Every finding on record at Meadow Brook Rehabilitation and Nursing

Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the dishmachine washing temperature was not reaching the required temperature, uncooked meat was stored with cooked foods, and the shelf above the steam table was soiled. Findings included: 1. On 9/22/25 at 9:13 AM, an initial tour was conducted of the facility kitchen. The following was observed with the dishmachine. (Note: All temperatures were in degrees Farenheit.)a. The wash temperature was 115 and the rinse 120. Dietary Aide (DA) 2 was observed to remove the bowls from the dishwasher and place them in the clean dish area. b. The wash temperature was 115 and rinse was over 120. DA 2 was observed to remove the dishes from the dishwasher and place them with the clean dishes. c. The wash temperature was 118 and the rinse temperature was 120. The Dietary Manager (DM) was observed to check the sanitizer which was 50-100 parts per million of chlorine. DA 2 was observed to remove the dishes from the dishwasher and place them with the clean dishes. d. At 9:45 AM, the wash temperature was 118 and rinse was 120. The dishes were removed from the dishwasher and placed with clean dishes. The September 2025 dishwasher temperature log was reviewed and the rinses were documented at 120 and the sanitizer was 100 parts per million. There was no column to record the wash temperature. The steam table had a shelf above the food and under the shelf was soiled. An interview was conducted with DA 2 who stated it was his first day and he did not check the dishmachine temperatures. An interview was conducted with the DM. The DM stated he checked the dishmachine temperatures before the meals.The DM stated he was not sure if both wash and rinse both needed to reach 120. The DM stated the shelf under the trayline was cleaned after each meal service. The freezer was observed to have two boxes of beef sirloins stored on the same shelf as pizza crust and buttermilk biscuits. The DM was observed to remove the boxes and place them in another freezer. The DM stated the uncooked meats should not be stored on the same shelf as pizza crust and buttermilk biscuits. 2. On 9/29/25 at 2:37 PM, a follow up observation was made of the kitchen. The trayline shelf was observed to be soiled.

Based on observation and interview, the facility was not clean, comfortable and homelike. Specifically, there was no process for cleaning dirty wheelchairs and mechanical lifts. In addition, there was a medication cart in the dining room that was soiled with dead bugs in it. Resident identifiers: 1 and 11.Findings included:1. On 9/22/25 at 11:32 AM, an observation was made of resident 11's wheelchair. The wheelchair was soiled with a white substance. On 9/29/25 at 2:58 PM, an observation was made of resident 1 and resident 11's wheelchair. Resident 1 and resident 11's wheelchair was soiled. Resident 11's wheelchair was soiled with a white substance on the side and on the cushion. 2. On 9/22/25 at 1:15 PM, an observation was made of a medication cart and emergency cart in the dining room. There were dead bugs, crumbs, and debris in the side of the medication cart. The emergency cart was observed to have dust and debris in a drawer with the suction machine. On 9/22/25 at 1:30 PM, an observation was made of the mechanical lifts in the dining room. The foot plates of the mechanical lifts were soiled with a black substance and debris. On 9/25/25 at 1:28 PM, an observation was made of the mechanical lifts in the dining room. One of the sit to stand lifts was soiled on the foot plates. Another sit to stand lift was observed to be dirty at the bottom of the lift. There were dead bugs, crumbs, and debris in the medication cart in the dining room. An emergency cart had dust in the bottom drawer where there was a suction machine. On 9/29/25 at 2:52 PM, an interview was conducted with the Administrator. The Administrator stated the lifts and wheel chairs were cleaned regularly. The Administrator stated they were planning to come up with a cleaning plan. On 9/29/25 at 2:56 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she was not sure when the lifts were cleaned but after each use she wiped down the handrails. CNA 1 stated she did not know of a cleaning schedule for the wheelchairs or mechanical lifts.

Based on interview and record review, the facility did not file in the resident's clinical record laboratory (lab) reports that were dated and contained the name and address of the testing laboratory. Specifically, for 3 out of 29 sampled residents, residents that had labs completed did not have those lab reports in their medical record. Resident identifiers: 3, 15, and 17. Findings included: 1. Resident 17 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, type 2 diabetes mellitus with hyperglycemia, diabetic chronic kidney disease, iron deficiency anemia, hypomagnesemia, acidosis, hyperkalemia, and diabetic polyneuropathy. Resident 17's medical record was reviewed. On 8/26/25, a physician's order documented obtain Microalbumin Creatinine Ratio (MAC) in 4 weeks for proteinuria one time only for to rule out proteinuria until 08/26/2025 23:59 [11:59 PM] -Start Date 08/26/2025 0430 [4:30 AM]. On 9/10/25, a physician's order documented UA [urinalysis] with culture and sensitivity by PCR [polymerase chain reaction] for ongoing UTI [urinary tract infection] one time only until 09/10/2025 23:59 -Start Date 09/10/2025 1130 [11:30 AM]. On 9/12/25, a physician's order documented obtain BMP [basic metabolic panel] one time only until 09/12/2025 23:59 -Start Date 09/12/2025 0645 [6:45 AM]. The lab results were unable to be located in resident 17's medical record. 2. Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, stage 4 pressure ulcer of sacral region, cellulitis of buttock and right upper limb, and dehydration. Resident 3's medical record was reviewed. On 8/12/25, a physician's order documented obtain wound culture on coccyx wound. one time only until 08/12/2025 23:59 -Start Date 08/12/2025 1230 [12:30 PM]. On 8/22/25, a physician's order documented obtain cbc [complete blood count], crp [c reactive protein], ESR [erythrocyte sedimentation rate] weekly while one [sic] abx [antibiotics]. every day shift every Fri [Friday] until 09/04/2025 23:59 -Start Date 08/22/2025 0600 [6:00 AM]. On 9/1/25, a physician's order documented Draw CMP [comprehensive metabolic panel] monthly for at risk of hyponatremia one time a day every 1 month(s) starting on the 1st for 3 day(s) Draw labs monthly -Start Date 09/01/2025 0600. On 9/10/25, a physician's order documented obtain cbc, cmp, crp, ESR in 1 week due to coccyx wound infection one time only until 09/10/2025 23:59 -Start Date 09/10/2025 0645. On 9/16/25, a physician's order documented obtain wound culture to coccyx wound one time only until 09/16/2025 23:59 -Start Date 09/16/2025 1300 [1:00 PM]. On 9/18/25, a physician's order documented repeat cbc, ESR, CRP in 1 week one time only until 09/18/2025 23:59 -Start Date 09/18/2025 0600. The lab results were unable to be located in resident 3's medical record. 3. Resident 15 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included schizoaffective disorder, extrapyramidal and movement disorder, diabetes mellitus, pseudobulbar, generalized anxiety disorder, and dementia. Resident 15's medical record was reviewed on 9/22/25 through 9/59/25. Physician's orders revealed the following laboratory orders: a. On 7/17/25, Magnesium level b. On 7/23/25, Urine analysis c. On 7/28/25, CBC d. On 8/28/25, Ammonia level e. On 9/11/25, BMP, Valproic acid, CMP There were no laboratory results in resident 15's medical record. On 9/24/25 at 12:09 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility had a lab portal where they could get the lab results. The DON stated she would print the lab orders out and match them with the lab to make sure they were drawn. The DON stated that she would print the individual lab orders to draw for the next lab day. The DON stated when the lab came to the facility they would look in the lab book for the orders for that day. The DON stated once the labs were in the portal she would print them and put them in the lab book. The DON stated once the Nurse Practitioner signed off on the labs she would put them in the basket to be uploaded to the resident medical record. On 9/29/25 at 12:05 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that the labs she provided were on a website that she and the nurses have access to. The ADON stated staff printed the lab results from the website and then downloaded them to the residents medical record. On 9/29/25 at 1:30 PM, an interview was conducted with the DON. The DON stated the laboratory results should be in the residents medical record. The DON stated she was unable to locate resident 15's laboratory results in the medical record.

Based on observation and interview, the facility did not serve food that was palatable. Specifically, for 4 out of 29 sampled residents, residents complained of the palatability of the food and a test tray was not palatable. Resident identifiers: 2, 5, 13, and 25.Findings included: On 9/22/25 at 11:36 AM, an interview was conducted with resident 25. Resident 25 stated that the food was bad. Resident 25 stated the quality of food was important. On 9/22/25 at 12:09 PM, an interview was conducted with resident 2. Resident 2 stated the kitchen staff needed to check temperatures of the food because the food was served cold.On 9/22/25 at 12:47 PM, an interview was conducted with resident 13. Resident 13 stated the food tasted good that day but she usually ate cereal because the food did not look or taste good. On 9/22/25 at 1:32 PM, an interview was conducted with resident 5. Resident 5 stated his food was usually blended and he did not know what he was served. On 9/24/25 at 12:37 PM, a test tray was obtained. (Note: All temperatures were in degrees Farenheit.)a. Meatloaf was 148.2, bland to the taste with a slimy texture and not palatable. b. Au gratin potatoes were 128.3, bland to the taste with a mushy texture. c. Mixed vegetables were 125.0, dull in color with a mushy texture. d. Corn bread was 103.2, and had an extra grainy texture. e. Dessert was 75.7, and was bland to the taste. On 9/29/25 at 11:21 AM, a phone interview was conducted with the Registered Dietitian (RD). The RD stated she did a test tray on 9/18/25, when she was at the facility. The RD stated she did not have concerns regarding the food quality. The RD stated that she had not asked residents about food quality.

Based on interview and record review, the facility did not ensure residents were offered the Coronavirus disease 2019 (COVID-19) vaccines. Specifically, for 3 out of 5 sampled residents, no documentation was located to demonstrate how the residents accepted or refused the COVID-19 vaccination. Resident identifiers: 2, 6, and 31. Findings included:1. Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included quadriplegia, protein-calorie malnutrition, and anxiety disorder. Resident 6's medical record was reviewed on 9/29/25.There was no information that the COVID-19 vaccine was offered or refused for 2024.2. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included type 2 diabetes mellitus, protein-calorie malnutrition, morbid obesity due to excess calories, and schizoaffective disorder.Resident 2's medical record was reviewed on 9/29/25. There was no information that the COVID-19 vaccine was offered or refused for 2024.3. Resident 31 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included major depressive disorder, dementia, and adult failure to thrive. Resident 31's medical record was reviewed on 9/29/25. There was no information that the COVID-19 vaccine was offered or refused for 2024.On 9/29/25 at approximately 2:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated there was no documentation that the residents were offered or refused the COVID-19 vaccine. The DON stated if a resident refused a vaccine there should be a form completed regarding refusal.

Based on interview and record review, the facility did not ensure each resident was free from abuse and neglect. Specifically, for 1 out of 29 sampled residents, a resident was left in a sling unattended by staff and the same resident experienced staff yelling at them. Resident identifiers: 15 and 18.Findings included: Resident 15 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder, extrapyramidal and movement disorder, and dementia. 1. The facility reported to the State Survey Agency (SSA) on 8/7/25 at 8:00 PM, resident 15 was left in a Hoyer lift for approximately one hour after the Certified Nursing Assistant (CNA) became frustrated with resident 15. Resident 15's medical record was reviewed on 9/22/25 through 9/29/25. Resident 15's progress notes were reviewed and there were no progress notes regarding resident 15 being left in the lift. A care plan dated 11/8/23 and revised on 10/12/24, revealed resident 15 had an activity of daily living performance deficit related to cognitive impairment, impaired mobility, arthritis, schizophrenia, dementia, and anemia. One of the interventions included Transfers: Provide dependent assistance with two staff for Sit To Stand with transfers. According to the facility reported incident investigation, the incident was an improper transfer procedure. The description of the How Injury/Critical Incident Occurred revealed a CNA was preparing resident 15 for bed. The CNA got resident 15 in the hoyer lift and left her there for approximately an hour after getting frustrated with resident 15. The standard suspension process was started until the schedule was reviewed and the CNA had already put in her resignation and no additional shifts were completed. The five day investigation report provided to the SSA revealed resident 15 was in the sit-to-stand lift and a CNA heard resident 15 calling out for help. The CNA that left resident 15 in the lift unattended refused to talk to management about the incident and resigned immediately. The incident was not verified as abuse or neglect. The rationale was cut off on the final investigation.On 9/25/25 at 1:12 PM, an interview was conducted with CNA 4. CNA 4 stated when using a mechanical lift there needed to be two CNA's. CNA 4 stated a staff member should never leave a resident unattended in the mechanical lift but heard a CNA left a resident in a sit-to-stand lift. On 9/29/25 at 9:58 AM, an interview was conducted with resident 18. Resident 18 was resident 15's roommate at the time of the incident. Resident 18 stated the CNA left resident 15 alone in a lift because she got frustrated with resident 15. Resident 18 stated she noticed resident 15 was getting frustrated because the CNA was not using the lift correctly and it was hurting her. Resident 18 stated she noticed resident 15 was alone in the lift and she alerted other CNA's who came and attended to resident 15. On 9/29/25 at 10:03 AM, an interview was conducted with the CNA coordinator. The CNA coordinator stated there needed to be two staff when conducting a mechanical lift transfer. The CNA coordinator stated one CNA needed to be a spotter and the other to operate the lift. The CNA coordinator stated there was an incident with a CNA leaving a resident in a lift. The CNA coordinator stated resident 15 was placed in a hoyer lift above the bed. The CNA coordinator stated immediate education was provided to all staff since the incident. On 9/29/25 at 10:25 AM, a phone interview was conducted with Nursing Assistant (NA) 1. NA 1 stated she was in the dining room and another CNA stated the resident was upset with her. NA 1 stated resident 15 was left in the sit-to-stand lift. NA 1 stated there always needed to have two CNA's to transfer. NA 1 stated education was not provided after the incident. NA 1 stated resident 15 seemed stressed afterwards. The CNA coordinator provided education to the CNA's dated 5/21/24, which revealed Hoyer lifts must be operated by two or more trained staff members to minimize the risk of injury to both residents/patients and medical personnel. Additionally, if a Hoyer lift or sit to stand device were not being used immediately after a transfer, it should be returned to the designated storage area to ensure safety and accessibility for future use. On 9/29/25 at 1:49 PM, an interview was conducted with the Director of Nursing (DON). The DON stated all residents should have two staff members during transfers with mechanical lifts. The DON stated there was an incident reported to the SSA. The DON stated the CNA was educated on using the sit-to-stand with two staff members but failed to comply. The DON stated resident 15 was left alone in a lift for about an hour. The DON stated she was not part of the investigation so she did not know where the resident was left. The DON stated she would have substantiated the allegation as neglect. On 9/29/25 at 2:05 PM, an interview was conducted with the Administrator. The Administrator stated he was not sure why the allegation of resident 15 being left in the lift alone was not substantiated. The Administrator stated the previous Administrator did the investigation and he guessed it was because there were no signs and symptoms of psychological stress.2. The facility reported to the SSA on 9/2/25 at 11:22 AM, that on 8/30/25 at 6:50 PM, resident 15 requested toileting assistance and a CNA raised her voice at the resident, stated she was only required to provide toileting assistance every two hours and told resident 15 she was not a child. Another CNA witnessed the event. There was no documentation in resident 15's medical record. The facility investigation was reported to the SSA and concluded it was not verified. The previous Administrator completed the investigation. The reasoning why the allegation was not verified was cut off in the documentation provided.On 9/25/25 at 1:12 PM, an interview was conducted with CNA 4. CNA 4 stated she heard there was a verbal altercation between a staff member and resident but did not know any details because she was not working that day. On 9/29/25 at 1:49 PM, an interview was conducted with the DON. The DON stated she was not sure she was there for the abuse investigation into the verbal altercations. The DON stated the previous Administrator asked her to remove the CNA from the schedule and did not know the details. On 9/29/25 at 2:05 PM, an interview was conducted with the Administrator. The Administrator stated he was not sure why the allegation of verbal abuse to resident 15 was not substantiated. The Administrator stated the previous Administrator did the investigation and he guessed it was because there were no signs and symptoms of psychological stress.The facility Identifying Types of Abuse policy and procedure revised September 2025 was reviewed and revealed the following:Abuse of any kind against residents was strictly prohibited. Abuse prevention included recognizing and understanding the definitions and types of abuse. Abuse was defined as punishment with resulting physical harm, pain or mental anguish. Abuse also included the deprivation by an individual, including caretaker, of goods or services that were necessary to attain or maintain physical, mental, and psychosocial well-being. c. Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.5. Abuse toward a resident can occur from staff-to resident.Neglect/Deprivation of Goods and Services by staffNeglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish or emotional distress.Mental and Verbal AbuseVerbal abuse may be considered to be a type of mental abuse. Verbal abuse included the use of verbal or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples of mental and verbal abuse included harassing a resident; mocking, insulting, ridiculing and; yelling or hovering over a resident with the intent to intimidate.

