because there was no nurse working and she could not administer medications to the residents. STNA #520 revealed she tried to offer other interventions for pain that were ineffective, and Resident #122 was in pain throughout the whole night on 03/06/22 and 03/07/22. On 03/21/22 at 1:55 P.M. the surveyor attempted to interview Resident #122. The resident was unable to communicate in sentences/conversation but nodded her head yes and no. Resident #122 indicated she was in pain throughout the night when she did not get her pain medication on the above dates. She was unable to verbalize anything specific to the pain but nodded yes to generalized pain. Resident #122 also nodded yes to being anxious about having no nurse in the facility and acknowledged it had not occurred again since those dates. b. On 03/08/22 at 11:48 A.M. interview with Resident #108 revealed she did not receive any medications or her pain medication on Saturday (03/05/22) night because there was no nurse. The resident reported she was having pain which she described as being intolerable. The resident revealed she repeatedly asked STNA #566 that night if the nurse was there to give her pain medication. On 03/08/22 at 3:23 P.M. interview with STNA #566 revealed when she arrived to work on 03/05/22 at 11:00 P.M., Resident #108 immediately voiced complaints of pain and stated she did not receive her bedtime medications or pain medications (Tylenol Extra Strength). STNA #566 indicated Resident #108 was in pain throughout the whole night (03/05/22 to 03/06/22) but there was no nurse working in the facility to administer pain medications to the resident. On 03/21/22 at 2:05 P.M. during a follow up interview with Resident #108 the resident again voiced concerns she discovered there were no nurses in the facility when she went to the nurses' station to check on her medications. Resident #108 revealed she became very frustrated and anxious because she did not get her anxiety medication or her pain medication. In addition, she stated she also did not get her [MEDICATION(S)] and was unable to sleep the entire night. She stated that she had a rough night. She indicated she takes Tylenol every night which is effective in managing her pain, she did not get any of her medications and was anxious about what would happen if there was an emergency in the facility. c. On 03/08/22 at 3:02 P.M. interview with STNA #520 revealed she worked at the facility on 03/05/22 from 11:00 P.M. to 7:00 A.M. and on 03/06/22 from 11:00 P.M. to 7:00 A.M. STNA #520 revealed when she arrived to work at 11:00 P.M. on 03/05/22, Resident #124 was asking if there was a nurse. STNA #520 indicated Resident #124 was one of many residents requesting medications and the STNA felt bad because there was no nurse working in the facility and she could not administer medications. STNA #520 indicated Resident #124 requested medication throughout the shift. On 03/21/22 at 1:50 P.M. interview with Resident #124 revealed she had pain all the time that was from her [CONDITION(S)] and had Tylenol ordered which helped. Resident #124 indicated she was anxious about not receiving her medications when there was no nurse but mostly anxious about not receiving her [MEDICATION(S)], which was ordered to be given at 9:00 P.M. Resident #124 indicated she had to take the [MEDICATION(S)] on an empty stomach and there had been at least two other times when she had missed the medication and this made her very anxious. d. On 03/09/22 at 2:23 P.M. interview with STNA #574 revealed when she worked on 03/05/22 from 11:00 P.M. to 7:00 A.M., she observed Resident #130 walking around the facility throughout the night and asking for a nurse and asking if there was a nurse. STNA #574 revealed throughout the night the resident did not specifically request pain medication but appeared very anxious. STNA #574 also indicated Resident #130 communicated with other residents there was no nurse in the facility. STNA #574 revealed this in turn made many other residents in the facility very anxious. During the interview, the STNA verified Resident #130 did not receive any of prescribed pain medication on 03/05/22 from 8:00 P.M. to 7:00 A.M. or on 03/07/22 from 1:00 A.M. to 7:00 A.M. On 03/21/22 at 2:20 P.M. interview with Resident #130 revealed he did not get his nighttime medications on 03/05/22 and at first it made him anxious. The resident revealed he thought the STNAs were not telling the truth about there being no nurse until he went looking for a nurse and could not find one. Resident #130 verified he could not get his pain medication or his blood sugar checked when there was no nurse working. Resident #130 acknowledged he was up throughout the night because he could not sleep and kept asking if the nurse was here yet. e. On 03/08/22 at 11:15 A.M. interview with Resident #117 revealed there was no nurse working in the facility during periods of time from 03/05/22 to 03/07/22. The resident voiced concerns related to not receiving her [MEDICATION(S)] medication. Resident #117 revealed the STNA staff had reported to her there was no nurse working to pass medications. Resident #117 revealed she was upset because if she does not get her medication, it can cause her problems with her [CONDITION(S)]. f. On 03/08/22 at 3:23 P.M. interview with STNA #566 revealed when she arrived to work on 03/05/22 at 11:00 P.M. Resident #120 was complaining she did not receive her bedtime medications or pain medications. On 03/21/22 at 1:35 P.M. interview with Resident #120 revealed she takes Tylenol at bedtime every night and when she did not receive her medication on 03/05/22 it was rough to sleep, she was anxious and up and down all night. g. On 03/08/22 at 11:35 A.M. interview with Resident #149 revealed she did not receive her medications on Saturday (03/05/22) night and she wanted to report the facility. Resident #149 revealed due to the lack of medications, she did not sleep much and kept asking if there was a nurse. On 03/08/22 at 4:05 P.M. interview with the Administrator revealed she received a call from facility staff on 03/05/22 at 7:15 P.M. indicating there was no licensed nurse available onsite to relieve the 7:00 A.M. to 7:00 P.M. nurses. The Administrator revealed the scheduled (7:00 P.M. to 7:00 A.M.) staff nurse called off and the scheduled agency nurse arrived on 03/05/22 but left by 7:30 P.M. leaving no licensed nurse to relieve the off-going shift nurses. The Administrator revealed she and Scheduler #539 made multiple calls without success to facility staff nurses and agencies to get a licensed nurse to work on 03/05/22 for the night shift (through 03/06/22 at 7:00 A.M.). Review of facility policy titled Abuse, Neglect and Misappropriation, dated June 2021 revealed it was the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. It was the intent of this facility to prevent the abuse, mistreatment, or neglect of residents or the misappropriation of their property, corporal punishment, and/or involuntary seclusion and to provide guidance to direct staff to manage any concerns or allegations of abuse, neglect or misappropriation of their property. The facility policy defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Accurate and timely reporting of incidents, both alleged and substantiated, would be sent to officials in accordance with the state law. If the alleged violation was verified, appropriate corrective action would be taken by the facility. The policy included, accurate and timely identification of any event which would place our residents was t risk is a primary concern of the facility. This deficiency substantiates Complaint Number OH 768.