Based on interview and record review, the facility did not ensure all alleged violations involving abuse or neglect were reported immediately, but not later than 24 hours if the events that caused the allegations did not involve abuse. Specifically, for 1 out of 29 sampled residents, the facility did not report within the timeframe when a resident was left in a sling unattended by staff and experienced staff yelling at them. Resident identifier: 15. Findings included:Resident 15 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder, extrapyramidal and movement disorder, and dementia. 1. The facility reported to the State Survey Agency (SSA) on 9/22/25 at 12:07 PM, that on 8/7/25 at 8:00 PM, resident 15 was left in a Hoyer lift for approximately one hour after the Certified Nursing Assistant (CNA) became frustrated with resident 15. 2. The facility reported to the SSA on 9/2/25 at 11:22 AM, that on 8/30/25 at 6:50 PM, resident 15 requested toileting assistance and a CNA raised her voice at the resident, stated she was only required to provide toileting assistance every two hours and told resident 15 she was not a child. Another CNA witnessed the event. On 9/29/25 at 1:49 PM, an interview was conducted with the Director of Nursing (DON). The DON stated there was an incident reported to the SSA regarding a CNA leaving resident 15 in a sit-to-stand lift unattended. The DON stated she was notified of the incident on 8/8/25, the morning after the incident. The DON stated she reported to the Administrator who was the abuse coordinator. The DON stated she did not know why it was not reported until 8/9/25. The DON stated she was not aware of why the allegation of verbal abuse was not reported to the SSA within 24 hours. On 9/29/25 at 2:05 PM, an interview was conducted with the Administrator. The Administrator stated there was documentation that the previous Administrator reported the incident with resident 15 being left in the sit-to-stand lift on 8/9/25 at 1:48 AM. The Administrator stated he reported the incident to the State again on 9/22/25, because the SSA did not have record of it being reported prior to 9/22/25. The Administrator stated the incident should have been reported within 24 hours. The Administrator stated the verbal altercation should have been reported within 24 hours.

Based on interview and record review, the facility did not provide the State Long-Term-Care Ombudsman notification when a resident was discharged from the facility. Specifically, for 1 out of 29 sampled residents, a resident left Against Medical Advice (AMA) and the ombudsman was not notified. Resident identifier: 35. Findings included:Resident 35 was admitted to the facility on [DATE] and discharged on 8/2/25 with diagnoses which included poly neuropathy, systolic heart failure, atrial fibrillation, and chronic kidney disease. Resident 35's medical record was reviewed on 9/22/25 through 9/29/25. A nursing progress note dated 8/1/25 at 2:22 PM, revealed, Resident stated that she is leaving AMA today. She stated that she is going to be going to the women's homeless shelter for a week or so in order to have their SSW [Social Service Worker] assist her in getting into low income housing. Resident was educated that [name of facility] could also help her with this, however she was determined to have the women's shelter help her. MD [Medical Doctor] was notified regarding residentv [sic] decision. She will be send [sic] with her scheduled medications and 14 day supply of her PRN [as needed] medications. Resident was also educated on the need to have another primary care provider in order to ensure that she can continue to receive her medications. Resident verbalized understanding. She stated she 'really needs to do this to get into an apartment'. DON [Director of Nursing] advised against it.A nursing progress note dated 8/2/25 at 8:30 PM, revealed Resident's family here with former resident to pick up resident belongings.The resident signed an AMA form on 8/1/25. On 9/24/25 at 1:17 PM, an interview was conducted with the Resident Advocate (RA). The RA stated she emailed the ombudsman when residents were discharged from the facility. The RA stated she was unable to find the email that the ombudsman was notified of the AMA discharge.

Based on observation, interview, and record review, the facility did not ensure that residents maintained acceptable parameters of nutritional status unless the resident's clinical condition demonstrated that this was not possible. Specifically, for 1 out of 29 sampled residents, a resident who had experienced a significant weight loss did not have recommendations from the Registered Dietitian (RD) implemented and the recommendations were not implemented in a timely manner. Resident identifier: 1.Findings included:Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, unspecified calorie protein malnutrition, adult failure to thrive, dysphagia, and anemia.On 9/22/25 at 12:22 PM, an observation was conducted. Resident 1 was observed in the dining room for lunch. Resident 1 was observed dropping his drinks on the floor and on his lap. There were no covers on the drinks. Resident 1 was also left with his feet up in his Geri chair for five minutes, before the Resident Advocate came to set resident 1 up for lunch.Resident 1's medical record was reviewed.On 7/10/25, resident 1 weighed 137.6 pounds (lbs). On 8/13/25, resident 1 weighed 128.2 lbs. Resident 1 had a 6.83% weight loss in approximately one month.On 9/22/25 at 11:24 AM, a Nutrition/Dietary Note documented Weight indicates significant weight loss. Loss is not clinically desired considering BMI [Body Mass Index] of 22.7. Loss is RT [related to] decreased PO [by mouth] intake. Diet texture was recently downgraded to puree. Hx [history] fortified diet. Medpass 60 ml [milliliters] BID [two times daily] is in place. He often accepts 240 ml BID. Magic Cup BID is also in place and he accepts this supplement. REC [recommendations]:1. document weight now 2. Change Medpass order to 180 ml QID [four times daily] 3. Evaluate efficacy of adding PO stimulant.It should be noted that the recommendation was added approximately a month after resident 1's significant weight loss.On 9/29/25 at 11:14 AM, an interview was conducted with the RD. The RD stated that she was in the facility once or twice a month. The RD stated the last weight on resident 1 was 8/13/25, because resident 1 refused weights. The RD stated if she made a recommendation to get a mid arm circumference (MAC) on a resident she would hope to see it if the resident agreed. The RD stated if a weight was obtained on 8/13/25, but entered later by staff, when the weight report was run she would not see that the resident had weight loss. The RD stated that either the weight for resident 1 was entered after she ran the report or she missed it.On 9/29/25 at 12:03 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the RD did not come to the facility often and when the RD did put in dietary recommendations she did not usually agree with the recommendations and had to discuss them with the Medical Director. The DON stated that resident 1 did not have an interest in eating. The DON stated the skin and weight meetings were held weekly and the Interdisciplinary Team attended those meetings. The DON stated that the RD did not attend the skin and weight meetings. The DON stated that resident 1 had been declining and was not doing well. The DON stated the staff had tried increasing resident 1's snacks and added a fortified diet. The DON stated that resident 1 refused to let the staff get a MAC.On 9/29/25 at 12:16 PM, a follow up interview was conducted with the RD. The RD stated resident 1's significant weight loss on 8/13/25, was missed.The facility policy Weight Assessment and Intervention was reviewed. Policy StatementResident weights are monitored for undesirable or unintended weight loss or gain.Policy Interpretation and ImplementationWeight Assessment1. Residents are weighed upon admission and at intervals established by the interdisciplinary team.2. Weights are recorded in each unit's weight record chart and in the individual's medical record.3. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation.a. If the weight is verified, nursing will notify the dietitian.4. Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time.5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight)/(usual weight) x 100]:a. 1 month - 5% weight loss is significant; greater than 5% is severe.b. 3 months -7.5% weight loss is significant; greater than 7.5% is severe.c. 6 months - 10% weight loss is significant; greater than 10% is severe.6. If the weight change is desirable, this is documented.Evaluation1. Undesirable weight change is evaluated by the treatment team whether or not the criteria for 'significant' weight change has been met. The evaluation includes:a. the resident's target weight range (including rationale if different from ideal body weight);b. the resident's calorie, protein, and other nutrient needs compared with the resident's current intake;c. the relationship between current medical condition or clinical situation and recent fluctuations in weight; andd. whether and to what extent weight stabilization or improvement can be anticipated.

Based on interview and record review, the facility did not obtain laboratory (lab) services to meet the needs of the residents. Specifically, for 1 out of 29 sampled residents, a resident that had a physician's order to collect a glycated hemoglobin (A1c) did not have the A1c completed. Resident identifier: 17.Findings included:Resident 17 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, type 2 diabetes mellitus with hyperglycemia, diabetic chronic kidney disease, and diabetic polyneuropathy.Resident 17's medical record was reviewed.On 8/13/25, a physician's order documented obtain A1c. one time only until 08/13/2025.The A1c lab was unable to be located.On 9/24/25 at 12:09 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility had a lab portal where they could get the lab results. The DON stated she would print the lab orders out and match them with the lab to make sure they were drawn. The DON stated that she had called the lab and they stated to her that they drew the A1c for resident 17 but they did not run the lab. The DON stated that she would print the individual lab orders to draw for the next lab day. The DON stated when the lab came to the facility they would look in the lab book for the orders for that day. The DON stated once the labs were in the portal she would print them and put them in the lab book. The DON stated once the Nurse Practitioner signed off on the labs she would put them in the basket to be uploaded to the resident medical record.

Based on interview and record review, the facility did not provide or obtain laboratory (lab) services only when ordered by a physician. Specifically, for 1 out of 29 sampled residents, a resident did not have a physician's order for an ammonia level, Complete Blood Count (CBC), and magnesium. Resident identifier: 15. Findings included: Resident 15 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included schizoaffective disorder, extrapyramidal and movement disorder, diabetes mellitus, pseudobulbar, generalized anxiety disorder, and dementia. Resident 15's medical record was reviewed on 9/22/25 through 9/59/25. An ammonia level was drawn on 7/7/25, a CBC was drawn on 7/9/25, and a Magnesium and CBC were drawn on 9/15/25. There were no physician's orders for the labs drawn. On 9/29/25 at 1:00 PM, an interview was conducted with the Director or Nursing (DON). The DON stated that all laboratory draws need to be ordered by the physician. The DON stated she did not know why there were no physician's orders for resident 15's laboratory values.