Based on record review, review of nursing staff schedules, review of the facility policy and procedures for Medication Administration, Pain Management and Diabetic Management, review of facility medication error reports, review of a facility self-reported incident (SRI) and staff interviews the facility failed to ensure medications were administered as ordered to all residents to prevent the actual occurrence of or potential for significant medication errors. This resulted in Immediate Jeopardy beginning on 03/05/22 at approximately 8:30 P.M. when no licensed nurse (licensed practical nurse (LPN) or registered nurse (RN)) was on duty to provide for the routine and as needed medication administration for all 52 residents residing in the facility. The facility remained without a licensed nurse from 03/05/22 at 8:30 P.M. until 03/06/22 at 7:00 A.M. and then was again without a licensed nurse on 03/07/22 from 1:00 A.M. to 7:00 A.M. The lack of licensed nurse in the facility to administer medications resulted in actual or the potential for actual harm for residents, including Resident #108, #122, #124, #130, #115, #117, #144, #116, #101, #111, #114, #120, #149, #125, #126, #129, #133, #134 and #139 related to the lack of administration of pain medication resulting in increased/intolerable pain, lack of blood glucose monitoring and/or insulin administration resulting in elevated blood glucose levels, and/or lack of [CONDITION(S)], antibiotic, anti-anxiety, anti-coagulation and anti-[CONDITION(S)] medications to treat and manage chronic and/or acute disease processes/diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] This had the potential to affect all 52 residents who were identified by the facility to have medications ordered to be administered during the time periods in which there was no licensed nurse on duty. All 52 residents had medications ordered for administration during the times when there were no nurses working in the facility. On 03/09/22 at 11:10 A.M. the Administrator, Regional Clinical Support Nurse #579, and the Interim Director of Nursing (IDON) were notified Immediate Jeopardy began on 03/05/22 at 8:30 P.M. when the facility failed to ensure a licensed nurse was on duty and present in the facility to provide for the routine care and medication administration of all 52 residents residing in the facility. There was no licensed nurse on duty from 03/05/22 at 8:30 P.M. until 03/06/22 at 7:00 A.M. and again on 03/07/22 at 1:00 A.M. until 7:00 A.M. leaving residents with no access to medications to address complaints of pain, to adequately manage blood sugars for diabetic residents and/or to administer routine medications necessary for disease process management. The Immediate Jeopardy was removed on 03/09/22 when the facility implemented the following corrective actions: · On 03/08/22 the facility identified all residents had the potential to be affected related to the lack of licensed nurse on duty and in the facility. · Beginning 03/08/22 the facility indicated they would attempt to schedule an additional licensed nurse for each 12-hour shift. · On 03/08/22 at 12:27 P.M. Medical Director #578 was notified by Regional Clinical Support Nurse #579 regarding the staffing concern from 03/05/22 for 7:00 P.M. to 7:00 A.M. and from 03/07/22 from 1:00 A.M. to 7:00 A.M. including resident missed medications and blood glucose checks. · On 03/08/22 the Administrator was educated by Regional Clinical Support Nurse #579 regarding communication via an immediate phone call to the Regional Support Team regarding any open nurse shift positions due to call-offs that are unable to be filled in a timely manner, nurse no shows, etc to meet the care needs of the residents including medication administration. · On 03/08/22 the Administrator, Human Resource #580 and Scheduler/STNA #539 were educated by Regional Clinical Support Nurse #579 regarding conducting staffing meetings two times daily to review any call-offs and ensure adequate coverage is obtained as needed to meet the care needs of the residents including medication administration. · On 03/08/22 at 2:02 P.M. all 18 facility nurses were educated via blast text through OnShift regarding the importance of safe staffing to foster safe resident care, proper procedure for nurse call-offs, and to immediately notify the Interim DON if an oncoming nurse does not report to work as scheduled and there is no coverage. Nurses were asked to please reply to the message to ensure they received and understood the education. · On 03/08/22 at 5:15 P.M. all 18 State tested Nursing Assistant (STNA) staff were educated via blast text through OnShift regarding if there is not a nurse in the building to immediately notify the Administrator, and then the Interim DON if there isn't an immediate response from the Administrator. STNAs were asked to please reply to the message to ensure they received and understood the education. · On 03/08/22 at 6:55 P.M. the Interim DON's phone number was posted at all nursing stations. · On 03/08/22 the facility implemented a plan to hold a staffing meeting with the Administrator, HR Director #580 and Scheduler/STNA #539 in attendance to review scheduled nursing staff for the day to ensure there was always a licensed nursing staff member on duty to meet the care needs of the residents including medication administration. The daily posted staffing would be reviewed during the meeting to ensure an adequate number of nurses were scheduled for the day. The staffing meeting would occur two times daily Monday through Friday for four weeks and then randomly thereafter. Ad hoc education will be given for any non-compliance. · Beginning 03/08/22 the facility implemented a plan for the Interim DON/designee to verify via a telephone call to facility on the off shift (7:00 P.M. to 7:00 A.M. (nights and weekends) all scheduled nurses had arrived for their scheduled shifts to ensure there was always licensed staff in the facility to meet the care needs of the residents including medication administration. This will occur daily for four weeks and then randomly thereafter. Ad hoc education will be given for any non-compliance. · Between 03/09/22 and 03/10/22 the facility completed medication error reports for each resident. · On 03/09/22 the facility Interdisciplinary (IDT) team, including the Activity Director, Admission Director, Nurse Scheduler, Administrator, Receptionist, Maintenance Director, and Therapy Director completed Ambassador rounds for all residents to conduct psycho-social wellness checks with no negative outcomes identified at that time. · On 03/09/22 at 8:42 A.M. Human Resource Director #580 made telephone contact with 35 nurse and STNA staff members who did not respond in OnShift to the text blasts from 03/08/22 at 2:02 P.M. and 5:15 P.M. and verbally educated them on those texts to complete the education. · On 03/09/22 at 7:30 P.M. all 36 nursing (RN, LPN and STNA) staff members were educated via telephone contact and in person by Human Resources Director #580 and Scheduler/STNA #539 on staffing guidelines regarding sufficient nursing staff required on each shift to meet the needs of the residents in the facility with notification to the IDON, ADON, and nursing scheduler for assistance if unable to schedule sufficient staff. The staff were also educated regarding the facility's proper call-off procedure. · On 03/09/22 one on one education was provided by Regional Clinical Support Nurse #579 to Licensed Practical Nurse (LPN) #507 who was the only nurse on duty on 03/05/22 at 7:00 P.M. and 03/07/22 at 1:00 A.M. who left the facility without having adequate coverage regarding her obligation to ensure adequate licensed nursing staff always remain in the facility to meet the care needs of the residents including administration of medications. · On 03/09/22 the facility implemented a plan for the IDON and/or Regional Support team to cover open nurse shifts until a DON was in place to meet the care needs of the residents including medication administration. · Results of all audits will be reviewed in QAPI for tracking and trending purposes. Although the Immediate Jeopardy was removed on 03/09/22, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Resident #122 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan initiated on 09/16/21 revealed Resident #122 had chronic pain related to physical debility and verbalization of intermittent pain with a goal of adequate relief of pain or ability to cope with pain incompletely relieved. Interventions included to administer analgesics as ordered, anticipate the resident's need for pain relief and respond immediately to any complaint of pain, monitor/record/report cause of pain, pain characteristics and signs/symptoms of non-verbal pain. Review of the physician's MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #122 was prescribed [MEDICATION(S)]-Acetaminophen 5-325 mg one tablet via gastrostomy (peg) tube every four hours as needed for pain. Resident #122's was medicated with [MEDICATION(S)] on 03/05/22 at 6:13 P.M. She received her next dose of [MEDICATION(S)]-Acetaminophen 5-325 mg on 03/06/22 at 8:00 A.M., verbalizing a pain level of 10 out of 10 on a scale of 1 to 10. The resident received a dose of [MEDICATION(S)] on 03/06/22 at 11:00 P.M. but no doses on 03/07/22 between 1:00 A.M. and 7:00 A.M. Review of the administration record revealed no medications at all including the ordered [MEDICATION(S)] for prevention of blood clots, [MEDICATION(S)] for blood pressure or prn pain medication was administered to the resident on 03/05/22 from 8:30 A.M. to 03/06/22 at 7:00 A.M. or from 03/07/22 from 1:00 A.M. to 7:00 A.M. On 03/08/22 at 3:02 P.M. interview with STNA #520 revealed she worked at the facility on 03/05/22 from 11:00 P.M. to 03/06/22 at 7:00 A.M. and on 03/06/22 from 11:00 P.M. to 03/07/22 at 7:00 A.M. STNA #520 revealed when she arrived at work on 03/05/22 at 11:00 P.M. Resident #122 was crying in pain and needed pain medication. STNA #520 indicated Resident #122 was one of many residents complaining of pain and the STNA felt bad because there was no nurse working and she could not administer medications to the residents. STNA #520 revealed she tried to offer other interventions for pain that were ineffective, and Resident #122 was in pain throughout the whole night on 03/06/22 and 03/07/22. On 03/21/22 at 1:55 P.M. the surveyor attempted to interview Resident #122. The resident was unable to communicate in sentences/conversation but nodded her head yes and no. Resident #122 indicated she was in pain throughout the night when she did not get her pain medication on the above dates. She was unable to verbalize anything specific to the pain but nodded yes to generalized pain. Resident #122 also nodded yes to being anxious about having no nurse in the facility and acknowledged it had not occurred again since those dates. 2. Resident #108 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed a plan of care, initiated on 11/27/18 related to acute/chronic pain due to chronic physical disability, depression and disease process with the goal of Resident #108 experiencing comfort. Interventions included to administer medication (analgesic) as ordered, monitor the effectiveness of pain interventions, monitor/record/report to nurse any signs and symptoms of non-verbal pain such as vocalizations including grunting, moaning or yelling out and to monitor/record/report to nurse resident complaints of pain or requests for pain treatment. Review of the physician's medication orders revealed a current order for Tylenol Extra Strength, two tablets every six hours as needed (prn) for pain. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. There was no evidence the medication was administered on 03/05/22 or 03/06/22. On 03/08/22 at 11:48 A.M. interview with Resident #108 revealed she did not receive any medications or her pain medication on Saturday (03/05/22) night because there was no nurse. The resident reported she was having pain which she described as being intolerable. The resident revealed she repeatedly asked STNA #566 that night if the nurse was there to give her pain medication. On 03/08/22 at 3:23 P.M. interview with STNA #566 revealed when she arrived to work on 03/05/22 at 11:00 P.M., Resident #108 immediately voiced complaints of pain and stated she did not receive her bedtime medications or pain medications (Tylenol Extra Strength). STNA #566 indicated Resident #108 was in pain throughout the whole night (03/05/22 to 03/06/22) but there was no nurse working in the facility to administer pain medications to the resident. On 03/21/22 at 2:05 P.M. during a follow up interview with Resident #108 the resident again voiced concerns she discovered there were no nurses in the facility when she went to the nurses' station to check on her medications. Resident #108 revealed she became very frustrated and anxious because she did not get her anxiety medication or her pain medication. In addition, she stated she also did not get her [MEDICATION(S)] and was unable to sleep the entire night. She stated that she had a rough night. She indicated she takes Tylenol every night which is effective in managing her pain, she did not get any of her medications and was anxious about what would happen if there was an emergency in the facility. 3. Resident #124 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A plan of care, initiated on 02/12/21 revealed Resident #124 had pain related to peripheral vascular disease with a goal of no side effects related to the use of analgesics. Interventions included to administer analgesics as per orders, monitor and report any complaints of pain or requests for pain treatment. Resident #124 was able to call for assistance when in pain, ask for medication, tell how much pain was experienced and tell what increased or alleviated pain. Review of the current physician's medication orders revealed Resident #124 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #124 also had physician orders including to monitor for side effects of anticoagulants and to monitor for pain. Record review revealed the resident did not receive the [MEDICATION(S)] (for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .M. to 03/06/22 at 7:00 A.M. or from 03/07/22 from 1:00 A.M. to 7:00 A.M. Review of the March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. to 03/06/22 at 7:00 A.M. Resident #124's previous pain levels were recorded as being 0/10. On 03/08/22 at 3:02 P.M. interview with STNA #520 revealed she worked at the facility on 03/05/22 from 11:00 P.M. to 7:00 A.M. and on 03/06/22 from 11:00 P.M. to 7:00 A.M. STNA #520 revealed when she arrived to work at 11:00 P.M. on 03/05/22, Resident #124 was asking if there was a nurse. STNA #520 indicated Resident #124 was one of many residents requesting medications and the STNA felt bad because there was no nurse working in the facility and she could not administer medications. STNA #520 indicated Resident #124 requested medication throughout the shift. On 03/21/22 at 1:50 P.M. interview with Resident #124 revealed she had pain all the time that was from her [CONDITION(S)] and had Tylenol ordered which helped. Resident #124 indicated she was anxious about not receiving her medications when there was no nurse but mostly anxious about not receiving her [MEDICATION(S)], which was ordered to be given at 9:00 P.M. Resident #124 indicated she had to take the [MEDICATION(S)] on an empty stomach and there had been at least two other times when she had missed the medication and this made her very anxious. 4. Resident #130 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the resident had no plan of care initiated relative to pain. A pain assessment, dated 02/24/22 revealed Resident #130 had back pain related to a 2018 surgery as well as phantom pain due to amputation of left lower leg. The resident identified his pain as an 8 out of 10 on the pain scale with 10 being the worst pain. Review of the current physician's MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #130 also had a physician's order to monitor for pain to be completed on the night shift. Resident #130 received a dose of [MEDICATION(S)] on 03/05/22 at 11:48 A.M. Review of the March 2022 administration records revealed no evidence of pain monitoring as ordered on 03/05/22 from 8:00 P.M. to 03/06/22 at 7:00 A.M. or on 03/07/22 during the night shift. On 03/05/22 Resident #130 did not receive scheduled 9:00 P.M. medications which included [MEDICATION(S)] 50 mg and [MEDICATION(S)] 10 mg for pain and muscle spasms. On 03/06/22 Resident #130 did not receive scheduled 6:00 A.M. medications including [MEDICATION(S)] 10 mg or [MEDICATION(S)] insulin (if needed) as there was no evidence the resident's blood glucose level was checked. Review of the resident's blood glucose level revealed on 03/05/22 at 5:02 P.M. the resident's blood glucose level was 70 mg/dL. Resident #130's blood glucose level was not checked again until 03/06/22 at 12:11 P.M. at which time the blood sugar was elevated at 274 mg/dL and the resident required [MEDICATION(S)] 9 units subcutaneously. On 03/09/22 at 2:23 P.M. interview with STNA #574 revealed when she worked on 03/05/22 from 11:00 P.M. to 7:00 A.M., she observed Resident #130 walking around the facility throughout the night and asking for a nurse and asking if there was a nurse. STNA #574 revealed throughout the night the resident did not specifically request pain medication but appeared very anxious. STNA #574 also indicated Resident #130 communicated with other residents there was no nurse in the facility. STNA #574 revealed this in turn made many other residents in the facility very anxious. During the interview, the STNA verified Resident #130 did not receive any of prescribed pain medication on 03/05/22 from 8:00 P.M. to 7:00 A.M. or on 03/07/22 from 1:00 A.M. to 7:00 A.M. On 03/21/22 at 2:20 P.M. interview with Resident #130 revealed he did not get his nighttime medications on 03/05/22 and at first it made him anxious. The resident revealed he thought the STNAs were not telling the truth about there being no nurse until he went looking for a nurse and could not find one. Resident #130 verified he could not get his pain medication or his blood sugar checked when there was no nurse working. Resident #130 acknowledged he was up throughout the night because he could not sleep and kept asking if the nurse was here yet. 5. Review of Resident #115's medical record revealed current physician orders for March 2022 for Insulin [MEDICATION(S)] 100 Units/ml 17 units subcutaneously at bedtime (9:00 P.M.) for diabetes mellitus, [MEDICATION(S)] five percent patch remove at 9:00 P.M., [MEDICATION(S)] 300 mg one capsule by mouth for nerve pain at 9:00 P.M. and [MEDICATION(S)] HCl 5 mg one tablet by mouth every eight hours (scheduled for 10:00 P.M. and 6:00 A.M.) for pain. Resident #115 also had a physician's order to have a pain assessment completed on night shift. Review of the March 2022 administration record revealed Resident #115 did not receive any of her medications, including Insulin [MEDICATION(S)] 100 Units/ml 17 units, [MEDICATION(S)] or [MEDICATION(S)] HCl 5 mg tablet at bedtime on 03/05/22. In addition, no pain monitoring was completed for the resident. On 03/06/22 Resident #115 did not receive the scheduled 6:00 A.M. dose of [MEDICATION(S)] five mg. On 03/06/22 Resident #115's blood glucose level was 189 mg/dL at 10:02 A.M., 217 mg/dL at 12:19 P.M., and 169 mg/dL at 6:21 P.M. Review of Resident #115's blood glucose level on 03/07/22 at 10:12 A.M. revealed it was elevated at 343 mg/dL after not receiving her prescribed insulin and she required insulin coverage of [MEDICATION(S)] insulin 10 units subcutaneously for the elevated blood glucose level. On 03/08/22 at 3:23 P.M. interview with STNA #566 revealed when she arrived to work on 03/05/22 at 11:00 P.M. Resident #115 was complaining she did not receive her bedtime medications for pain. STNA #566 explained to the resident the medications could not be administered as there was no nurse working in the facility to administer any medications. On 03/21/22 at 1:40 P.M. interview with Resident #115 revealed she had concerns she did not receive any medications as ordered by the physician on 03/05/22 and 03/07/22. Although the medications were not administered, the resident denied having any excessive pain or blood sugar concerns on these dates. 