Based on observation, interview, and record review, the facility did not ensure each resident received food prepared in a form designed to meet individual needs. Specifically, for 1 out of 29 sampled residents, a resident with a physician order for thickened liquids was not provided the appropriate thickened liquids. Resident identifier: 15. Findings included: Resident 15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included schizoaffective disorder, extrapyramidal and movement disorder, pneumonia, dementia, and moderate oropharyngeal dysphagia. On 9/22/25 at 12:35 PM, an observation was made of resident 15 during the lunch meal. Resident 15 was observed to be fed by Certified Nursing Assistant (CNA) 2. CNA 2 was feeding resident 15 a pink frozen substance and resident 15 was coughing after each bite. Resident 15 was observed to have thickened milk and juice which were observed to have a nectar consistency and resident 15 was coughing after drinking the liquids. CNA 2 was interviewed and stated the pink frozen substance was a magic cup and was a thickened nutritional ice cream. CNA 2 stated resident 15's magic cup was thicker than her drinks. At 12:39 PM, resident 15 was coughing after a bite of the magic cup. CNA 2 stated it sounded bad girl and do your lungs hurt. Resident 15 stated yes. On 9/24/25 at 12:32 PM, an observation was made of resident 15 during the lunch meal. Resident 15 was observed coughing while she was drinking and eating. Resident 15 was observed to have a white thickened beverage and a red thin beverage. CNA 2 stated resident 15 had thickened milk and cranberry juice. CNA 2 stated the nurses, CNA's, and dietary staff were able to thicken beverages. CNA 2 stated they followed a chart on the back of the thickener to thicken beverages. CNA 2 stated resident 15 needed her liquids mildly thickened. CNA 2 picked up the cranberry juice which was in a mug and swirled it around. CNA 2 stated the cranberry juice was not thickened. On 9/24/25 at 12:35 PM, an interview was conducted with Dietary Aide (DA) 1. DA 1 stated he thickened beverages for residents who required thickened liquids. DA 1 stated he put three scoops of thickening powder into resident 15's cranberry juice. DA 1 stated it was full which was 550 milliliters or 18 ounces (oz) of cranberry juice. Resident 15's medical record was reviewed on 9/22/25 through 9/29/25. A diet order dated 7/22/25, revealed Fortified diet, Mechanical Soft texture, Honey consistency.An annual Minimum Data Set assessment dated [DATE], revealed that resident 15 did not have a swallow disorder. Resident 15 had a mechanically altered diet which included mechanically altered liquids. A care plan dated 11/16/23 and revised on 9/15/25, revealed resident 15 was at risk for malnutrition related to diabetes, dysphagia, poor cognition, impaired communication, psychotropic medications, diuretic use. Resident 15 was on a therapeutic diet with altered consistency and thickened liquids. Resident 15 was often adamant about refusing her diet. The goal was resident 15 would maintain adequate nutritional and hydrational status through the review date. Interventions included to Monitor/document/report as needed any signs and symptoms of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Other interventions included to provide and serve diet as ordered, supplements per order, diet texture per order, and encourage her to follow her diet/fluid orders, and educate her on the importance of following her orders. A Dysphagia Evaluation was conducted on 5/28/25, which revealed oral diet orders for pureed and moist, soft, easily formed bolus foods with honey thick liquids. On additional swallow following each/bite/sip for increased swallowing safety. Crush medications and place in yogurt/applesauce with no mixed consistencies. Ice chips or water per Speech Language Pathology (SLP). A physician's progress note dated 8/26/25, documented . Review of her recent course indicates that she previously demonstrated frustration and agitation regarding diet restrictions, specifically repeated requests for popcorn. These episodes were associated with yelling at staff when offered thickened liquids, and were documented earlier this month. Since that time, supportive redirection and substitution with safer snacks such as Pirate Booty have helped reduce fixation and agitation around food. Staff report that these behaviors have improved overall, and she has been more redirectable.On 9/25/25 at 8:08 AM, an observation and interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated resident 15 had aspiration pneumonia and was on antibiotics. LPN 1 stated resident 15 was ordered honey thickened liquids about one to two months ago. LPN 1 was observed to ask the CNA Coordinator to get her thickened juice from the kitchen for resident 15's medication administration. LPN 1 was observed to have whole pills for resident 15. It should be noted that the Dysphagia Evaluation on 5/28/25, recommended resident 15 have her medications crushed in yogurt or applesauce. An interview was immediately conducted with the CNA Coordinator who stated the kitchen staff thickened the liquids according to the resident care plan. The CNA Coordinator stated there was a label on the thickener that was a guide to thicken the liquids. Resident 15 was observed to tell LPN 1 that she did not like the thickened and that she did not want the thickened. Resident 15 was observed to throw the cup with thickened liquids. A follow up interview was immediately conducted with the CNA Coordinator who stated if a resident did not want thickened liquids then the resident was provided education on the risk and benefits and staff continued to provide the liquids as ordered. The CNA Coordinator stated resident 15 freaked out when she was served food and beverages she did not like. On 9/25/25 at 8:28 AM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 15 had cognitive impairment and mental illness with behaviors. The DON stated staff encouraged thickened liquids with resident 15 but she was non compliant at times. The DON stated the kitchen staff thickened the liquids. The DON stated resident 15 had a Barium Swallow Study completed and was provided SLP services. On 9/25/25 at 8:28 AM, an interview was conducted with the Dietary Manager (DM). The DM stated resident 15 was the only resident with thickened liquids. The DM stated resident 15 required honey thick liquids which were thickened by the kitchen staff. The DM stated if residents were not provided the correct thickened liquids, the liquids could go into their lungs and they could choke. On 9/25/25 at 8:30 AM, an interview was conducted with CNA 3. CNA 3 stated nurses and dietary staff thickened liquids. CNA 3 stated resident 15 required honey thickened liquids. CNA 3 stated if a resident was not served thickened liquids, then she would remove the liquids. CNA 3 stated resident 15 hated thickened liquids so she provided education to resident 15 about how it was safe for her and she understood the education. On 9/25/25 at 8:34 AM, an interview was conducted with the Assistant Dietary Manager. The Assistant Dietary Manager stated she was learning how to thicken and looked at the manufacturer instructions on the container. The Assistant Dietary Manager stated resident 15 required thickened liquids and she thickened to the moderate/mild thick. The Assistant Dietary Manager stated the CNAs asked the residents what drinks they want, then the kitchen staff thickened the beverage. The Assistant Dietary Manager stated sometimes juice did not thicken like it should and needed to be modified and she used her best judgement when thickening beverages. On 9/25/25 at 12:50 PM, an observation was made of the thickener and the scoop. For a International Dysphagia Diet Standard Initiative level 3 Moderately thick honey-like for 3 cups (24 oz) of water, coffee, and clear juices 2 1/2 cups should be used. The scoop had 1 tablespoon and the other side was 3/4 teaspoon.It should be noted resident 15's cranberry juice was 18 oz or 2 1/4 cup with 3 tablespoons of thickener.On 9/25/25 at 1:33 PM, a follow-up interview was conducted with the DON and the Regional Nurse Consultant (RNC). The DON stated resident 15 needed to have honey thick. The DON stated resident 15 was sent to the hospital and diagnosed with aspiration pneumonia. The DON stated staff tried to have resident 15 sit up when eating. The DON and RNC stated they did the training yesterday regarding thickening liquids. The RNC stated there was a standard order for residents to have their medications crushed if they needed it and there was not a specific order for resident 15 to have her medications crushed.

Based on interview and record review it was determined, for 1 out of 13 sampled residents, that the facility failed to ensure that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, staff were not monitoring oxygen levels for a resident who had a diagnosis of pneumonia. Resident identifier: 1. Findings include 1. Resident 1 was admitted to the facility on [DATE] with diagnoses which included aneurysm, hypertensive heart disease, heart failure, moderate protein-calorie, gout, obstructive and reflux uropathy, muscle weakness, unsteadiness on feet, obstructive sleep apnea, urinary tract infection, prediabetes, and dysphagia. On 10/22/24 resident 1's medical record was reviewed. On 8/15/24 at 11:40 am a Nurses Note documented that resident 1 was sent to the hospital due to a blocked nasogastric (NG) tube. On 8/15/24 at 7:00 pm a Nurses Note documented that resident 1 had returned from the hospital with a diagnosis of pneumonia. An order of Amoxicillin-Pot Clavulanate Tablet 875 -125 milligrams (mg) twice a day for ten days was placed. Resident 1's orders were reviewed. Resident 1 had an order that stated, O2 [oxygen] per nc [nasal cannula] @ 2L/min [Liters per minute] PRN [as needed]. Goal to maintain Sats > 90%. Resident 1's care plan was reviewed. A care plan was initiated on 8/7/24 and revised on 8/27/24 documented, [resident 1] has altered respiratory status rt [related to] OSA [obstructive sleep apnea], pleural effusion, and PE [pulmonary embolism]. The interventions included, Monitor for s/sx [signs and symptoms] of respiratory distress and report to MD [medical direction] PRN: Increased Respirations; Decreased Pulse oximetry; Increased heart rate (Tachycardia); Restlessness; Diaphoresis; Headaches; Lethargy; Confusion . Resident 1's vitals were reviewed. Resident 1's medical record revealed that staff did not record oxygen saturation levels (O2 stats) 8/16/24, 8/17/24, 8/18/24, 8/20/24. On 10/23/24 an interview with the Director of Nursing (DON) was conducted. The DON explained that the Certified Nursing Assistants (CNAs) check and record the resident's vitals on a vital sheet, then give the vital sheet to the nurses to review and record in the electronic medical record. The nurses turn in the vitals sheet to the DON to be reviewed then shredded. The DON stated that she could not find the missing O2 stats for resident 1. The DON indicated that the facility would change the process to ensure that all vitals were recorded properly into the resident's medical record.

Based on observation, interview, and record review it was determined, for 10 out of 40 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident was transported via the facility van and the wheelchair was not secured properly inside the vehicle which resulted in the resident falling backwards causing hyperextension of his neck. The resident was diagnosed with central cord syndrome and edema at the level of C6 and C7 of his cervical spine. Upon return to the facility the resident's cervical collar was removed by Certified Nursing Assistant(s) (CNA) during grooming and bathing cares. After the resident's shower, the CNAs attempted to transfer the resident to bed unsuccessfully and the resident was assisted to the floor. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. Additionally, a resident sustained four falls in the facility with the last one resulting in a fractured hip; a resident tripped over the broken base of a structural column outside the facility and sustained a laceration requiring sutures; and a resident had an unsafe discharge to the community, was found wandering the streets and was subsequently placed on a medical hold in the hospital. These identified deficient practices were found to have occurred at a Harm Level. Lastly, two residents eloped from the facility; a resident struck another resident with a razor cutting them and was not monitored or restricted from further sharp objects after the incident; a resident was provided a germicidal cleaning wipe by another resident and used it to blow and clean their nose; and a resident was hit by the meal cart during delivery service of the meals. Resident identifiers: 3, 6, 19, 31, 34, 91, 92, 93, 94, and 96. NOTICE On [DATE] at 4:00 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to identify hazard(s) and risk(s): evaluate and analyze the hazard(s) and risk(s); implement interventions to reduce hazard(s) and risk(s); and monitor for effectiveness and modify the interventions when necessary. Specifically, the facility failed to ensure that staff transporting residents and their equipment were trained on how to secure residents properly to prevent falls or injury; that residents with medical devices or fixtures surgically placed, or otherwise applied to, or adjacent to their person were reviewed to validate monitoring orders, care planning, and appropriate staff training were in place; and that resident's mobility and transfer status including type of transfers and number of staff to perform were assessed and care planned. Notice of the IJ was given verbally and in writing to the Chief Nursing Officer (CNO), Regional [NAME] President (RVP), Administrator (ADM), Administrator in Training (AIT), Director of Nursing (DON), and the Corporate Resource Nurse (CRN) and they were informed of the findings of IJ pertaining to F689 for resident 96. On [DATE], the Administrator provided the following revised abatement plan for the removal of the Immediate Jeopardy effective [DATE] at 11:59 PM. F689/F726: Free of Accident/Hazards & Competent Nursing Staff. Resident #96 is no longer a resident of this facility; therefore, an individualized plan of action is not possible. The Certified Nursing Assistant Coordinator's employment with the facility was self-terminated on [DATE]. The Director of Nursing who was at the facility in [DATE] is no longer an employee of this facility. Abatement Plan. Accident/Hazards Prevention The Director of Nursing/Designee to do an audit of all residents on [DATE] to identify residents with medical devices or fixtures surgically placed, or otherwise applied to, or adjacent to their person. Identified devices reviewed to validate monitoring orders, care planning, and appropriate staff training are in place. The Director of Rehab/Designee to complete an assessment of all resident's transfer status, including type of transfer and number of staff to perform safely. Care Plans Reviewed and Updated as indicated to reflect current needs. The Director of Nursing/Designee to provide training on safe transfers and accident/hazards prevention to Facility Nurses and Nursing Assistants on [DATE]. Training to include proper transfer techniques utilized in the facility, the prohibition of using towel transfers, and where to find information in the care plan regarding individualized requirements for transfers. This training will be validated by a post-test to validate understanding of the material and Physical Therapist to complete return demonstration of transfer techniques with staff. The Director of Nursing to provide training on [DATE] to all Facility Nurses and Nursing Assistants on the definition of a fall and what documentation must be completed when a fall occurs. This training will be validated by a post-test to validate understanding of the material. Transportation The Administrator reviewed all individuals who perform transport duties and validated they have received training including securement of wheelchairs, securement of ambulatory residents, and securement of equipment in the transport van. A return demonstration checklist will be completed with transportation staff prior to their next transport. Any future staff member(s) providing transport services are to receive this training prior to beginning transport duties. Existing drivers to receive refresher training annually and as needed. Staffing Training/Orientation The Chief Nursing Officer (CNO)/designee will provide education to the Inter-disciplinary team (IDT) on [DATE] about company policy on orientation and training to staff who provide direct patient care to residents of the facility and how to properly transfer residents. The Director of Nursing/Designee to review employees who have been hired in the past three months to verify orientation training has been completed on [DATE]. Any employee who does not have the orientation completed will meet with the Director of Nursing/Designee prior to the start of their next shift to create a plan to complete their training and review key interventions to keep residents safe. Agency The Director of Nursing/Designee to create a summary of this training and put this in the agency binder, to provide agency staff resources to prevent accident/hazards. Training Timeline All Staff will receive training by Director of Nursing/Designee prior to their next working shift. Monitoring The Director of Nursing/Designee to do interview with Charge Nurse(s) for each shift and review expectations for accident/hazards prevention and reporting until the IJ abatement is completed. The facility to review the 24-hour report in daily (M-F) stand-up meetings, and as needed to validate that any accidents/hazards were followed up with in accordance with professional accepted standards of care. This audit to continue ongoing. On [DATE], while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on [DATE]. Findings included: IMMEDIATE JEOPARDY 1. Resident 96 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included central cord syndrome at C6, acute respiratory failure, type II diabetes mellitus, polyneuropathy, hepatic failure, pneumonia, lack of coordination, reduced mobility, muscle weakness, dysphagia, contusion of right wrist, cervicalgia, Parkinson's Disease, dementia, pressure ulcer of sacrum, atrial fibrillation, chronic kidney disease, hypertension and hyperlipidemia. On [DATE], resident 96's Admission Assessment documented that resident 96 required extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. The assessment documented that resident 96 was alert and oriented to person and situation, had poor memory and could not recall place and time. Resident 96 was assessed as requiring extensive assistance for locomotion on and off the unit and a wheelchair was used as a mobility device. On [DATE], the Morse fall scale documented a score of 65, which would indicate high risk for falls. The assessment documented that resident 96 had fallen before. The assessment documented that resident 96's gait was weak and he overestimated or forgets his limits with his ability to ambulate safely. On [DATE], resident 96's Minimum Data Set (MDS) Assessment documented that resident 96 required a one-person extensive assist for bed mobility, transfers, and toilet use. The assessment documented a Brief Interview for Mental Status (BIMS) score of 3, which would indicate a severe cognitive impairment. On [DATE] at 4:40 PM, an order for C-Collar to be worn AT ALL TIMES, please check to make sure that collar is on resident was initiated for resident 96. The order indicated that it was indefinite with no end date. The [DATE] Treatment Administration Record (TAR) revealed the order for the C-collar to be worn AT ALL TIMES. The order was discontinued on [DATE]. The November and [DATE] TAR did not have any orders monitoring for the c-collar. Resident 96's progress notes and incident reports revealed the following: a. On [DATE] at 1:53 PM, the Incident Note documented, I received a phone call today from the CNA [Certified Nurse Assistant] Coordinator, who was providing transportation for this resident to an appointment at the [name of hospital omitted], the CNA Coordinator stated that when coming to a stop, the wheelchair became dislodged and tipped backwards, CNA Coordinator immediately stopped vehicle and called for assistance from EMS [emergency medical services], the Administrator and I arrived at the scene at about 14:20 [1:20 PM], the resident was complaining of head and neck pain, EMS was treating him, the police officer and the EMS workers all stated that the resident was still strapped into the wheelchair with the seatbelts (EMS reported that there was tension in the belts still), resident was transferred via EMS to [local area hospital] for evaluation, provider notified, family notified. On [DATE] at 1:53 PM, the incident report further documented that resident 96 was very agitated, clutching his head while leaned over, unable to provide description of what occurred (resident has dementia). Resident 96 Pain Assessment in Advanced Dementia (PAINAD) score was assessed as a 9, which would indicate severe pain. The report documented that resident 96 required extensive assistance with transfers. The report further documented, resident possibly secured improperly, improper instruction given to CNA Coordinator about how to strap patient down properly in wheelchair. b. On [DATE] at 6:16 PM, the Incident Note documented, I have called [local hospital] for update: no fractures, some weakness on left side, they will do MRI [Magnetic Resonance Imaging] to rule out any damage to brain, they will call and update me when information is available. I called family of resident to update them on situation. They will continue to await any call on an update on his condition. c. On [DATE] at 10:23 PM, the Nurses Note documented, Hospital called facility and stating they are going to admit him and continue to monitor overnight. d. On [DATE] at 1:04 PM, the Nurses Note documented, Central cord syndrome found on MRI, resident currently in ICU [Intensive Care Unit] r/t [related to] he was having a difficult time maintaining his blood pressure, he is currently not on any supplemental blood pressure medication and the nurse stated that he will soon be ready to transfer either to a step down unit or back to facility, I gave them my name and phone number as a contact for [resident 96], will call again tomorrow for a new update. e. On [DATE] at 4:26 PM, the MDS Note documented, [Resident 96] readmitted from hospital on [DATE] on Medicare part A services with dx [diagnosis] of central cord syndrome at C6 level. f. On [DATE] at 9:26 AM, the Incident Note documented, Investigation completed. Facility will be completing training on all drivers and 2 sets of trained eyes will verify proper strap placement on transports. Interventions put in place. MD [Medical Director] to follow up. g. On [DATE] at 8:44 AM, the Nurses Note documented, Resident had episode of syncope this morning, NP [Nurse Practitioner] orders vital signs to be taken BID [two times a day]. It should be noted that no other documentation could be found for the syncopal episode. h. On [DATE] at 5:37 AM, the Incident Note documented, Resident was up in chair in dining room for dinner, CNA noticed and reported to nurse that resident did not look well. VS [vital signs]: BP [blood pressure]:,d+[DATE], P [pulse]: 62, o2[oxygen saturation]: 74%, R [right] pupil enlarged, L [left] pupil smaller, A&O [alert and oriented] x1. CNA transferred resident to bed, Nurse administered oxygen at 3L [liters], and raised head of bed. Vitals taken every 10 min [minutes] until stable and o2 at 85%. Nurse informed MD and DON, per MD, transfer to hospital. EMT [Emergency Medical Technician] arrived at 1900 [7:00 PM] and transferred resident to [local hospital]. DON notified family. On [DATE] at 5:37 AM, the incident note further documented that the predisposing physiological factors were drowsy, hypotensive, recent change in condition, and weakness/fainted. i. On [DATE] at 11:13 AM, the Nurses Note documented, I spoke to nurse at [local hospital] today. Resident is on diltalazem (sic) drip, insulin drip. He is normo-tensive. Now on 13L high flow oxygen, lung sounds are diminished. No discharge date set yet. I informed provider and family. j. On [DATE] at 1:44 PM, the incident report documented, resident was about to slide out of his chair. so the nurse tried to help him up but he slid down more and more and the nurse assisted him to the floor and asked for more help to assist him back to the chair. no apparent injury, no head hitting. He denied of pain. The report documented that the therapy staff assisted the resident back to the chair and 4 staff members were needed for the transfer. k. On [DATE] at 9:37 AM, the Interdisciplinary Team (IDT) Event Review documented, IDT fall review: root cause is found to be this resident's change in condition after accident that resulted in central cord syndrome, intervention: new wheelchair is in process of being purchased, resident will also be moved to room [ROOM NUMBER] to be closer to nurse station, current wheelchair has been modified by physical therapy to help prevent further falls, all other least restrictive interventions in place, will continue with plan of care. Attendees: Administrator DON MDS Nurse Office Manager l. On [DATE] at 10:00 AM, the IDT Event Review documented, Follow up [DATE] incident: [Resident 96] has been moved to room [ROOM NUMBER] for increased monitoring. Therapy is getting tilt-in-space wheelchair. m. On [DATE] at 3:20 PM, the Nurses Note documented, MD in to visit per MD if we don't already have a end date neck brace lets do end date to come off after 12 weeks x-ray cervical spine 2 view 1 week prior to that. n. On [DATE] at 5:14 PM, the Nurses Note documented, Resident had hair cut today, then shower this afternoon. Within minutes after laying him back down he stopped breathing. The nurses performed assessment on him, he had no pulse and was not breathing. DNR [Do Not Resuscitate]. Family notified, MD notified. On [DATE], the Hospital History & Physical documented the chief complaint as a fall. An MRI of the cervical spine documented the impression as Focal edema within the spinal cord at and below the level of the C6/C7 disc space which may be secondary to contusion from adjacent osteophytes at C6/C7. The MRI further documented, Diffuse edema within the paravertebral soft issue from the occiput through the craniocervical junction and a Small amount of fluid in the C6/C7 disc space. Findings could be secondary to hyperextension injury. The Medical Decision Making documented that the MRI revealed a central cord syndrome with cord edema at C,d+[DATE] level secondary to adjacent osteophytes. The resident was admitted to ICU so that the mean arterial pressure could be monitored and kept at greater than 85 millimeters of mercury (mmHg). The resident was transitioned from a hard collar into an Aspen collar. The assessment documented that the resident suffered a hyperextension injury of the C-spine when he toppled in his wheelchair in a transport vehicle, and this resulted in central cord syndrome involving C6/C7. On [DATE], the Hospital Discharge Summary documented that resident 96 was to follow-up with a neurosurgeon in four weeks with a repeat CT of the cervical spine. On [DATE], the Record of Death documented that resident 96 had expired. Resident 96's Care Plans revealed the following: a. A care area for central cord syndrome r/t trauma related to motor vehicle incident that was initiated on [DATE]. The interventions identified included: Discuss with resident/resident and family any concerns, fears, issues regarding diagnosis or treatments; Ensure that c-collar is in place every shift; Give medications as ordered. Monitor/document for side effects and effectiveness; and Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST) to evaluate and treat as ordered. b. A care area for Activities of Daily Living (ADL) selfcare performance deficit r/t Confusion, Dementia, Fatigue, Impaired balance, BUE [bilateral upper extremity] tremors, recent motor vehicle incident with injury to neck and right wrist, pain. The interventions identified included: Resident has a neck brace and right wrist restriction due to pain and injury, use caution and assist with ADLs; scheduled every 2 hour turning to keep resident off of his tailbone (coccyx); Adjust ADL assistance per level of need at time of care; The resident required substantial/maximum assistance of 1 staff for bathing/showering, bed mobility, dressing, personal hygiene, and toileting; The resident required substantial/maximum assistance of 1 staff for 1:1 dining assistance and the resident was at risk for choking and aspiration; The resident required substantial/maximum assistance of 2 staff for transfers; and PT/OT evaluation and treatment as per MD orders. On [DATE] at 1:50 PM, the facility investigation documented that the resident was involved in an accident while being transported in the facility van. The initial report documented that the resident fell back in the transport vehicle on his way to an appointment. The facility's final investigation documented that the resident outcome to the incident was a Central Cord Syndrome injury. At the time of injury, the resident reported some pain but was unable to state what happened in the van. The summary of interviews documented that Nurse Assistant (NA) 2 had reported that he had wheeled the resident out to the transport vehicle where the CNA Coordinator (CNAC) strapped the patient in with all four straps and seat belt. NA 2 stated that he had never done anything with transportation prior. The summary of interviews documented that the CNAC stated that when she came to a stop and looked back, she saw that the resident was no longer sitting upright. The CNAC stated that she came to a stop, turned on her hazards, exited the vehicle, and waved down help. The CNAC stated that she put down the ramp with the patient. The CNAC stated that she did not receive training on how to use the van prior to transporting resident 96. The investigation documented under the summary that the CNAC was scheduled to be trained to assist in covering for the normal transport driver. The day the CNAC was scheduled to be trained she was sent home due to having COVID. The Previous Transport Driver (PTD) confirmed that the CNAC had participated in a previous transport by watching and sitting at an appointment with a patient. The report documented that the CNAC had placed the safety straps on the wheelchair wheels and not the wheelchair frame. The report documented that they assumed that the patient pushed on the [NAME] in front of him and tipped backward as a result of the strap placement. The conclusion of the facility investigation documented that the incident was a result of improper placement of safety straps on the wheelchair wheels and not the wheelchair frames. The root cause identified was insufficient training in transportation. The facility provided a driving in-service on [DATE]. On [DATE] at 2:37 PM, an interview was conducted with the CNAC. The CNAC stated that she was the driver of the vehicle at the time of the accident with resident 96. The CNAC stated that she had only transported for the facility twice, and once with resident 96. The CNAC stated that she had not been given training on how to transport residents, had never ridden with another driver, and was not shown how to properly secure someone down inside the van. The CNAC stated that she secured resident 96's wheelchair wheels down with the straps and placed the seatbelt over resident 96. The CNAC stated that she thought she had secured resident 96 correctly. The CNAC stated that she placed the straps from the floor of the van and hooked them to the wheels of the wheelchair on both sides, four straps in total. The CNAC stated that she did not connect the straps to the frame of the wheelchair. The CNAC stated that she was told after the accident that this was not how it was supposed to be done. The CNAC stated that she checked the resident in the rearview mirror during the transport and talked to him. The CNAC stated that she had just made it to the freeway entrance when she looked back and noticed that resident 96 had fallen backwards. He was folded in half like a taco. The CNAC stated that she pulled over and stopped the vehicle. The CNAC stated that she found resident 96 folded up against the drop gate. The CNAC stated that before she let the drop gate down, she removed her hoodie and placed it under resident 96's neck to support it. The CNAC stated that resident 96's legs were positioned up towards his chest and torso, and his head was folded down towards his chest. The CNAC stated that as she lowered the gate, she placed her hoodie for support so his neck would not hyperextend. The CNAC stated that resident 96 was able to answer questions, and said his head hurt. The CNAC stated that resident 96 had a small scrap on the back right side of his head from contact with the drop gate. The CNAC stated that when EMS arrived, they moved resident 96 without placing a c-collar on the resident first. The CNAC stated that EMS undid the seatbelt, moved the chair to a seated position, and backed him out of the van. The CNAC stated that resident 96 began to convulse, and he had no history of a seizure disorder prior. The CNAC stated that the ADM and Previous Director of Nursing (PDON) arrived at the scene and started drilling her. The CNAC stated that she was suspended for abuse and returned to work 5 days later. The CNAC stated that the facility substantiated the allegation of abuse, and that the facility was at cause because she had never received proper training. The CNAC stated that the next day they started training everyone in the facility on how to transport someone. The CNAC stated that she refused to sign the in-service training log because the training was conducted during her suspension period. The CNAC stated that she was suspended on Sunday and the incident occurred on Friday. The CNAC stated that she worked remotely on Saturday and Sunday and then she was on suspension for a week. The CNAC stated that resident 96 had returned to the facility and she had told the PDON that she was uncomfortable working with resident 96 again. The CNAC stated that she did not want to lose her license. The CNAC stated that resident 96's family had come to the facility and said they were upset that she was still working at the facility. The CNAC stated that she did not mind training the staff on how to care for resident 96. The CNAC stated that she showed staff from a distance how to clean the c-collar, and how to safely transfer resident 96. The CNAC stated that for resident 96 they could not use a hoyer lift for transfers because this was contraindicated with a spinal cord injury. The CNAC stated that she did not participate in resident 96 care for quite some time after the incident. The CNAC stated she had noticed before resident 96 passed away he was unkept, his beard and nails were long. The CNAC stated that she clipped his nails and then asked the PDON if the hair school could give him a haircut. The CNAC stated that the PDON stated it was safe to remove the c-collar for care. The CNAC stated that she thought the resident was going to have his c-collar removed the following day at a scheduled doctor's appointment. It should be noted that the transportation schedule did not document that resident 96 was scheduled for any appointments on [DATE], which would have been the following day. The CNAC stated that she was never asked not to have contact with resident 96, that it was a personal preference. The CNAC stated that resident 96 passed away that day, and he was not on hospice and it was not expected. The CNAC stated that she assisted resident 96 during his hair cut. The CNAC stated that resident 96's c-collar was removed for the haircut, and she held his head still, with no sudden movements and no flexion or extension of the neck. The CNAC stated that NA 3 and NA 5 had assisted resident 96 with a shower. The CNAC stated that she believed resident 96's c-collar was removed for the shower under the direction of the PDON. The CNAC stated that NA 3 and NA 5 were both new aides that time. The CNAC stated that the PDON called her at approximately 5:15 PM, on the day that resident 96 received his haircut and shower and was told that resident 96 had just passed away. On [DATE] at 8:38 AM, an interview was conducted with the DON. The DON stated that if a resident had a c-collar applied she would expect to see an order for it and monitoring. The DON stated that documentation of the monitoring could be in the TAR or in a progress note. The DON confirmed that the October TAR documented that the c-collar order was discontinued on [DATE]. The DON stated that she would interpret the nurse note on [DATE] as discontinue the c-collar in 12 weeks from [DATE]. On [DATE] at 2:12 PM, a follow-up interview was conducted with the DON. The DON stated that the order for the c-collar should not have been discontinued and the c-collar was to stay on at all times. The DON stated that the PDON stated that the c-collar had stayed on resident 96 up until his death. The DON stated that if you had a spinal injury, it might be necessary to have the c-collar at all times, and it would stabilize the neck. The DON stated that the provider should supervise any removal of the collar. The DON stated that if the c-collar was removed it would be possible to re-injury the injury you were trying to fix. On [DATE] at 2:22 PM, an interview was conducted with NA 3. NA 3 stated that she had provided care for resident 96. NA 3 stated that she was not sure why resident 96 wore a neck brace. NA 3 stated that she showered resident 96 one time with the assistance of the CNAC on the day that he passed away. The shower was provided in the communal shower room. NA 3 stated that the residents were doing their monthly haircuts and resident 96 had a haircut and his beard shaved. NA 3 stated that afterwards she informed the CNAC that it was resident 96's scheduled shower day. NA 3 stated that this was the first time she had provided resident 96 with a shower, and the CNAC said since resident 96 was already up she would assist NA 3 with the shower. NA 3 stated that they washed resident 96's hair, beard, chest, and feet. NA 3 stated that while they were performing the shower resident 96 was having a bowel movement. NA 3 stated that the CNAC told her that when resident 96 received a shower they took his c-collar off, and that the CNAC was the person who removed the collar. NA 3 stated that the CNAC was helping her with the shower by holding the shower head and rinsing resident 96 off. NA 3 stated that she was washing resident 96 while the CNAC was holding the shower head. NA 3 stated that she washed resident 96's chest and neck. NA 3 stated that resident 96 was sitting in a shower chair during the shower. NA 3 stated that they washed the front, sides and back of resident 96's neck. NA 3 stated that while the CNAC was holding the shower head she was guiding NA 3, saying that as long as she was washing the neck gently and the neck and spine were aligned it would be okay. NA 3 stated that they made sure that resident 96 was not moving around. NA 3 stated that NA 5, PDON and the CNAC were all present during resident 96's shower. NA 3 stated that she was training NA 5 and asked the CNAC how to shower resident 96. NA 3 stated that the CNAC had the PDON come assist with transferring resident 96 onto and then off the shower chair. NA 3 stated that once resident 96 was transferred only she, NA 5 and the CNAC were present. NA 3 stated that she did not recall if the PDON was present when they removed the neck collar. NA 3 stated that at that point in time she had only worked at the facility for ,d+[DATE] months, and she was training NA 5. NA 3 stated that NA 5 only observed during the shower. NA 3 stated that resident 96 wore his c-collar during the transfers and it was only removed during the shower. NA 3 stated that resident 96 was good at sitting up straight, and he was not leaning. NA 3 stated that no one was holding or stabilizing resident 96's head once the c-collar was removed, and the c-collar was off for approximately 20 minutes for the duration of the shower. NA 3 stated that the CNAC switched positions, and she held the shower head while the CNAC washed resident 96's genitals. NA 3 stated resident 96 did not have to shift positions to have his genitals cleaned as the shower chair had a hole in the seat. NA 3 stated that she asked the CNAC how to put the neck brace back on, and the CNAC placed the c-collar back on resident 96. NA 3 stated that the c-collar had two parts to it, a front and a back. NA 3 stated that the CNAC first placed the front on to make sure the neck was visible, and the sides were placed near his collar bones. NA 3 stated that the back piece had two Velcro tabs that strapped around to the front to make sure it stayed in place. NA 3 stated that she asked the CNAC how she knew the difference between the back and the front piece, and she told her that the back piece should be longer than the front. NA 3 stated that the c-collar was solid and did not have a whole in the front piece to visualize the neck. NA 3 stated that she could not tell the difference between the front and back piece, had never worked with a neck brace before, and wanted to know what to do if she came across it again. NA 3 stated that she did not confirm with the nurse prior to removing the neck brace. NA 3 stated that the CNAC said that they would just quickly give him a shower without it. NA 3 stated that after they reapplied the neck brace, they put a hospital gown on resident 96. NA 3 stated that the CNAC and PDON transferred resident 96 from the shower chair onto the wheelchair and the CNAC told her to put him back into bed. NA 3 stated that she and NA 5 took resident 96 back to his room. NA 3 stated that they tried to transfer resident 96 back to bed, but they could not physically do it. NA 3 stated that she and NA 5 attempted to do the same transfer method as the PDON and CNAC, [TRUNCATED]