6. Review of Resident #117's physician's MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] .M.) for diabetes, [MEDICATION(S)] 100 mcg one tablet by mouth at 6:00 A.M. for [CONDITION(S)] disease and blood glucose checks with [MEDICATION(S)] Solution Insulin per sliding scale at 6:00 A.M. and 9:00 P.M. Resident #117 also had a physician's order to monitor for signs and symptoms of hypo/[CONDITION(S)]. Review of the March 2022 administration records revealed Resident #117 did not receive any of her medications or hypo/[CONDITION(S)] monitoring as ordered on 03/05/22 from 8:00 P.M. to 03/06/22 at 7:00 A.M. or on 03/07/22 from 1:00 A.M. to 7:00 A.M. as ordered. On 03/05/22 Resident #117 did not receive her blood glucose check at 9:00 P.M. or 9:00 P.M. medications which included routine insulin, [MEDICATION(S)] Solution 22 units. On 03/06/22 Resident #117 did not receive her scheduled 6:00 A.M. medications including [MEDICATION(S)] 100 mcg or blood sugar check to determine whether any [MEDICATION(S)] insulin per sliding scale was necessary. Review of Resident #117's blood glucose level on 03/06/22 at 11:02 A.M. revealed the blood glucose level was elevated at 219 mg/dL (milligrams per deciliter) which required [MEDICATION(S)] Insulin 6 units subcutaneously per sliding scale. On 03/08/22 at 11:15 A.M. interview with Resident #117 revealed there was no nurse working in the facility during periods of time from 03/05/22 to 03/07/22. The resident voiced concerns related to not receiving her [MEDICATION(S)] medication. Resident #117 revealed the STNA staff had reported to her there was no nurse working to pass medications. Resident #117 revealed she was upset because if she does not get her medication, it can cause her problems with her [CONDITION(S)]. 7. Review of Resident #144's current physician's MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 9:00 P.M. Review of the March 2022 administration records revealed Resident #144 did not receive any of her ordered medications on 03/05/22 from 8:00 P.M. to 03/06/22 at 7:00 A.M. or on 03/07/22 from 1:00 A.M. to 7:00 A.M. The resident had an order to assess for pain and signs/symptoms of hypo/[CONDITION(S)] that were not completed as ordered during these time periods. On 03/05/22 Resident #144 did not receive her scheduled 9:00 P.M. medications including Acetaminophen 500 mg, [MEDICATION(S)] HCl 5 mg or blood glucose monitoring to determine if the resident required [MEDICATION(S)] Insulin per sliding scale. On 03/06/22 Resident #144 did not receive her scheduled 6:00 A.M. blood glucose check or [MEDICATION(S)] Insulin per sliding scale if it would have been needed. Review of Resident #144's blood glucose level on 03/06/22 at 1:40 P.M. revealed the level was elevated at 225 mg/dL (milligrams per deciliter) which required [MEDICATION(S)] Insulin four units subcutaneously per sliding scale at that time. On 03/08/22 at 11:22 A.M. interview with Resident #144 revealed she did not receive her bedtime medication on Saturday. 8. Review of Resident #116's current physician's MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, there was no assessment of the resident's pain as ordered during these time periods. Medications not administered included on 03/05/22 at 9:00 P.M. [MEDICATION(S)] 7.5 mg, [MEDICATION(S)] 10 mg and [MEDICATION(S)] HCl 50 mg. On 03/08/22 at 11:24 A.M. interview with Resident #116 revealed she had not received any medications including pain medication on 03/05/22 and no one did anything about her pain all night. On 03/21/22 at 11:35 A.M. during a follow up interview with Resident #116, the resident indicated when she did not get her medications she had a lot of pain all over and was unable to sleep. 9. Review of the current physician's orders for Resident #101 for March 2022 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 9:00 P.M. Review of the March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. 10. Review of Resident #111's current medication physician's orders for March 2022 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M., 11:00 A.M., 4:00 P.M. and 9:00 P.M. with sliding scale insulin orders with [MEDICATION(S)]. Review of the March 2022 administration record revealed Resident #111 did not receive any of medications or blood glucose monitoring on 03/05/22 from 8:00 P.M. to 7:00 A.M. or on 03/07/22 from 1:00 A.M. to 7:00 A.M. as ordered. On 03/05/22 Resident #111 did not receive his scheduled 9:00 P.M. blood glucose check to determine if [MEDICATION(S)] Insulin was to be administered per sliding scale. On 03/06/22 Resident #111 did not receive his scheduled 6:00 A.M. blood glucose check to determine if [MEDICATION(S)] Insulin was to be administered per sliding scale. The next blood glucose level obtained on 03/06/22 at 1:40 P.M. revealed the resident's blood glucose was elevated at 225 mg/dL (milligrams per deciliter) which required [MEDICATION(S)] Insulin four units subcutaneously per sliding scale. 11. Review of Resident #114's current physician orders for March 2022 revealed Resident #114 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M. for low [CONDITION(S)] hormone level, [MEDICATION(S)] 3 mg one tablet by mouth at 9:00 P.M. for restlessness, [MEDICATION(S)] HCl Extended Release 240 mg one tablet by mouth at 9:00 P.M. for hypertension, [MEDICATION(S)] 0.5 mg one tablet by mouth at 9:00 P.M. for anxiety and Mucinex Extended Release 12 Hour 600 mg one tablet by mouth two times a day for congestion Ibuprofen 200 mg two tablets by mouth at bedtime for pain. Review of the March 2022 administration records for Resident #114 revealed the resident did not receive all of her scheduled bedtime medications on 03/05/22 which included 9:00 P.M. medications, Ibuprofen 200 mg, [MEDICATION(S)] 125 mcg, [MEDICATION(S)] 3 mg, [MEDICATION(S)] HCl ER 240 mg, [MEDICATION(S)] 0.5 mg and Mucinex ER 600 mg. On 03/21/22 at 1:30 P.M. an attempt was made to interview Resident #114. However, the resident had difficulty hearing/understanding the questions posed. 12. Review of Resident #120's current physician's orders for March 2022 revealed the resident had mediation orders including orders for [MEDICATION(S)] Sodium ER 24-hour 250 mg three tablets by mouth at bedtime, [MEDICATION(S)] Solution 0.005 percent one drop both eyes at bedtime for [CONDITION(S)], Artificial Tears Solution 0.4 percent one drop both eyes at bedtime for dry eyes, [MEDICATION(S)] [MEDICATION(S)] Solution 0.2 percent one drop both eyes at bedtime for [CONDITION(S)], [MEDICATION(S)] Suspension 1 percent one drop both eyes at bedtime for [CONDITION(S)], [MEDICATION(S)] Solution 0.5 percent one drop both eyes at bedtime for [CONDITION(S)], [MEDICATION(S)] 2 mg one tablet at bedtime for [CONDITION(S)] and Tylenol 325 two tablets by mouth at bedtime for pain. Resident #120 also had a physician's order for monitoring for pain and antipsychotic side effects on the night shift. Review of the March 2022 administration record revealed Resident #120 did not receive medications as ordered or monitoring for pain or antipsychotic side effects on 03/05/22 including the administration of Tylenol 650 mg, [MEDICATION(S)] Sodium ER 750 mg, [MEDICATION(S)] Solution 0.005 percent 1 drop both eyes, Artificial Tears Solution 0.4 percent, [MEDICATION(S)] [MEDICATION(S)] Solution 0.2 percent, [MEDICATION(S)] Suspension 1 percent, [MEDICATION(S)] 2 mg and [MEDICATION(S)] Solution 0.5 percent. On 03/08/22 at 3:23 P.M. interview with STNA #566 revealed when she arrived to work on 03/05/22 at 11:00 P.M. Resident #120 was complaining she did not receive her bedtime medications or pain medications. On 03/21/22 at 1:35 P.M. interview with Resident #120 revealed she takes Tylenol at bedtime every night and when she did not receive her medication on 03/05/22 it was rough to sleep, she was anxious and up and down all night. 13. Review of Resident #149's physician MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #149 also had an orde

Based on record review, review of nursing staff schedules, review of the Executive Director Job Description, review of a facility self-reported incident (SRI) and staff interviews the facility failed to maintain effective administrative services to prevent and/or timely address a lack of licensed nursing staff in the facility to meet the total care needs of all residents. This resulted in Immediate Jeopardy beginning on 03/05/22 at approximately 8:30 P.M. when no licensed nurse (licensed practical nurse (LPN) or registered nurse (RN)) was on duty to provide for the routine care, monitoring, medication administration, assessments, response to urgent resident needs and/or treatments for all 52 residents residing in the facility. The facility remained without a licensed nurse from 03/05/22 at 8:30 P.M. until 03/06/22 at 7:00 A.M. and then was again without a licensed nurse on 03/07/22 from 1:00 A.M. to 7:00 A.M. The lack of effective administration to address these staffing issues resulted in resident neglect, significant medication errors and actual or the potential for actual harm for residents related to the lack of administration of medications, wound care, supervision, enteral nutrition administration and/or treatment/management of chronic and/or acute disease processes/diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An essential job function and responsibility of the Executive Director/Administrator is to ensure an adequate number of appropriately trained professionals and auxiliary personnel are on duty at all times to meet the needs of the residents. This had the potential to affect all 52 residents. On 03/09/22 at 11:10 A.M. the Administrator, Regional Clinical Support Nurse #579, and the Interim Director of Nursing (IDON) were notified Immediate Jeopardy began on 03/05/22 at 8:30 P.M. when the facility failed to ensure a licensed nurse was on duty and present in the facility to provide for the routine care, monitoring, medication administration, assessments, response to urgent resident needs and treatments for all 52 residents residing in the facility. There was no licensed nurse on duty from 03/05/22 at 8:30 P.M. until 03/06/22 at 7:00 A.M. and again on 03/07/22 at 1:00 A.M. until 7:00 A.M. leaving residents without access to a licensed nurse to meet their total care needs. The Immediate Jeopardy was removed on 03/09/22 when the facility implemented the following corrective actions: · On 03/08/22 the facility identified all residents had the potential to be affected related to the lack of licensed nurse on duty and in the facility. · Beginning 03/08/22 the facility indicated they would attempt