Based on interview and record review it was determined, for 1 out of 40 sampled residents, that the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, a resident was transported via the facility van and the wheelchair was not secured properly inside the vehicle which resulted in the resident falling backwards causing hyperextension of his neck. The resident was diagnosed with central cord syndrome and edema at the level of C6 and C7 of his cervical spine. Upon return to the facility the resident's cervical collar was removed by Certified Nursing Assistant(s) (CNA) during grooming and bathing cares. After the resident's shower, the CNAs attempted to transfer the resident to bed unsuccessfully and the resident was assisted to the floor. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. Additionally, staff reported that orientation training to newly hired Nurse Assistants and Certified Nurse Assistants was not performed and Nurse Assistants were in charge of training new hires. Resident identifier: 96. NOTICE On [DATE] at 4:00 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to identify hazard(s) and risk(s): evaluate and analyze the hazard(s) and risk(s); implement interventions to reduce hazard(s) and risk(s); and monitor for effectiveness and modify the interventions when necessary. Specifically, the facility failed to ensure that staff transporting residents and their equipment were trained on how to secure residents properly to prevent falls or injury; that residents with medical devices or fixtures surgically placed, or otherwise applied to, or adjacent to their person were reviewed to validate monitoring orders, care planning, and appropriate staff training were in place; and that resident's mobility and transfer status including type of transfers and number of staff to perform were assessed and care planned. Notice of the IJ was given verbally and in writing to the Chief Nursing Officer (CNO), Regional [NAME] President (RVP), Administrator (ADM), Administrator in Training (AIT), Director of Nursing (DON), and the Corporate Resource Nurse (CRN) and they were informed of the findings of IJ pertaining to F726 for resident 96. On [DATE], the Administrator provided the following revised abatement plan for the removal of the Immediate Jeopardy effective [DATE] at 11:59 PM. F689/F726: Free of Accident/Hazards & Competent Nursing Staff. Resident #96 is no longer a resident of this facility; therefore, an individualized plan of action is not possible. The Certified Nursing Assistant Coordinator's employment with the facility was self-terminated on [DATE]. The Director of Nursing who was at the facility in [DATE] is no longer an employee of this facility. Abatement Plan. Accident/Hazards Prevention The Director of Nursing/Designee to do an audit of all residents on [DATE] to identify residents with medical devices or fixtures surgically placed, or otherwise applied to, or adjacent to their person. Identified devices reviewed to validate monitoring orders, care planning, and appropriate staff training are in place. The Director of Rehab/Designee to complete an assessment of all resident's transfer status, including type of transfer and number of staff to perform safely. Care Plans Reviewed and Updated as indicated to reflect current needs. The Director of Nursing/Designee to provide training on safe transfers and accident/hazards prevention to Facility Nurses and Nursing Assistants on [DATE]. Training to include proper transfer techniques utilized in the facility, the prohibition of using towel transfers, and where to find information in the care plan regarding individualized requirements for transfers. This training will be validated by a post-test to validate understanding of the material and Physical Therapist to complete return demonstration of transfer techniques with staff. The Director of Nursing to provide training on [DATE] to all Facility Nurses and Nursing Assistants on the definition of a fall and what documentation must be completed when a fall occurs. This training will be validated by a post-test to validate understanding of the material. Transportation The Administrator reviewed all individuals who perform transport duties and validated they have received training including securement of wheelchairs, securement of ambulatory residents, and securement of equipment in the transport van. A return demonstration checklist will be completed with transportation staff prior to their next transport. Any future staff member(s) providing transport services are to receive this training prior to beginning transport duties. Existing drivers to receive refresher training annually and as needed. Staffing Training/Orientation The Chief Nursing Officer (CNO)/designee will provide education to the Inter-disciplinary team (IDT) on [DATE] about company policy on orientation and training to staff who provide direct patient care to residents of the facility and how to properly transfer residents. The Director of Nursing/Designee to review employees who have been hired in the past three months to verify orientation training has been completed on [DATE]. Any employee who does not have the orientation completed will meet with the Director of Nursing/Designee prior to the start of their next shift to create a plan to complete their training and review key interventions to keep residents safe. Agency The Director of Nursing/Designee to create a summary of this training and put this in the agency binder, to provide agency staff resources to prevent accident/hazards. Training Timeline All Staff will receive training by Director of Nursing/Designee prior to their next working shift. Monitoring The Director of Nursing/Designee to do interview with Charge Nurse(s) for each shift and review expectations for accident/hazards prevention and reporting until the IJ abatement is completed. The facility to review the 24-hour report in daily (M-F) stand-up meetings, and as needed to validate that any accidents/hazards were followed up with in accordance with professional accepted standards of care. This audit to continue ongoing. On [DATE], while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on [DATE]. Findings included: IMMEDIATE JEOPARDY 1. Resident 96 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included central cord syndrome at C6, acute respiratory failure, type II diabetes mellitus, polyneuropathy, hepatic failure, pneumonia, lack of coordination, reduced mobility, muscle weakness, dysphagia, contusion of right wrist, cervicalgia, Parkinson's Disease, dementia, pressure ulcer of sacrum, atrial fibrillation, chronic kidney disease, hypertension and hyperlipidemia. On [DATE], resident 96's Admission Assessment documented that resident 96 required extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. The assessment documented that resident 96 was alert and oriented to person and situation, had poor memory and could not recall place and time. Resident 96 was assessed as requiring extensive assistance for locomotion on and off the unit and a wheelchair was used as a mobility device. On [DATE], the Morse fall scale documented a score of 65, which would indicate high risk for falls. The assessment documented that resident 96 had fallen before. The assessment documented that resident 96's gait was weak and he overestimated or forgets his limits with his ability to ambulate safely. On [DATE], resident 96's Minimum Data Set (MDS) Assessment documented that resident 96 required a one-person extensive assist for bed mobility, transfers, and toilet use. The assessment documented a Brief Interview for Mental Status (BIMS) score of 3, which would indicate a severe cognitive impairment. On [DATE] at 4:40 PM, an order for C-Collar to be worn AT ALL TIMES, please check to make sure that collar is on resident was initiated for resident 96. The order indicated that it was indefinite with no end date. The [DATE] Treatment Administration Record (TAR) revealed the order for the C-collar to be worn AT ALL TIMES. The order was discontinued on [DATE]. The November and [DATE] TAR did not have any orders monitoring for the c-collar. Resident 96's progress notes and incident reports revealed the following: a. On [DATE] at 1:53 PM, the Incident Note documented, I received a phone call today from the CNA [Certified Nurse Assistant] Coordinator, who was providing transportation for this resident to an appointment at the [name of hospital omitted], the CNA Coordinator stated that when coming to a stop, the wheelchair became dislodged and tipped backwards, CNA Coordinator immediately stopped vehicle and called for assistance from EMS [emergency medical services], the Administrator and I arrived at the scene at about 14:20 [1:20 PM], the resident was complaining of head and neck pain, EMS was treating him, the police officer and the EMS workers all stated that the resident was still strapped into the wheelchair with the seatbelts (EMS reported that there was tension in the belts still), resident was transferred via EMS to [local area hospital] for evaluation, provider notified, family notified. On [DATE] at 1:53 PM, the incident report further documented that resident 96 was very agitated, clutching his head while leaned over, unable to provide description of what occurred (resident has dementia). Resident 96 Pain Assessment in Advanced Dementia (PAINAD) score was assessed as a 9, which would indicate severe pain. The report documented that resident 96 required extensive assistance with transfers. The report further documented, resident possibly secured improperly, improper instruction given to CNA Coordinator about how to strap patient down properly in wheelchair. b. On [DATE] at 6:16 PM, the Incident Note documented, I have called [local hospital] for update: no fractures, some weakness on left side, they will do MRI [Magnetic Resonance Imaging] to rule out any damage to brain, they will call and update me when information is available. I called family of resident to update them on situation. They will continue to await any call on an update on his condition. c. On [DATE] at 10:23 PM, the Nurses Note documented, Hospital called facility and stating they are going to admit him and continue to monitor overnight. d. On [DATE] at 1:04 PM, the Nurses Note documented, Central cord syndrome found on MRI, resident currently in ICU [Intensive Care Unit] r/t [related to] he was having a difficult time maintaining his blood pressure, he is currently not on any supplemental blood pressure medication and the nurse stated that he will soon be ready to transfer either to a step down unit or back to facility, I gave them my name and phone number as a contact for [resident 96], will call again tomorrow for a new update. e. On [DATE] at 4:26 PM, the MDS Note documented, [Resident 96] readmitted from hospital on [DATE] on Medicare part A services with dx [diagnosis] of central cord syndrome at C6 level. f. On [DATE] at 9:26 AM, the Incident Note documented, Investigation completed. Facility will be completing training on all drivers and 2 sets of trained eyes will verify proper strap placement on transports. Interventions put in place. MD [Medical Director] to follow up. g. On [DATE] at 8:44 AM, the Nurses Note documented, Resident had episode of syncope this morning, NP [Nurse Practitioner] orders vital signs to be taken BID [two times a day]. It should be noted that no other documentation could be found for the syncopal episode. h. On [DATE] at 5:37 AM, the Incident Note documented, Resident was up in chair in dining room for dinner, CNA noticed and reported to nurse that resident did not look well. VS [vital signs]: BP [blood pressure]:,d+[DATE], P [pulse]: 62, o2[oxygen saturation]: 74%, R [right] pupil enlarged, L [left] pupil smaller, A&O [alert and oriented] x1. CNA transferred resident to bed, Nurse administered oxygen at 3L [liters], and raised head of bed. Vitals taken every 10 min [minutes] until stable and o2 at 85%. Nurse informed MD and DON, per MD, transfer to hospital. EMT [Emergency Medical Technician] arrived at 1900 [7:00 PM] and transferred resident to [local hospital]. DON notified family. On [DATE] at 5:37 AM, the incident note further documented that the predisposing physiological factors were drowsy, hypotensive, recent change in condition, and weakness/fainted. i. On [DATE] at 11:13 AM, the Nurses Note documented, I spoke to nurse at [local hospital] today. Resident is on diltalazem (sic) drip, insulin drip. He is normo-tensive. Now on 13L high flow oxygen, lung sounds are diminished. No discharge date set yet. I informed provider and family. j. On [DATE] at 1:44 PM, the incident report documented, resident was about to slide out of his chair. so the nurse tried to help him up but he slid down more and more and the nurse assisted him to the floor and asked for more help to assist him back to the chair. no apparent injury, no head hitting. He denied of pain. The report documented that the therapy staff assisted the resident back to the chair and 4 staff members were needed for the transfer. k. On [DATE] at 9:37 AM, the Interdisciplinary Team (IDT) Event Review documented, IDT fall review: root cause is found to be this resident's change in condition after accident that resulted in central cord syndrome, intervention: new wheelchair is in process of being purchased, resident will also be moved to room [ROOM NUMBER] to be closer to nurse station, current wheelchair has been modified by physical therapy to help prevent further falls, all other least restrictive interventions in place, will continue with plan of care. l. On [DATE] at 10:00 AM, the IDT Event Review documented, Follow up [DATE] incident: [Resident 96] has been moved to room [ROOM NUMBER] for increased monitoring. Therapy is getting tilt-in-space wheelchair. m. On [DATE] at 3:20 PM, the Nurses Note documented, MD in to visit per MD if we don't already have a end date neck brace lets do end date to come off after 12 weeks x-ray cervical spine 2 view 1 week prior to that. n. On [DATE] at 5:14 PM, the Nurses Note documented, Resident had hair cut today, then shower this afternoon. Within minutes after laying him back down he stopped breathing. The nurses performed assessment on him, he had no pulse and was not breathing. DNR [Do Not Resuscitate]. Family notified, MD notified. On [DATE], the Hospital History & Physical documented the chief complaint as a fall. An MRI of the cervical spine documented the impression as Focal edema within the spinal cord at and below the level of the C6/C7 disc space which may be secondary to contusion from adjacent osteophytes at C6/C7. The MRI further documented, Diffuse edema within the paravertebral soft issue from the occiput through the craniocervical junction and a Small amount of fluid in the C6/C7 disc space. Findings could be secondary to hyperextension injury. The Medical Decision Making documented that the MRI revealed a central cord syndrome with cord edema at C,d+[DATE] level secondary to adjacent osteophytes. The resident was admitted to ICU so that the mean arterial pressure could be monitored and kept at greater than 85 millimeters of mercury (mmHg). The resident was transitioned from a hard collar into an Aspen collar. The assessment documented that the resident suffered a hyperextension injury of the C-spine when he toppled in his wheelchair in a transport vehicle, and this resulted in central cord syndrome involving C6/C7. On [DATE], the Hospital Discharge Summary documented that resident 96 was to follow-up with a neurosurgeon in four weeks with a repeat CT of the cervical spine. On [DATE], the Record of Death documented that resident 96 had expired. Resident 96's Care Plans revealed the following: a. A care area for central cord syndrome r/t trauma related to motor vehicle incident that was initiated on [DATE]. The interventions identified included: Discuss with resident/resident and family any concerns, fears, issues regarding diagnosis or treatments; Ensure that c-collar is in place every shift; Give medications as ordered. Monitor/document for side effects and effectiveness; and Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST) to evaluate and treat as ordered. b. A care area for Activities of Daily Living (ADL) selfcare performance deficit r/t Confusion, Dementia, Fatigue, Impaired balance, BUE [bilateral upper extremity] tremors, recent motor vehicle incident with injury to neck and right wrist, pain. The interventions identified included: Resident has a neck brace and right wrist restriction due to pain and injury, use caution and assist with ADLs; scheduled every 2 hour turning to keep resident off of his tailbone (coccyx); Adjust ADL assistance per level of need at time of care; The resident required substantial/maximum assistance of 1 staff for bathing/showering, bed mobility, dressing, personal hygiene, and toileting; The resident required substantial/maximum assistance of 1 staff for 1:1 dining assistance and the resident was at risk for choking and aspiration; The resident required substantial/maximum assistance of 2 staff for transfers; and PT/OT evaluation and treatment as per MD orders. On [DATE] at 1:50 PM, the facility investigation documented that the resident was involved in an accident while being transported in the facility van. The initial report documented that the resident fell back in the transport vehicle on his way to an appointment. The facility's final investigation documented that the resident outcome to the incident was a Central Cord Syndrome injury. At the time of injury, the resident reported some pain but was unable to state what happened in the van. The summary of interviews documented that Nurse Assistant (NA) 2 had reported that he had wheeled the resident out to the transport vehicle where the CNA Coordinator (CNAC) strapped the patient in with all four straps and seat belt. NA 2 stated that he had never done anything with transportation prior. The summary of interviews documented that the CNAC stated that when she came to a stop and looked back, she saw that the resident was no longer sitting upright. The CNAC stated that she came to a stop, turned on her hazards, exited the vehicle, and waved down help. The CNAC stated that she put down the ramp with the patient. The CNAC stated that she did not receive training on how to use the van prior to transporting resident 96. The investigation documented under the summary that the CNAC was scheduled to be trained to assist in covering for the normal transport driver. The day the CNAC was scheduled to be trained she was sent home due to having COVID. The Previous Transport Driver (PTD) confirmed that the CNAC had participated in a previous transport by watching and sitting at an appointment with a patient. The report documented that the CNAC had placed the safety straps on the wheelchair wheels and not the wheelchair frame. The report documented that they assumed that the patient pushed on the [NAME] in front of him and tipped backward as a result of the strap placement. The conclusion of the facility investigation documented that the incident was a result of improper placement of safety straps on the wheelchair wheels and not the wheelchair frames. The root cause identified was insufficient training in transportation. The facility provided a driving in-service on [DATE]. On [DATE] at 2:37 PM, an interview was conducted with the CNAC. The CNAC stated that she was the driver of the vehicle at the time of the accident with resident 96. The CNAC stated that she had only transported for the facility twice, and once with resident 96. The CNAC stated that she had not been given training on how to transport residents, had never ridden with another driver, and was not shown how to properly secure someone down inside the van. The CNAC stated that she secured resident 96's wheelchair wheels down with the straps and placed the seatbelt over resident 96. The CNAC stated that she thought she had secured resident 96 correctly. The CNAC stated that she placed the straps from the floor of the van and hooked them to the wheels of the wheelchair on both sides, four straps in total. The CNAC stated that she did not connect the straps to the frame of the wheelchair. The CNAC stated that she was told after the accident that this was not how it was supposed to be done. The CNAC stated that she checked the resident in the rearview mirror during the transport and talked to him. The CNAC stated that she had just made it to the freeway entrance when she looked back and noticed that resident 96 had fallen backwards. He was folded in half like a taco. The CNAC stated that she pulled over and stopped the vehicle. The CNAC stated that she found resident 96 folded up against the drop gate. The CNAC stated that before she let the drop gate down, she removed her hoodie and placed it under resident 96's neck to support it. The CNAC stated that resident 96's legs were positioned up towards his chest and torso, and his head was folded down towards his chest. The CNAC stated that as she lowered the gate, she placed her hoodie for support so his neck would not hyperextend. The CNAC stated that resident 96 was able to answer questions, and said his head hurt. The CNAC stated that resident 96 had a small scrap on the back right side of his head from contact with the drop gate. The CNAC stated that when EMS arrived, they moved resident 96 without placing a c-collar on the resident first. The CNAC stated that EMS undid the seatbelt, moved the chair to a seated position, and backed him out of the van. The CNAC stated that resident 96 began to convulse, and he had no history of a seizure disorder prior. The CNAC stated that the ADM and Previous Director of Nursing (PDON) arrived at the scene and started drilling her. The CNAC stated that she was suspended for abuse and returned to work 5 days later. The CNAC stated that the facility substantiated the allegation of abuse, and that the facility was at cause because she had never received proper training. The CNAC stated that the next day they started training everyone in the facility on how to transport someone. The CNAC stated that she refused to sign the in-service training log because the training was conducted during her suspension period. The CNAC stated that she was suspended on Sunday and the incident occurred on Friday. The CNAC stated that she worked remotely on Saturday and Sunday and then she was on suspension for a week. The CNAC stated that resident 96 had returned to the facility and she had told the PDON that she was uncomfortable working with resident 96 again. The CNAC stated that she did not want to lose her license. The CNAC stated that resident 96's family had come to the facility and said they were upset that she was still working at the facility. The CNAC stated that she did not mind training the staff on how to care for resident 96. The CNAC stated that she showed staff from a distance how to clean the c-collar, and how to safely transfer resident 96. The CNAC stated that for resident 96 they could not use a hoyer lift for transfers because this was contraindicated with a spinal cord injury. The CNAC stated that she did not participate in resident 96 care for quite some time after the incident. The CNAC stated she had noticed before resident 96 passed away he was unkept, his beard and nails were long. The CNAC stated that she clipped his nails and then asked the PDON if the hair school could give him a haircut. The CNAC stated that the PDON stated it was safe to remove the c-collar for care. The CNAC stated that she thought the resident was going to have his c-collar removed the following day at a scheduled doctor's appointment. It should be noted that the transportation schedule did not document that resident 96 was scheduled for any appointments on [DATE], which would have been the following day. The CNAC stated that she was never asked not to have contact with resident 96, that it was a personal preference. The CNAC stated that resident 96 passed away that day, and he was not on hospice and it was not expected. The CNAC stated that she assisted resident 96 during his hair cut. The CNAC stated that resident 96's c-collar was removed for the haircut, and she held his head still, with no sudden movements and no flexion or extension of the neck. The CNAC stated that NA 3 and NA 5 had assisted resident 96 with a shower. The CNAC stated that she believed resident 96's c-collar was removed for the shower under the direction of the PDON. The CNAC stated that NA 3 and NA 5 were both new aides that time. The CNAC stated that the PDON called her at approximately 5:15 PM, on the day that resident 96 received his haircut and shower and was told that resident 96 had just passed away. On [DATE] at 8:38 AM, an interview was conducted with the DON. The DON stated that if a resident had a c-collar applied she would expect to see an order for it and monitoring. The DON stated that documentation of the monitoring could be in the TAR or in a progress note. The DON confirmed that the October TAR documented that the c-collar order was discontinued on [DATE]. The DON stated that she would interpret the nurse note on [DATE] as discontinue the c-collar in 12 weeks from [DATE]. On [DATE] at 2:12 PM, a follow-up interview was conducted with the DON. The DON stated that the order for the c-collar should not have been discontinued and the c-collar was to stay on at all times. The DON stated that the PDON stated that the c-collar had stayed on resident 96 up until his death. The DON stated that if you had a spinal injury, it might be necessary to have the c-collar at all times, and it would stabilize the neck. The DON stated that the provider should supervise any removal of the collar. The DON stated that if the c-collar was removed it would be possible to re-injury the injury you were trying to fix. On [DATE] at 2:22 PM, an interview was conducted with NA 3. NA 3 stated that she had provided care for resident 96. NA 3 stated that she was not sure why resident 96 wore a neck brace. NA 3 stated that she showered resident 96 one time with the assistance of the CNAC on the day that he passed away. The shower was provided in the communal shower room. NA 3 stated that the residents were doing their monthly haircuts, and resident 96 had a haircut and his beard shaved. NA 3 stated that afterwards she informed the CNAC that it was resident 96's scheduled shower day. NA 3 stated that this was the first time she had provided resident 96 with a shower, and the CNAC said since resident 96 was already up she would assist NA 3 with the shower. NA 3 stated that they washed resident 96's hair, beard, chest, and feet. NA 3 stated that while they were performing the shower resident 96 was having a bowel movement. NA 3 stated that the CNAC told her that when resident 96 received a shower they took his c-collar off, and that the CNAC was the person who removed the collar. NA 3 stated that the CNAC was helping her with the shower by holding the shower head and rinsing resident 96 off. NA 3 stated that she was washing resident 96 while the CNAC was holding the shower head. NA 3 stated that she washed resident 96's chest and neck. NA 3 stated that resident 96 was sitting in a shower chair during the shower. NA 3 stated that they washed the front, sides and back of resident 96's neck. NA 3 stated that while the CNAC was holding the shower head she was guiding NA 3, saying that if she was washing the neck gently and the neck and spine were aligned it would be okay. NA 3 stated that they made sure that resident 96 was not moving around. NA 3 stated that NA 5, PDON and the CNAC were all present during resident 96's shower. NA 3 stated that she was training NA 5 and asked the CNAC how to shower resident 96. NA 3 stated that the CNAC had the PDON come assist with transferring resident 96 onto and then off the shower chair. NA 3 stated that once resident 96 was transferred only she, NA 5 and the CNAC were present. NA 3 stated that she did not recall if the PDON was present when they removed the neck collar. NA 3 stated that at that point in time she had only worked at the facility for ,d+[DATE] months, and she was training NA 5. NA 3 stated that NA 5 only observed during the shower. NA 3 stated that resident 96 wore his c-collar during the transfers and it was only removed during the shower. NA 3 stated that resident 96 was good at sitting up straight, and he was not leaning. NA 3 stated that no one was holding or stabilizing resident 96's head once the c-collar was removed, and the c-collar was off for approximately 20 minutes for the duration of the shower. NA 3 stated that the CNAC switched positions, and she held the shower head while the CNAC washed resident 96's genitals. NA 3 stated resident 96 did not have to shift positions to have his genitals cleaned as the shower chair had a hole in the seat. NA 3 stated that she asked the CNAC how to put the neck brace back on, and the CNAC placed the c-collar back on resident 96. NA 3 stated that the c-collar had two parts to it, a front and a back. NA 3 stated that the CNAC first placed the front on to make sure the neck was visible, and the sides were placed near his collar bones. NA 3 stated that the back piece had two Velcro tabs that strapped around to the front to make sure it stayed in place. NA 3 stated that she asked the CNAC how she knew the difference between the back and the front piece, and she told her that the back piece should be longer than the front. NA 3 stated that the c-collar was solid and did not have a whole in the front piece to visualize the neck. NA 3 stated that she could not tell the difference between the front and back piece, had never worked with a neck brace before, and wanted to know what to do if she came across it again. NA 3 stated that she did not confirm with the nurse prior to removing the neck brace. NA 3 stated that the CNAC said that they would just quickly give him a shower without it. NA 3 stated that after they reapplied the neck brace, they put a hospital gown on resident 96. NA 3 stated that the CNAC and PDON transferred resident 96 from the shower chair onto the wheelchair and the CNAC told her to put him back into bed. NA 3 stated that she and NA 5 took resident 96 back to his room. NA 3 stated that they tried to transfer resident 96 back to bed, but they could not physically do it. NA 3 stated that she and NA 5 attempted to do the same transfer method as the PDON and CNAC, the towel transfer. NA 3 stated that this transfer method had a towel under the resident's knees and the staff arm under the resident armpit, and as you hold the towel you shift the resident's weight to transfer them. NA 3 described the towel transfer method as standing at the residents' side facing him with the arm closest to the resident placed under his arm and the arm further away was crossed and holding the towel. NA 3 stated that when you transferred the resident the staff arms slightly uncross, enough to move the resident legs. NA 3 stated that this method caused the aide to twist her upper back during the transfers. NA 3 stated that she and NA 5 could lift resident 96. NA 3 stated that resident 96' [TRUNCATED]

Based on observation, interview, and record review, the facility did not establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. Specifically, multiple areas of immediate jeopardy and harm were identified on the recertification survey. Resident identifiers: 3, 6, 17, 19, 21, 28, 29, 31, 34, 39, 90, 91, 92, 93, 94, 96, and 97. Findings include: 1. Based on observation, interview, and record review it was determined, for 10 out of 40 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident was transported via the facility van and the wheelchair was not secured properly inside the vehicle which resulted in the resident falling backwards causing hyperextension of his neck. The resident was diagnosed with central cord syndrome and edema at the level of C6 and C7 of his cervical spine. Upon return to the facility the resident's cervical collar was removed by Certified Nursing Assistant(s) (CNA) during grooming and bathing cares. After the resident's shower, the CNAs attempted to transfer the resident to bed unsuccessfully and the resident was assisted to the floor. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. Additionally, a resident sustained four falls in the facility with the last one resulting in a fractured hip; a resident tripped over the broken base of a structural column outside the facility and sustained a laceration requiring sutures; and a resident had an unsafe discharge to the community, was found wandering the streets and was subsequently placed on a medical hold in the hospital. These identified deficient practices were found to have occurred at a Harm Level. Lastly, two residents eloped from the facility; a resident struck another resident with a razor cutting them and was not monitored or restricted from further sharp objects after the incident; a resident was provided a germicidal cleaning wipe by another resident and used it to blow and clean their nose; and a resident was hit by the meal cart during delivery service of the meals. Resident identifiers: 3, 6, 19, 31, 34, 91, 92, 93, 94, and 96. [Cross refer to F689] 2. Based on interview and record review it was determined, for 1 out of 40 sampled residents, that the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, a resident was transported via the facility van and the wheelchair was not secured properly inside the vehicle which resulted in the resident falling backwards causing hyperextension of his neck. The resident was diagnosed with central cord syndrome and edema at the level of C6 and C7 of his cervical spine. Upon return to the facility the resident's cervical collar was removed by Certified Nursing Assistant(s) (CNA) during grooming and bathing cares. After the resident's shower, the CNAs attempted to transfer the resident to bed unsuccessfully and the resident was assisted to the floor. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. Additionally, staff reported that orientation training to newly hired Nurse Assistants and Certified Nurse Assistants was not performed and Nurse Assistants were in charge of training new hires. Resident identifier: 96. [Cross refer to F726] 3. Based on interview and record review, the facility did not ensure that 1 of 40 sampled residents had the right to refuse medical treatment and formulate an advance directive. Specifically, one resident with an advanced health care directive received treatment that was documented as against the resident's wishes. This resulted in a finding of harm. Resident identifier: 39. [Cross refer to F578] 4. Based on interview and record review, the facility did not provide and document sufficient preparation to 2 of 40 sampled residents to ensure safe and orderly transfer or discharge from the facility. Specifically, one resident with cognitive impairment was discharged to a hotel room, but was subsequently seen at a local emergency room after becoming lost. This resulted in a finding of harm. In addition, one resident left on a leave of absence, and was not oriented for discharge upon return to the facility. Resident identifiers: 94 and 97. [Cross refer to F624] 5. Based on interview and record review it was determined, for 3 of 40 sampled residents, that the facility did not incorporate the recommendations from the pre-admission screening and resident review (PASRR) level II determination and the PASRR evaluation report into the resident assessment, care planning, and transitions of care. Specifically, residents had PASRR level II recommendations for mental health services and none were provided. The deficient practice identified was cited at a HARM Level. Resident identifiers: 21, 29, and 34. [Cross refer to F644] 6. Based on observation, interview, and record review it was determined, for 3 of 40 sampled residents, that the facility did not ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, a resident had moisture associated skin damage. This finding was cited at a harm level for resident 6. In addition, another resident sat in a soiled brief for an hour and toileting services were not provided to a resident for 3 hours. Resident Identifiers: 6, 17, and 28. [Cross refer to F690] 7. Based on observation, interview and record review it was determined, for 2 of 40 sampled residents, that the facility did not ensure that pain management was provided to residents who required such services. Specifically, two residents complained of uncontrolled pain and the pain medication follow up was documented as ineffective pain control, and the physician was not notified in a timely manner. A resident was also observed to vocalize pain during a wound treatment and was not provided pain medication prior to the treatment as was care planned, this will be sited at a harm level. Resident identifiers: 29 and 90. [Cross refer to F697] 8. Based on interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not ensure that the resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, a resident with suicidal ideation, suicidal attempt, and homicidal ideation was assessed as requiring mental health services and those services were not provided. The deficient practice identified was cited at a harm Level. Resident identifier: 29. [Cross refer to F740] On 2/14/24 at 1:00 PM, an interview was conducted with the facility Administrator (ADM). The ADM stated that she had conducted the first new Quality Assurance (QA) meeting in January of 2024. The ADM stated that prior to January 2024, items in QA were brought up just adhoc, and there weren't consistent items reviewed at each meeting. The ADM stated that as of January 2024, she had completed education with each of the department heads, and reviewed what everyone's responsibilities were. The ADM also stated that QA meetings were now more structured, and that every department head had to do reporting and tracking on specific items.