to schedule an additional licensed nurse for each 12-hour shift. · On 03/08/22 at 12:27 P.M. Medical Director #578 was notified by Regional Clinical Support Nurse #579 regarding the staffing concern from 03/05/22 for 7:00 P.M. to 7:00 A.M. and from 03/07/22 from 1:00 A.M. to 7:00 A.M. including resident missed medications, treatments, enteral feedings and blood glucose checks. · On 03/08/22 the Administrator was educated by Regional Clinical Support Nurse #579 regarding communication via an immediate phone call to the Regional Support Team regarding any open nurse shift positions due to call-offs that are unable to be filled in a timely manner, nurse no shows, etc to meet the care needs of the residents including medication administration. · On 03/08/22 the Administrator, Human Resource #580 and Scheduler/STNA #539 were educated by Regional Clinical Support Nurse #579 regarding conducting staffing meetings two times daily to review any call-offs and ensure adequate coverage is obtained as needed to meet the care needs of the residents including medication administration. · On 03/08/22 at 2:02 P.M. all 18 facility nurses were educated via blast text through OnShift regarding the importance of safe staffing to foster safe resident care, proper procedure for nurse call-offs, and to immediately notify the Interim DON if an oncoming nurse does not report to work as scheduled and there is no coverage. Nurses were asked to please reply to the message to ensure they received and understood the education. · On 03/08/22 at 5:15 P.M. all 18 State tested Nursing Assistant (STNA) staff were educated via blast text through OnShift regarding if there is not a nurse in the building to immediately notify the Administrator, and then the Interim DON if there isn't an immediate response from the Administrator. STNAs were asked to please reply to the message to ensure they received and understood the education. · On 03/08/22 at 6:55 P.M. the Interim DON's phone number was posted at all nursing stations. · On 03/08/22 the facility implemented a plan to hold a staffing meeting with the Administrator, HR Director #580 and Scheduler/STNA #539 in attendance to review scheduled nursing staff for the day to ensure there was always a licensed nursing staff member on duty to meet the care needs of the residents including medication administration. The daily posted staffing would be reviewed during the meeting to ensure an adequate number of nurses were scheduled for the day. The staffing meeting would occur two times daily Monday through Friday for four weeks and then randomly thereafter. Ad hoc education will be given for any non-compliance. · Beginning 03/08/22 the facility implemented a plan for the Interim DON/designee to verify via a telephone call to facility on the off shift (7:00 P.M. to 7:00 A.M. (nights and weekends) all scheduled nurses had arrived for their scheduled shifts to ensure there was always licensed staff in the facility to meet the care needs of the residents including medication administration. This will occur daily for four weeks and then randomly thereafter. Ad hoc education will be given for any non-compliance. · On 03/09/22 the facility Interdisciplinary (IDT) team, including the Activity Director, Admission Director, Nurse Scheduler, Administrator, Receptionist, Maintenance Director, and Therapy Director completed Ambassador rounds for all residents to conduct psycho-social wellness checks with no negative outcomes identified at that time. · On 03/09/22 at 8:42 A.M. Human Resource Director #580 made telephone contact with 35 nurse and STNA staff members who did not respond in OnShift to the text blasts from 03/08/22 at 2:02 P.M. and 5:15 P.M. and verbally educated them on those texts to complete the education. · On 03/09/22 at 7:30 P.M. all 36 nursing (RN, LPN and STNA) staff members were educated via telephone contact and in person by Human Resources Director #580 and Scheduler/STNA #539 on staffing guidelines regarding sufficient nursing staff required on each shift to meet the needs of the residents in the facility with notification to the IDON, ADON, and nursing scheduler for assistance if unable to schedule sufficient staff. The staff were also educated regarding the facility's proper call-off procedure. · On 03/09/22 the facility implemented a plan for the IDON and/or Regional Support team to cover open nurse shifts until a DON was in place to meet the care needs of the residents including medication administration. · Results of all audits will be reviewed in QAPI for tracking and trending purposes. Although the Immediate Jeopardy was removed on 03/09/22, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: The current facility Administrator had a hire date of 02/08/2022. Review of the Executive Director (Administrator) Job Description revealed the purpose of the job description was to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to ensure that the highest degree of quality care can be provided to our residents at all times. Personnel functions on the job description included ensuring an adequate number of appropriately trained professionals and auxiliary personnel were on duty at all times to meet the needs of the residents. Review of a facility self-reported incident (SRI), tracking number 0 created on 03/10/22 a 3:52 P.M. revealed the facility reported an allegation of neglect/mistreatment to the State agency. The SRI revealed during the evening of 03/05/22 from 8:30 P.M. to 7:00 A.M. (03/06/22) and 03/07/22 from 1:00 A.M. to 7:00 A.M. the facility did not have a nurse in the building. The facility identified 52 residents affected by the incident. A narrative summary of the incident revealed a staff nurse called off prompting the agency nurse to leave the facility. The SRI noted as a result of the incident, on 03/08/22 the facility medical director and physicians were notified of the staffing concerns from 03/05/22 at 8:30 P.M. to 03/06/22 at 7:00 A.M. and from 03/07/22 from 1:00 A.M. to 7:00 A.M. including missed medications, wound treatments, enteral (tube feedings) and blood glucose checks. In addition, resident responsible parties were also notified of the missed medications and blood glucose checks. The facility substantiated the allegation of neglect. (See Findings at F600). Review of the facility staffing schedules, assignments sheets and punch detail revealed on 03/05/22 from 7:00 A.M. to 7:00 P.M. there were two nurses, LPN #507 and LPN #576 on duty for the entire 12 hour shift and one nurse LPN #506 on duty for 8 hours from 7:00 A.M. to 3:00 P.M. to provide care for the 52 residents residing in the nursing facility. Review of a nurse/STNA schedule for 03/05/22 as well as the attendance punch records for 03/05/22, revealed LPN #507 punched in at 8:30 A.M. and punched out at 8:30 P.M. The facility schedule reflected on 03/05/22 there were two nurses, facility LPN #577 and agency LPN #581, scheduled for the shift beginning at 7:00 P.M. However, interview and record review revealed facility LPN #577 never arrived for his shift. Agency LPN #581 arrived at 7:00 P.M. but left at 7:26 P.M. because she did not want to be the only nurse in the facility. The facility schedule reflected on 03/06/22 there were two nurses, facility LPN #507 and facility LPN #505 scheduled for the entire 12 hour shift from 7:00 A.M. to 7:00 P.M. Facility LPN #577 and agency LPN #582 were scheduled for the shift beginning at 7:00 P.M. Interview and record review revealed LPN #577 never arrived to start the 7:00 P.M. shift. Agency LPN #582 arrived at 7:00 P.M. but was unable to punch in or gain access to the facility electronic medical record (EMR) system with her agency badge and password. LPN #582 got frustrated because she could not do anything, called her agency, and left the facility at approximately 7:30 P.M. Review of the facility attendance punch records indicated LPN #505 remained in the facility until 03/07/22 at 12:00 A.M. and LPN #507 remained in the facility on 03/07/22 until 1:00 A.M. However, no nurse(s) arrived to replace them. And LPN #507 left the facility after working 18 hours. (See Findings at F725). On 03/08/22 at 3:02 P.M. interview with STNA #520 revealed she worked at the facility on 03/05/22 from 11:00 P.M. to 03/06/22 at 7:00 A.M. and on 03/06/22 from 11:00 P.M. to 7:00 A.M. STNA #520 revealed when she arrived to work at 11:00 P.M. on 03/05/22 quite a few of the residents were asking for pain medication. STNA #520 revealed the same thing happened on Sunday, 03/06/22. STNA #520 revealed there was no licensed nurse working in the facility and she and two other aides, STNA #566 and STNA #574 were working to keep all the residents' safe, clean and dry and to prevent any falls. STNA #520 indicated she contacted both the Administrator and Scheduler #539 multiple times on 03/05/22 from 11:00 P.M. until 12:00 A.M. The scheduler responded and indicated they knew about the staffing situation, and they were making phone calls. At the end of her shift on 03/06/22 at 7:00 A.M. STNA #520 revealed she left written messages regarding the staffing situation in the mailboxes of the Administrator and Scheduler. STNA #520 revealed the Administrator and Scheduler called her for a conference call on Monday, 03/07/22 to discuss the staffing situation and asked her to be patient and understanding regarding the staffing and they were working on it and it would not be an overnight fix. (See Findings at F760). On 03/09/22 at 1:16 P.M. interview with STNA #518 revealed she worked the 3:00 P.M. to 11:00 P.M. shift on 03/05/22 and 03/06/22. STNA #518 revealed there was no nurse in the facility on 03/05/22 after 8:30 P.M. and she was aware there was no nurse in the facility on 03/07/22 after 1:00 A.M. She stated she personally spoke with the scheduler on 03/05/22 at approximately 7:30 P.M. and was told they were working on getting a nurse and to do the best they could. STNA #518 revealed the situation was the same on 03/06/22 when no nurses arrived for the 7:00 P.M. shift but LPN #505 and LPN #507 stayed over until 12:00 A.M. and 1:00 A.M., respectively. LPN #507 came and found her at 11:00 P.M. and indicated her replacement had shown up at approximately 7:00 P.M. but left almost immediately after discovering she would be the only nurse. On 03/09/22 at 1:36 P.M. interview with STNA #575 revealed during shift change at 7:00 P.M. on 03/06/22, an agency nurse (LPN #581) showed up but she had no log-in information for the facility electronic medical record system. STNA #575 indicated the nurse called the agency and then left because there was nothing she could do. The facility nurse, LPN #507 was sick and dizzy and called the Administrator on 03/05/22 at 8:30 P.M. STNA #575 revealed LPN #507 did not receive a return call (from the Administrator) and eventually locked up the narcotic keys and left. STNA #575 revealed we took care of the residents and put them to bed. She stated some were requesting their medications, but we were STNAs and could not do anything but take care of them. On 03/09/22 at 2:05 P.M. interview with LPN #576 revealed she was an agency nurse who was scheduled to work on 03/05/22 from 7:00 A.M. to 7:30 P.M. at the facility. She stated she had worked at the facility in the past and this was the second or third time she had experienced staffing problems. She indicated she was assigned two halls when she arrived at the facility at 7:00 A.M., the 300 Hall (secured dementia unit) and the 400 Hall with two STNAs to assist her. LPN #576 indicated on 03/05/22 the relief nurse LPN #577 called off at 5:14 P.M. and the agency relief nurse LPN #581 arrived at 7:00 P.M. but indicated that she was not staying because she did not want to be the only nurse in the facility. LPN #576 revealed she called the Administrator at 7:15 P.M. regarding LPN #581's staffing concerns and again at 7:26 P.M. when LPN #581 decided she was not staying because it was unsafe, and she left. LPN #576 indicated she counted the narcotics in the medication carts with LPN #507 and left the facility at 8:00 P.M. LPN #507 was still in the facility when she left. LPN #576 indicated on 03/05/22 when she left the facility, there was only one nurse, LPN #507 along with three STNAs (#520, #566 and #574) remaining in the facility. On 03/09/22 at 3:40 P.M. interview with Scheduler/STNA #539 revealed she had worked at the facility since July 2021. She stated she schedules staffing for the facility a month out and posts the entire month at least two weeks before, usually on the 18th of the month. She posts the schedule so if staff want to pick up extra shifts, they know what shifts are available. She also sends out mass texts via the On Shift System for facility staff and enters information into staffing agency portals or emails them directly to let them know of the availability of shifts and facility staffing needs. Scheduler/STNA #539 revealed she typically staffs three nurses for the 7:00 A.M. to 7:00 P.M. shift and two nurses for the 7:00 P.M. to 7:00 A.M. shift and tries to get a medication pass nurse for 7:00 P.M. to 11:00 P.M. and then drops to two nurses at 11:00 P.M. Schedule/STNA #539 revealed when she received the call off notification from LPN #577, she immediately started making attempts to replace him with another licensed nurse. She stated she contacted the Administrator and was working with her using On Shift, texting people, offering bonuses but got a lot of no. She stated she also posted to all of the agencies and still got no response. Scheduler/STNA #539 indicated she continued to try to get staffing for the facility and went to bed with the phone still making phone calls and worrying about the STNAs left to work in the facility with no licensed nurse as well as the residents. On 03/10/22 at 12:58 A.M. interview with LPN #507 revealed she was scheduled to work at the facility on 03/05/22 from 7:00 A.M. to 7:30 P.M. with another staff nurse (LPN #506) scheduled from 7:00 A.M. to 3:00 P.M. and an agency nurse (LPN #576) scheduled for the 7:00 A.M. to 7:30 P.M. shift. LPN #507 indicated LPN #506 left at 3:00 P.M. and she assumed care for the residents on the 100 hall and 200 hall by herself, which was difficult for one nurse. Agency LPN #576 was assigned to care for residents on the 300 Hall and the secured dementia unit. At 7:00 P.M., both LPN #507 and Agency LPN #576 were waiting for their relief staff to arrive. LPN #507 indicated she was sick and barely making it to the end of the shift. She had a headache, vomiting, diarrhea and was dizzy. LPN #507 revealed she sent messages to the scheduler (regarding staffing) with no response. She also called the Administrator at approximately 7:30 P.M. and told her she was sick and couldn't stay. The Administrator's response was, can you hang in for a little longer- about an hour? LPN #507 revealed Agency LPN #576 left at 7:30 P.M. and she (LPN #507) stayed until 8:30 P.M. as the only nurse in the facility and was trying to hang on. LPN #507 revealed at that time no one had told her an oncoming nurse had called off. LPN #507 indicated she stayed for another hour (until approximately 8:00 P.M.-8:30 P.M.), and no one came. LPN #507 stated she sent four messages to the scheduler with no response. LPN #507 revealed she locked the keys in the medication room and placed the medication room key in the office and told the Administrator where they were in a hidden location. During the interview, LPN #507 revealed she returned to the facility on [DATE] at 7:00 A.M. and worked until 03/07/22 at 1:00 A.M. (although she was scheduled to leave on 03/06/22 at 7:30 P.M.). LPN #507 revealed it was like [NAME]-[NAME] all over again. Facility LPN #577 who was scheduled to come in on 03/06/22 at 7:00 P.M. did not show up and she was told he had quit. An agency nurse, LPN #582 did arrive to the facility at 11:00 P.M. but did not stay because she had no access to anything, was unable to scan her badge to administer medications and stated she was not staying because she felt it was unsafe. On 03/08/22 at 4:05 P.M. interview with the Administrator revealed she received a call from facility staff on 03/05/22 at 7:15 P.M. indicating there was no licensed nurse available onsite to relieve the 7:00 A.M. to 7:00 P.M. nurses. The Administrator revealed the scheduled (7:00 P.M. to 7:00 A.M.) staff nurse called off and the scheduled agency nurse arrived on 03/05/22 but left by 7:30 P.M. leaving no licensed nurse to relieve the off-going shift nurses. The Administrator revealed she and Scheduler #539 made multiple calls without success to facility staff nurses and agencies to get a licensed nurse to work on 03/05/22 for the night shift (through 03/06/22 at 7:00 A.M.). During the interview, the Administrator failed to provide any additional information to support evidence of any interviews or direct administrative oversight during these days/shifts when there was no licensed nurse on duty and present in the facility to care for all 52 residents residing in the facility. This deficiency substantiates Complaint Number OH 768.

Based on closed medical record review, review of the facility's incident investigation, staff interviews, and the facility policies and procedures, the facility failed to ensure one resident (Resident #79) of four residents reviewed was free from neglect. On [DATE] at 8:15 P.M., State tested Nurse Aide (STNA) #1 reported to the charge nurse, Licensed Practical Nurse (LPN) #2, that Resident #79 appeared weak with a complaint of abdominal pain. LPN #2 failed to respond and assess Resident #79, even though STNA #1 notified LPN #2 five additional times between 8:15 P.M. and 11:45 P.M. of a significant change in Resident #1's status including onset of diarrhea, increased abdominal pain, and vomiting, sweating, shivering, and unclear speech. There was no evidence of an assessment from a licensed nurse until 11:45 P.M. when LPN #2 and LPN #3 entered Resident #79's room and found the resident sweating, with lips and nailbeds blue; a faint carotid pulse, shallow, slow respirations and unresponsive to verbal, physical and painful stimuli. Pulse and respirations were absent within two to three minutes. Cardiopulmonary resuscitation was initiated and Resident #79 was transported by emergency medical services to the hospital where he expired on [DATE] at 12:35 A.M. This resulted in Immediate Jeopardy and life-threatening harm and subsequent death when LPN #2 failed to respond to a significant health change in Resident #79 for four and a half hours after STNA #1 repeatedly reported a decline in the resident's condition. On [DATE] at 1:55 P.M., the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 8:15 P.M. when LPN #2 neglected to assess Resident #79 after STNA #1 repeatedly reported a change in Resident #79's condition. STNA #1 continued to report the decline in the resident's condition to LPN #2, who failed to assess Resident #79, he became unresponsive and subsequently died at the hospital at 12:35 A.M. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] beginning at 12:45 A.M., LPN #4 observed 41 residents on the 100 and 200 units who received care by LPN #2 on [DATE]. There was no evidence found of any additional residents who were neglected or who required services relative to a change in condition. · On [DATE] at 1:30 A.M., LPN #4 interviewed LPN #2 about Resident #79. LPN #2 was suspended, leaving the facility on [DATE] at 2:35 A.M. LPN #2 did not return to the facility and was terminated on [DATE]. · On [DATE] between 2:40 A.M. and 5:15 A.M., LPN #4 educated two LPNs working the night shift regarding change of condition notification to the unit manager, DON, physician, and family members; comprehensive documentation of resident assessment in the nurse's notes; and steps to take when assessing a resident's change in condition. They were also educated on the facility Resident Abuse and Neglect policy and procedure (revised [DATE]). · On [DATE] between 2:40 A.M. and 5:15 A.M., LPN #4 educated five STNAs working the night shift regarding use of the facility electronic resources to document resident change in condition; notifying the charge nurse of change of condition; and if no follow-up from the charge nurse, the STNA was to go to another nurse and call the nursing supervisor. They were also educated on the facility Resident Abuse and Neglect policy and procedure. · On [DATE] between 10:00 A.M. and 8:00 P.M., the Director of Nursing (DON) continued educating the nurses as they became available during the shift regarding change of condition notification to the unit manager, DON, physician, and family members; comprehensive documentation of resident assessment in the nurse's notes; and