Based on interview and record review it was determined, for 3 of 40 sampled residents, that the facility did not incorporate the recommendations from the pre-admission screening and resident review (PASRR) level II determination and the PASRR evaluation report into the resident assessment, care planning, and transitions of care. Specifically, residents had PASRR level II recommendations for mental health services and none were provided. Resident identifiers: 21, 29, and 34. Findings included: 1. Resident 29 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included a traumatic brain injury (TBI), hemiplegia and hemiparesis, major depressive disorder, panic disorder, anxiety disorder, low back pain, hepatitis C, seizures, insomnia, migraine, schizoaffective disorder, and history of suicidal behavior. On 6/22/23, resident 29's Patient Health Questionnaire (PHQ)-9 depression assessment documented a score of 17, which indicated moderately severe depression. On 9/21/23, resident 29's PHQ-9 depression assessment documented a score of 11, which indicated moderate depression. On 10/4/23, resident 29's PHQ-9 depression assessment documented a score of 7, which indicated mild depression. On 8/14/23, resident 29's Brief Interview for Mental Status (BIMS) assessment documented a score of 9, which indicated a moderate cognitive impairment. On 10/9/23, resident 29's BIMS assessment documented a score of 11, which indicated a moderate cognitive impairment. On 6/27/23, resident 29's PreAdmission Screening and Resident Review (PASRR) Level II documented the resident's past medical history of a TBI was due to assault that resulted in a craniotomy. Resident 29 then sustained a car accident that affected the right hemisphere with paralysis of the left upper extremity. On 4/28/23, resident 29 was hospitalized with increased extracranial fluid and periorbital cellulitis with Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Resident 29's history of psychiatric symptoms documented a history of depression and anxiety dating back to childhood. Resident 29 reported that his mother was abusive and neglectful and she forced him to go with a man who was a pedophile for money. Resident 29 endorsed a history of depressed mood, anhedonia, problems with sleep, problems with concentration, feeling of worthlessness and history of suicidal ideation. Resident 29 stated, I am depressed and I'm anxious and I have panic attacks. I feel like I'm absolutely no good. Resident 29 reported that he was hospitalized multiple times for mental health and attempted suicide at least twice. Resident 29 reported worsening of depression since accident and stated, I just wish life would be over. I just want to give this body back. Resident 29 stated he was depressed and very anxious. The assessment documented resident 29's mental illness diagnoses as major depressive disorder, panic disorder, and anxiety disorder. The assessment recommendations for specialized services for mental illness treatment were individual counseling and review of psychotropic medications. On 9/21/23, resident 29's PASRR level II documented the current psychiatric functioning was that resident 29 was struggling with feeling he needed to use the bathroom constantly and not being able to urinate. Resident 29 reported that this made him extremely anxious and he perseverated about this all the time. Resident 29 reported that his depression was less and he felt he was doing okay. The assessment recommendations for specialized services for mental illness treatment were individual counseling and review of psychotropic medications. On 9/21/23 at 10:33 AM, the Social Service Note documented, [resident 29] returned to the facility after going to hospital for suicidal comments and stating that he has a plan. He will be referred to [local mental health services] today. No documentation could be found that resident 29 was referred to any behavioral or mental health services. On 7/18/23, resident 29 had a care plan initiated for Level II PASRR determination for serious mental illness due to major depressive disorder, anxiety disorder, and panic disorder. Interventions identified included assist case worker with obtaining any needed information; coordinate services with habilitative coordinator; invite the habilitative coordinator and be responsible to the quarterly care plan meeting that discussed resident status; recommendations for services to be provided by the facility for physical therapy (PT), occupational therapy (OT), medication management and assist with activities of daily living (ADLs); monitor for increase in symptoms of depression; recommendations for specialized services for mental illness treatment: patient was in need of mental health services including individual counseling and a review of his psychotropic medications; and report any need to re-evaluate for additional specialized services On 8/2/23, resident 29 had a care plan initiated for patient meets PASRR Level II level of determination secondary to major depression, generalized anxiety disorder, and panic disorder. The care plan documented that resident 29 had a history of recurrent depression, anhedonia, problems with sleep and appetite, fatigue, concentration, history of suicidal ideation and attempts. The care plan further documented that resident 29 had difficulty controlling worry, had a history of panic where he feels abrupt surge of fear, trembling, shaking, abdominal distress, fear of dying, feelings of light-headedness, numbness, tingling. Interventions identified included would receive appropriate specialized services as indicated on the PASRR Level II; refer to mental health Services as needed; arrange for PASRR re-evaluation if there was a significant change in status that results in new evidence of possible mental disorder, intellectual disability and/or related condition; coordinate and/or inform the appropriate agency to conduct the PASRR evaluation and obtain results if it was learned that Resident's/Patients PASRR was not completed or was incorrect; recommendation for specialized services for mental illness was mental health services needed including individual counseling and a review of his psychotropic medications; recommendations for services to be provided by the facility for physical therapy (PT), occupational therapy (OT), medication management and assist with activities of daily living (ADLs); and monitor for increase in symptoms of depression. On 2/08/24 at 10:18 AM, an interview was conducted with the Certified Nurse Assistant Coordinator (CNAC). The CNAC stated that the facility provided behavioral training which covered de-escalation techniques for the residents. The CNAC stated that the techniques were resident specific and she along with the previous Director of Nursing (DON) would identify interventions and care plan them together. The CNAC stated that they had a Resident Advocate that had been at the facility for about a month. The CNAC stated that prior to that they had been without a social service worker for approximately 3 months. The CNAC stated that they had a local behavioral health provider that came to the facility to provide mental health services. The CNAC stated that they came to the facility weekly and as needed. On 2/12/24 at 9:06 AM, an interview was conducted with Nursing Assistant (NA) 1. NA 1 stated that resident 29 did not have any behaviors that she was aware of. NA 1 stated that on one occasion she witnessed resident 29 yelling from the bathroom. NA 1 stated that resident 29 stayed in his room a lot, and maybe was depressed. On 2/12/24 at 9:47 AM, a follow-up interview was conducted with the CNAC. The CNAC stated that resident 29 liked to sleep a lot. The CNAC stated that resident 29 reported sad thoughts and that he had some issues with his ex-girlfriend. The CNAC stated that resident 29 was suicidal a few months ago and it had to do with his girlfriend. The CNAC stated that resident 29 gets down when he was lonely. The CNAC stated that resident 29 needed to feel more valued as an individual. He may be a little depressed, a lot of the residents feel that way when they don't have 1:1. The CNAC stated that resident 29 reported to one of the employees, I'm down, I want to die. The CNAC stated that they took this statement seriously. He needed a bit more help. The CNAC stated that they transferred resident 29 to the hospital. On 2/12/24 at 11:57 AM, an interview was conducted with the Resident Advocate (RA). The RA stated that the Minimum Data Set (MDS) Coordinator was arranging the residents referrals to the contracted behavioral health provider but now they were training her on how to do it. The RA stated that a couple of weeks ago the MDS Coordinator provided her a list of residents that needed referrals to the behavioral health provider. The RA stated that the Director of Nursing (DON) stated that they were no longer using the previous contracted behavioral health provider and would need to send the referrals to the new mental health provider. The RA stated that she was still waiting for the new provider information. On 2/12/24 at 1:12 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that she was in charge of referrals to behavioral health services for the time period between when the previous RA (PRA) left and when the new Resident Advocate arrived. The MDS Coordinator stated it was not clear that she should have been doing referrals, and she did not make any new referrals during this time. The MDS Coordinator stated that as of 12/5/23 the residents that were receiving mental health services through the contracted behavioral health provider did not include resident 29. The MDS Coordinator stated that if the resident was receiving mental health services then the notes would be located in the electronic medical records under miscellaneous. On 2/12/24 at 2:00 PM, an interview was conducted with the Corporate Social Service Worker (CSSW). The CSSW stated that the facility contracted with a behavioral health provider for mental health services, but they were in the process of obtaining a new contracted provider. The CSSW stated that residents were also able to use their own provider if they already had one. The CSSW stated that if the residents had not been seen by the contracted provider then they had not been seen for mental health services. The CSSW stated that they had identified that there was a need for residents to be connected with behavioral health services. The CSSW stated that for a lot of the residents they could not find documentation that mental health services had been provided. The CSSW stated that they reviewed all the residents two weeks ago and made a bunch of referrals. The CSSW stated that when they received a PASRR in the admission process that identified a mental illness they should be asking the resident about behavioral health services and if they have a provider. If the resident was open to services the CSSW stated that someone in the facility should be coordinating those services. The CSSW stated that the referrals and coordination of care should be documented in the resident progress notes. The CSSW stated that resident 29 would like to get counseling. The CSSW stated that resident 29 was sent to the hospital in September 2023 for suicidal ideation and the PRA was supposed to have made a referral for mental health services. On 2/12/24 at 2:52 PM, a follow-up interview was conducted with the CSSW. The CSSW stated that resident 29 was referred to the contracted behavioral health provider on 1/19/24 and again on 1/23/24. The CSSW stated that resident 29 was not referred for mental health services prior to this. 22992 2. Resident 34 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included moderate protein calorie malnutrition, intellectual disabilities, chronic pain, scoliosis, major depressive disorder, anxiety disorder, impulse control disorder, mood disorder, and intracranial injury. Resident 34's medical record was reviewed from 2/5/24 through 2/22/24. Resident 34's Level II PASRR dated 10/31/23 was reviewed. The Level II evaluator documented the following: Diagnostic Formulation: [Resident 34] has a history of recurring depressive symptoms which have contributed to recurring functional impairment and distress, and is presenting with [signs and symptoms] of anxiety at this time as well. He has significant cognitive limitations/deficits secondary to a TBI. He has a history of alcohol, tobacco, and illicit substance use. Recommendations for services to be provided by the Nursing Facility: Medical management, assistance with ADLs (activities of daily living), therapies for rehabilitation, support from SNF staff, referrals for community resources Recommendation for Specialized Services for mental illness treatment: [Resident 34] feels he would benefit from the support of mental health treatment services, although his memory impairment might limit the benefit he gets from said services. Resident 34's care plan dated 11/9/23 indicated that resident 34 had a serious mental illness. One of the interventions listed was to Refer to Mental Health Services As needed. In addition, the care plan indicated that resident 34 was at risk for suicidal impulsive/ideations of self-harm related to Psychiatric Disorder. Resident 34's Level II PASRR dated 1/15/24 was reviewed. The Level II indicated that resident 34 had been hospitalized in the inpatient psychiatric unit at a local hospital in June 2023 secondary to depression and suicidal ideation. He has been in the ER or hospital at multiple locations 15 [plus] times in the past 6 months due to recurring back pain, SI (suicidal ideations), neck pain, and when found wandering in stores or in parking lots.He was taken to the [emergency room of a local hospital] on 10/23/23 secondary to suicidal ideation with a plan to cut his throat. He was readmitted to the inpatient psychiatric unit for safety, stabilization, and treatment. After admission to SNF (skilled nursing facility) [resident 34] was documented to have multiple behavioral issues and a significant altercation with another resident. Notes and SNF staff report that pt would become easily angered if he did not get what he wanted, especially when told he cannot go outside and smoke as much as he wants. He was noted to put hand sanitizer in his eyes and on his face; he told staff he had done this multiple times prior to his being observed. Notes indicate; 'Resident had many unusual behaviors during shift but was easily redirected' .'angry about having to wait for supervised smoking times.' On 11/12/23 notes state: 'Patient has been easily explosive for the last two days especially when he doesn't get what he wants. Patient exploded at nurse 11/11 around 2200 (10:00 PM) because he wanted a cigarette called this nurse every name in the book. Most of the time he is easily calmed down, but 20 minutes later another resident turned the lights off in the dining room and this patient became explosive and yelled an expletive and punched the resident the (sic) turned off the light 3 times in the face causing the patient's ear to bleed. When the resident stood up to defend himself being unstable with the assault the resident fell to the floor.' . The police were called, [resident 34] was cited, and [resident 34] was blue sheeted and taken back to the ER at [name of local hospital] for re-evaluation. Since returning to the SNF [resident 34] has still struggled with mood dysregulation and agitation/aggression and he was put on 1:1 supervision for a time. His records do indicate issues with impulsivity, anger management, rapid mood swings/mood dysregulation, and recurring depression with SI (suicidal ideation). It was recommended to hospital staff by this evaluator that [resident 34] be referred for services through DSPD (Division of Services for People with Disabilities) if appropriate to engage more community resources on [resident 34's] behalf, such as moving to a group home where pt could have more flexibility but also have supervision and structure/safety. The evaluator for the Level II PASRR documented the following: Diagnostic Formulation: [Resident 34] has a very complex presentation. He has a documented history of recurring depressive symptoms which have contributed to functional impairment and distress, and is presenting with sxs (signs and symptoms) of anxiety at this time as well. He has significant cognitive limitations/deficits and severe mood dysregulation/difficulty managing his anger and actions secondary to a TBI. He has been prescribed multiple psychotropic medications to try to regulate his severe behavioral concerns, agitation, and impulsivity . Recommendations for services to be provided by the Nursing Facility: Medical management, assistance with ADL's (activities of daily living), therapies for rehabilitation, support from SNF staff, referral to a neuropsychiatrist/neuropsychologist for further cognitive testing, referrals for community resources including DSPD services if applicable Recommendation for Specialized Services for mental illness treatment: [Resident 34] feels he might benefit from the support of mental health treatment services, although his memory impairment would likely limit the benefit he gets from said services. [Resident 34's] father stated the he feels pt would benefit 'from a good psychiatrist'. On 2/13/24 an interview was conducted with the local county mental health provider (CMHP). The CMHP stated that resident 34 was not referred over to their services until February 2024. 3. Resident 21 was admitted to the facility on [DATE] with diagnoses that included hepatic failure, generalized anxiety disorder, major depressive disorder, cirrhosis of liver, dementia, and history of traumatic brain injury. Resident 21's medical record was reviewed from 2/5/24 through 2/22/24. Resident 21's Level II PASRR dated 5/24/23 was reviewed. The Level II evaluator documented that resident 21 presented to a local emergency roiagnom on [DATE] secondary to increasing depression/anxiety with suicidal ideation. The Level II evaluator documented the resident 21 reported being hospitalized on multiple occasions in the past d/t (due to) severe depression and suicidal ideations. He endorsed symptoms including depressed mood, anhedonia, loss of energy and motivation, sadness, isolation and withdrawal from others, feelings of worthlessness and hopelessness, loss of appetite, impaired sleep/concentration, thoughts of being better off dead, and recurring SI (suicidal ideations). He endorsed problems with excessive anxiety and worry about many things, inability to control feelings of worry, restlessness/tension, trouble sleeping, and difficulty concentrating when anxious. The evaluator for the Level II PASRR documented the following: Diagnostic Formulation: [Resident 21] appears to have experienced recurring symptoms of both depression and anxiety which have contributed to significant disruption and distress in his life, and which have required treatment with psychotropic medications for years. He was also involved in outpatient and inpatient treatment d/t (due to) the severity of his symptoms. He has a long history of alcohol use and used alcohol as a way to cope with his psychiatric symptoms. Recommendations for services to be provided by the Nursing Facility: Medical management, assistance with ADL's, therapies for rehabilitation, support from SNF staff Recommendation for Specialized Services for mental illness treatment: Pt would like a referral for mental health services (counseling, psychotropic medication management). Resident 21's care plans were reviewed and revealed the following: a. On 5/15/23, a hospice care plan was developed which documented, Makes statements that he wishes there is something that would speed up the process of dying but he would like to make amends with people from his past . Pt denies wanting to hurt himself or having any kind of plan. Pt. endorses that he is trying to cope and process information and having fleeting thoughts, but nothing related to self harm. b. On 8/23/23, a level II care plan was developed. One of the interventions listed was Refer to Mental Health Services As needed . Pt would like a referral for mental health services (counseling, psychotropic medication management .) c. On 12/5/23, a suicidal ideations care plan was developed. One of the interventions listed was Obtain/provide for Psych/Behavioral Health consult. Resident 21's progress notes indicated that on 1/23/24, resident 21 had been referred over to the local county mental health provider for counseling and medication management. No evidence could be found to indicate resident 21 had been referred over for mental health services between admission in May 2023 until January 2024.