steps to take when assessing a resident's change in condition. They were also educated on the facility Resident Abuse and Neglect policy and procedure. · On [DATE] between 10:00 A.M. and 8:00 P.M., the DON continued educating the STNAs as they became available during the shift regarding use of the facility electronic resources to document resident change in condition; notifying the charge nurse of change of condition; and if no follow-up from the charge nurse, the STNA was to go to another nurse and call the nursing supervisor. They were also educated on the facility Resident Abuse and Neglect policy and procedure. · On [DATE] by 9:00 P.M., the DON, Registered Nurse (RN) #9, LPN #7, and LPN #4 completed the education of the remaining nurses and STNAs in person as they were available at the facility, or by phone, until all nursing staff, including seven RNs, 18 LPNs, and 38 STNAs were educated. · On [DATE] by 9:00 P.M. the DON, RN #9, LPN #7, and LPN #4 completed the education of four Activity staff and nine management staff regarding the facility Resident Abuse and Neglect policy and procedure. · An audit will be completed by the unit manager three times each week for three weeks and then monthly to ensure the change of condition documentation is addressed by the nurse. · On [DATE] a quality assurance monitoring system was developed by the administrator to review the audit and ensure the effectiveness of education and ongoing education relative to resident change in condition. All changes in condition will be reported in morning meeting attended by nursing management and administration to ensure all parties are aware of the change in condition and who was notified. The process began on [DATE] and is ongoing. · On [DATE], six licensed nurses completed a Cardiopulmonary Resuscitation Training (CPR) course. The second CPR training course is scheduled for eight licensed nurses on [DATE] at 7:30 P.M. The training will be completed on [DATE] when seven licensed nurses are scheduled for training. · LPN #4 will train new nurses upon hire regarding the facility procedures for response to resident change in condition, and related notification and documentation. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Closed record review revealed Resident #79 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #79 was alert and oriented with no cognitive impairment, unable to walk and used a wheelchair for mobility. Resident #79 was completely dependent for transfers in and out of bed, and had limited range of motion of upper and lower extremities. Review of a physician order [REDACTED].#79 had advanced directives which included full resuscitative measures (Full Code). This was included in the plan of care dated [DATE]. Review of the facility Self-Reported Incident (SRI) investigation dated [DATE] for an incident that occurred on [DATE], a witness statement obtained from STNA #1 on [DATE] (immediately following the incident), and an interview with STNA #1 on [DATE] at 11:50 A.M., revealed she was completing her rounds on [DATE] at 8:15 P.M. when Resident #79 complained of a stomach ache. He was in bed but appeared a little bit weak. STNA #1 finished assisting Resident #79 and reported the resident's complaint and her observation to LPN #2. LPN #2 said she would check on Resident #79. STNA #1 indicated she went back to check on Resident #79 around 9:00 P.M. Resident #79 was clenching his fist and guarding his abdomen. He was incontinent of a very large amount of loose stool. STNA #1 cleaned the resident and then STNA #1 went to the nurses station and told LPN #2, that it was too much BM and unusual for Resident #79. LPN #2 was at the nurse's station and did not respond. STNA #1 went back to check on Resident #79 around 9:30 P.M. He asked if she had told the nurse his stomach hurt because the nurse had not come to check on him. He had been incontinent of another large, liquid stool. While she was cleaning him, the stool continued so she again went to the nurse's station and told the nurse the liquid stool was still coming and it's like too much for him. STNA #1 revealed LPN #2 instructed her put a diaper on him, and she would be there to check on him. STNA #1 went back to the resident and he vomited. STNA #1 raised the head of the bed and bathed Resident #79. Around 10 minutes later (9:40 P.M.), LPN #2 came into the room and gave Resident #79 some medicine. According to Medication Administration Record, [REDACTED]. During the same interview and review of the witness statement, STNA #1 revealed she was in the resident's room the entire time LPN #2 administered the medication and gave Resident #79 a drink of water. Resident #79 told LPN #2 his stomach hurt and then he asked to call his brother. STNA #1 revealed LPN #2 did nothing else. She didn't even ask why he wanted to call his brother. She just left the room. STNA #1 verified LPN #2 did not touch any part of the resident's body and did not even have a stethoscope in her hand. STNA #1 revealed she left the resident's room to begin her last resident rounds. Around 10:00 P.M., STNA #1 went back to check on Resident #79. Resident #79 was sweating, in pain, started vomiting and was again, incontinent of loose stool. STNA #1 immediately went to the nurse's station. LPN #2 said she would give Resident #79 some medicine and stood and went to the medication cart. During the same interview, STNA #1 verified she returned to Resident #79 and stayed with him. STNA #1 said I never did finish my last rounds. STNA #1 wrote in her statement that near 11:00 P.M., LPN #2 had not yet arrived to assess and medicate Resident #79, when he started shivering and his voice was not clear. STNA #1 immediately went to LPN #2 again, and told her, This time he cannot even speak well and he is sweating too much! LPN #2 said OK and instructed STNA #1 to check the resident's vital signs. STNA #1 returned to the resident and checked his vital signs. STNA #1 immediately went back to the nurse's station and reported the vital signs to LPN #2. STNA #1 reported the resident's blood pressure as ,[DATE], and his respirations as 55. During the same interview and SRI investigation, STNA #1 revealed she repeated the respirations as 55 because she was not sure LPN #2 heard her. LPN #2 remained in her chair and turned to another nurse who had just arrived for shift change. STNA #1 ran back to the resident's room and Resident #2 was coughing, a large amount of stool was everywhere and STNA #1 described the stool as too light. Again, she ran back to the nurse's station, notified LPN #2 and said, You have to take him to the hospital! STNA #1 revealed LPN #2 initially said she could not do that, and then said OK, I will try and do something. STNA #1 revealed she ran back to Resident #79 and LPN #2 headed in another direction. When STNA #1 entered the resident's room, Resident #79 was gasping from his mouth and his mouth was a little blue. As STNA #1 exited the room to call an ambulance, she saw other nurses coming to help. Further review of the SRI regarding the [DATE] incident involving Resident #79, revealed an interview with LPN #3 on [DATE] at 12:19 P.M. LPN #3 revealed she had arrived at work on [DATE] at 7:00 P.M. for the 7:00 P.M. to 7:00 A.M. shift. LPN #3 said she had just clocked out for lunch and was entering the staff lunch room when LPN #2 approached and asked her if she would come with her to see Resident #79 because he was having some respiratory distress. LPN #2 explained STNA #1 took the resident's vital signs and reported his respiratory rate as 55 (per minute). LPN #3 revealed she was surprised an STNA had obtained the vital signs and initially believed it was an error because 55 per minute are just about impossible. In addition, LPN #3 revealed LPN #2 had no sense of urgency. Review of the time card punch revealed LPN #3 had clocked out for lunch on [DATE] at 11:44 P.M. Review of the nurse's note written on [DATE] at 11:40 P.M. by LPN #3 revealed Resident #79 was diaphoretic (sweating); his lips and nail beds were blue with agonal respirations (slow respirations associated with impending death). His respiratory rate was eight and initially, a faint carotid pulse was palpated. Resident #79 was unresponsive to both verbal and painful stimuli. A pulse oximeter reading was obtained, which was 86%. The resident's pulse ceased, emergency medical transport was notified (911) and cardiopulmonary resuscitation (CPR) was initiated. LPN #3 revealed she was returning the crash cart and noticed STNA #1 was crying. Initially, LPN #3 believed it might have been STNA #1's first experience with a death. LPN #3 inquired because she wanted to offer STNA #1 emotional support. However, STNA #1 responded saying 'No, that's not it. It didn't have to happen.' STNA #1 explained the evening's events as described in the facility incident and investigation including witness statements. LPN #3 revealed she reported the events of the evening as described by STNA #1 immediately to the DON and on-call charge nurse LPN #4. Review of nurse's notes from [DATE] through [DATE] revealed the first notes referencing a change of condition were written by LPN #2 on [DATE] at 10:54 P.M. and 10:56 P.M. Resident #79 refused a protein supplement and scheduled laxative due to a complaint of an upset stomach and loose stools. There was no documented evidence in this note that the nurse had assessed Resident #79 at that time. Review of a nurse's note dated [DATE] at 12:40 A.M. revealed the hospital contacted the facility to notify them Resident #79 expired at 12:35 A.M. Review of a nurse's note written by LPN #2 dated [DATE] at 1:29 A.M. revealed Resident #79 complained of a stomach ache and had multiple loose stools. An emesis (vomiting) was also reported by STNA #1 between 8:00 P.M. and 11:00 P.M. The resident's blood pressure was ,[DATE] with respirations over 30 at 11:30 P.M. Two nurses assessed Resident #79. He appeared pale with shallow breathing. LPN #2 called 911 and notified other staff for assistance, CPR was initiated and emergency transport arrived at 11:50 P.M. There was no documented evidence in this nurse's note that LPN #2 responded and assessed Resident #79 between 8:00 P.M. and 11:00 P.M. following the STNA notification of stomach pain, loose stools and vomiting. The previous nurse's note written by LPN #4 verified the vital signs were obtained by STNA #1 rather than a licensed nurse. An interview completed with LPN #4 on [DATE] at 12:33 P.M. revealed she received a telephone call from the facility on [DATE] at 12:06 A.M. She was notified CPR was initiated for Resident #79, and Resident #79 was transported to the hospital. LPN #4 revealed she received a second telephone call a few minutes later and was notified STNA #1 was very upset regarding the circumstances surrounding the resident's change in condition. LPN #4 came to the facility and immediately began the investigation. LPN #4 interviewed LPN #2 and STNA #1, separately. LPN #4 revealed LPN #2 kept changing her story, and was unable to provide details. LPN #4 said Nothing made sense of what she was telling me. LPN #4 instructed each to write a witness statement. LPN #4 revealed after reading the witness statements, the account of the events as described by LPN #2 did not add up. Therefore, she immediately suspended LPN #2. Review of the punch card detail revealed LPN #2 clocked out at 2:35 A.M. During the same interview, LPN #4 verified on [DATE] she initiated an investigation immediately and assessed the health status of the remaining 41residents under the care of LPN #2 without any significant findings. Interview with the DON on [DATE] revealed all staff education to address the incident with Resident #79, and the expected staff response to a resident's change in condition, began on [DATE] at 12:30 A.M. and were completed on [DATE] at 9:00 P.M. These inservices were held by the DON, LPN #4 and LPN #5. Inservices for all licensed nursing staff (including seven RNs and 18 LPNs) included responding to resident change in condition; notification of the unit manager, DON, physician, and family members; comprehensive documentation of resident assessment in the nurse's notes; and steps to take when assessing a resident's change in condition. Inservices for all 38 STNAs included notifying the charge nurse of change of condition and, if no follow-up from the charge nurse, the STNA was to go to another nurse and call the nursing supervisor. Additional inservices regarding the Resident Abuse and Neglect policy and procedure (revised [DATE]) were held for all facility staff, including seven RNs, 18 LPNs, 38 STNAs, four Activity staff, and nine management staff. A Quality Assessment and Performance Improvement (QAPI) was completed [DATE] to ensure effectiveness of education and ongoing education. Team members were the DON, Staff Development Coordinator LPN #4, Unit Manager RN #6, Unit Manager LPN #7, RN #8 and the Executive Director. All SBARS will be brought to the daily morning meeting to ensure completion and accuracy. All changes in condition will be reported in morning meeting to ensure all parties are aware of the change and who was notified. The process began [DATE] and will be ongoing. Review of the Abuse and Neglect policy and procedure revised [DATE] revealed: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. The same policy defines 'neglect' as, Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This deficiency substantiates Master Complaint/Self-Reported Incident Number OH 559 and Complaint Number OH 488.

Based on observations, resident and staff interview and record review, the facility failed to reassess, develop and implement interventions and consult the physician when current pain interventions did not effectively treat Resident #11's chronic expressed pain and to address her psychosocial well-being. This affected one of three residents reviewed for pain management. Actual harm occurred when Resident #11's routine pain medication was discontinued due to interaction with the prescribed antibiotic. There was no evidence alternative routine medications or non medications were initiated in an attempt to address the residents continued pain. Findings include: Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was confined to bed due to her chronic abdominal wound. Registered Nurse #29 completed a pain observation assessment tool on 04/11/15 indicating Resident #11 received scheduled and as needed pain medication as well as non medication interventions. The assessment indicated Resident #11 experienced pain almost constantly, her day to day activities were limited because of pain, she described her pain as severe with a rating of 8 out of 10. She displayed non-verbal sounds (crying whining gasping moaning or groaning) had vocal complaints, facial expressions of pain and protective body movements. Review of the pain plan of care initiated on 03/03/15 indicated the interventions to treat Resident #11's pain included to assess the resident for pain using the pain scale of 0-10 (10 indicated the highest severity of pain) using as needed narcotic pain medication and to notify the physician of new or increased intensity of existing pain and to respond immediately to any complaints of pain. Review of the mood plan of care initiated on 03/11/15 indicated Resident #11 felt down, depressed and hopeless. The interventions included administering medications, assess for exacerbation of issues related to pain and loss of mobility, encourage adequate food and fluid intake and provide ongoing support. Review of the activities of daily living plan of care dated 04/24/15 indicated she did not get out of bed "per her choice". (SIC) Review of the current physician orders [REDACTED].#31 indicated the resident could not take food or fluids by mouth and had prescribed the use of 0.5 milligrams of intravenous narcotic pain medication every four hours as needed for moderate pain and 1.0 milligrams for severe pain. There were no routine orders for pain medication. There were no orders for antidepressant medications. Review of the Medication Administration Record [REDACTED]. Each entry identified her pain from 8-10 on the pain scale. Review of the PHQ-9 depression assessment dated [DATE] and 04/22/15 indicated Resident #11 had mild depression. Review of the psychology consult note authored by psychologist (Ph.D.) #30 dated 03/18/15 identified Resident #11 as having [MEDICAL CONDITION]. Ph.D. #30 noted Resident #11 struggled with depression over the past several months due to increased debility. Her depression was exacerbated by [MEDICAL CONDITION] following hernia surgery. The resident was noted as discouraged as her wounds have not healed. The concept of Hospice was introduced. Ph.D. #30 indicated Resident #11 was prescribed two antidepressant medications. Ph.D. #30 noted on 03/25/15 Resident #11 smiled but was very sad indicating she was too young to live in the facility the rest of her life. Ph.D. #30 noted no change in [MEDICAL CONDITION] medication. Ph.D. #30 noted on 04/15/15 Resident #11 was alert and oriented with some sadness. Resident #11 indicated she was aware her prognosis was not good but she lived with illness and disability all of her life. Ph.D. #30 noted no changes in [MEDICAL CONDITION] medications. Review of M.D. #31's note dated 04/15/15 indicated he discontinued the routine narcotic pain medication patch due to contraindications with the antibiotic. MD #31 did not provide any alternative modalities to treat Resident #11's severe pain. Observation and interview of Resident #11 on 04/21/15 at 10:09 A.M. indicated she was grimacing because of her severe abdominal pain. She stated that often changing her dressing relieved the pain. She indicated she would never have had the hernia surgery if she knew her life would be like this. Resident #11 indicated the dressing was changed about four times daily. Resident #11 was observed wincing on 04/22/15 at 8:04 A.M. but indicated her pain was okay. Resident #11 was observed on 04/23/15 at 5:22 P.M. in bed grimacing. Resident #11 indicated it was near time for dressing to be changed. She stated she told Licensed Practical Nurse (LPN) #32 but informed her she needed to pass medications to the other residents first. Interview with Registered Nurse (RN) #25 on 04/22/15 at 2:56 P.M. indicated the resident had a hernia repair surgery in which her bowel was nicked. Her abdomen dehisced and developed an enormous abdominal wound with three draining fistulas. The resident was identified as essentially immobile because the fistula would drain with movement. She verified Resident #11 was ordered strict NPO (nothing by mouth), received as needed pain medication for her chronic severe pain but was on no routine pain medication. She stated the resident asked for anti-nausea medication looked at the clock and asked for her as needed pain medication. Interview with the director of nursing on 04/24/15 at 9:09 A.M. confirmed Resident #11's routine pain medication was discontinued due to interaction with the prescribed antibiotic. She verified there was no evidence alternative routine medications or non medications were initiated at that time. The director of nursing asked LPN #32 what non medication interventions seemed to help the resident. LPN #32 informed the director of nursing she used guided imagery once, distraction, a little repositioning and massaging of her shoulders helped. It was confirmed by the director of nursing these interventions were not identified in the plan of care. Further interview with the director of nursing on 04/24/15 at 9:34 A.M. indicated she thought the resident needed additional interventions to relieve her chronic severe pain and asked the surveyor to ask MD #31 why he did not add alternative intervention when he discontinued the routine pain medication. She also confirmed there was no evidence nursing staff communicated the need for additional interventions as the current pain medication orders were not effectively treating her pain. Interview with the director of nursing on 04/24/15 at 10:23 A.M. confirmed Resident #11 was not prescribed any antidepressant medication during her stay in the facility as Ph.D. #30 had noted and verified no other non medication interventions were initiated related to Resident #11's depression. The director of nursing noted MD #31 commented on her mood and affect on each visit. Interview with the administrator on 04/24/15 at 10:04 A.M. indicated he spoke with MD #31 on 04/24/15 at 8:55 A.M. indicated he did not want to reinstate routine pain medication for this resident. This deficiency is an example of continued non compliance from the complaint investigated on 04/08/15.