Based on observation, interview, and record review it was determined, for 3 of 40 sampled residents, that the facility did not ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, a resident had moisture associated skin damage. This finding was cited at a harm level for resident 6. In addition, another resident sat in a soiled brief for an hour and toileting services were not provided to a resident for 3 hours. Resident Identifiers: 6, 17, and 28. Findings Included: HARM 1. Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses that included schizophrenia, type 2 diabetes mellitus, major depressive disorder, generalized anxiety disorder, dementia, repeated falls, vitamin b12 deficiency, extrapyramidal and movement disorder, and overactive bladder. On 2/6/24 at 9:29 AM, an interview was conducted with resident 6. Resident 6 stated recently they were not given a brief change the entire night and there had been numerous times where they were left in a brief for a long time. Resident 6 stated sometimes they were left in a dirty brief for more hours than they appreciated. Resident 6 complained about the redness on their bottom. On 2/21/24 at 9:16 AM, an observation was made of Certified Nursing Assistant (CNA) 2 assisting resident 6 with a brief change. The CNA 2 was observed to ask resident 6 if they were wet and then proceed to check resident 6's brief. Resident 6's brief was removed and resident 6's buttocks area was observed to be erythematous with red dots of varying sizes present. The CNA 2 was observed to wipe resident 6 clean and then applied barrier ointment to resident 6's posterior. The CNA 2 stated they also tried to keep resident 6's diaper semi loose to prevent further skin irritation. On 12/27/23, a Quarterly Minimum Data Set (MDS) assessment documented resident 6's bowel and bladder function as incontinent. Resident 6 was also documented to have moisture associated skin damage (MASD) as a skin condition. Resident 6's care plan was reviewed and documented the following care areas associated with incontinence: a. A care plan focus area, initiated on 11/7/23, documented resident 6 was at risk for skin break related to incontinence and a history of MASD to peri-area. Documented intervention included but not limited to weekly skin checks. b. A care plan focus area, initiated on 11/20/23, documented resident 6 had an alteration in bowel and bladder elimination due to incontinence and it stated resident 6 required assistance with toileting care. Documented interventions included but not limited to changing resident 6's disposable brief every shift and during rounds as needed. c. A care plan focus area, initiated on 2/18/24 documented, resident 6 had MASD to their bottom related to incontinence. Documented interventions included but not limited to keeping the skin clean and dry and checking for incontinence frequently. Resident 6's physician orders were reviewed and documented the following orders in regard to resident 6's skin condition: a. An order with a start date of 1/8/24 stated as followed, Calmoseptine External Ointment 0.44-20.6 % (Menthol-Zinc Oxide). Apply to coccyx fissure topically every shift for MASD May D/C [discontinue] once resolved. This order was discontinued on 2/27/24. b. An order with a start date of 2/1/24 stated as followed, Nystatin External Powder 100000 UNIT/GM [gram] (Nystatin (Topical). Apply to under breast, groin topically every shift for yeast, redness. c. An order with a start date of 2/19/24 stated as followed, WOUND CARE - MASD breakdown to crack of buttocks Cleanse with wound cleanser and pat dry. Apply medihoney sheet (cut to fit) to wound bed and cover with silicone foam dressing. Change daily and as needed for soiling/dislodgement. On 11/21/23, a weekly skin review/assessment documented, Patient is incontinent of bowel and bladder. She does try and use the restroom but constantly has soiled briefs. She has slight redness in groin area, using Nystatin to help. She has no other skin breakdown. Skin warm, dry and intact. On 11/28/23, weekly skin review/assessment documented, Patient is incontinent of bowel and bladder. She does try and use the restroom but constantly has soiled briefs and needs assistance to get changed. She has slight redness in groin area, using Nystatin to help. She has no other skin breakdown. Skin clear, warm, dry and intact. Will continue to monitor. On 12/31/23, a weekly skin review/assessment documented, Resident continues to have some redness and applied nystatin to groin, [NAME] and buttock and encouraged resident to take scheduled showers. On 1/7/24, a weekly skin review/assessment documented, Resident continues with treatment of rash to groin, [NAME] and buttock folds. Nystatin applied with brief changes. On 1/8/24 at 11:06 AM, a nurse note stated, Aide came to LN [licensed nurse] and stated that when they went to go and change pt [patient] brief, that they noticed pt had an open area. LN went in and assessed; pt has some redness noted to their coccyx area, with open fissure noted. LN communicated with management and received instruction to go ahead and apply calmoseptine r/t [related to] MASD and use Q [every] Shift, until resolved. On 1/14/24, a weekly skin review/assessment documented as followed, No skin issues skin is clean dry and intact barrier cream being used because of incontinences, WCTM [will continue to monitor]. On 2/4/24, a weekly skin review/assessment documented, Resident continues with treatment for redness under breasts, [NAME] and groin skin is pink and dry flaking around the edges. On 2/11/24, a weekly skin review/assessment documented, Resident continues with treatment for redness under breasts, [NAME] and groin skin is more inflammed [sic] and dry flaking around the edges. On 2/18/24 at 11:23 AM, a nurse note stated, MASD noted in buttocks along the crack skin has broken down - area cleansed and dressing applied. MD [medical doctor] and administration notified to add to wound rounds. new orders for daily dressing changes. On 2/18/24, a weekly skin review/assessment documented the following, Resident continues with nystatin under both breasts (both very red and starting to breakdown, bilateral [NAME] (light pink areas on each side). MASD noted in buttocks along the crack skin has broken down - dressing applied. On 2/21/24 at 8:32 AM, an interview was conducted with Nursing Assistant (NA) 4. The NA 4 stated resident 6 was able to reposition themselves in bed and used a brief. The NA 4 stated resident 6 was a heavy wetter and was able to notify staff when they needed a brief change. The NA 4 stated staff attempted to check on resident 6 between every 1-2 hours. The NA stated when they did their rounding, there was a high probability that resident 6 needed to be changed. The NA stated resident 6 had a bad rash on their butt and described it as red, patchy, and peeling like dry skin. On 2/21/24 at 8:40 AM, an interview was conducted with Certified Nursing Assistant (CNA) 5. The CNA 5 stated resident 6 did very minimal to help with their cares. The CNA 5 states resident 6 was able to reposition themselves in bed and was able to help turn themselves with brief changes. The CNA 5 stated resident 6 was incontinent but was able to notify staff when they needed a brief change and became impatient if not changed quick enough. The CNA 5 stated resident 6 had a rash on their bottom and believed it was either due to a reaction to the brief or because of resident 6's excessive sweat. The CNA 5 described resident 6 had a rash with red dots on their bottom and stated that ointment was applied with every brief change to help the rash. On 2/21/24 at 9:06 AM, an interview was conducted with CNA 2. The CNA 2 stated resident 6 had a hard time communicating their needs and stated resident 6 sometimes yelled and screamed to get staff's attention. The CNA 2 stated resident 6 had some mental delays and behaved like a child. The CNA 2 stated resident 6's briefs were changed at least every 2 hours. The CNA 2 stated resident 6 had been told to go in their brief since they were heavy to get up. The CNA 2 stated resident 6 was able to call when they needed a brief change. The CNA 2 stated resident 6 had sensitive skin which had lead to their current skin problems. The CNA 2 stated resident 6's skin around their bottom was irritated like when a baby had diaper rash. The CNA 2 stated they applied cream with every brief change to prevent it from getting worse. The CNA 2 stated resident 6 had a history of this and this irritation was new. The CNA 2 stated the type of rash resident 6 had occurred more frequently on light colored skin since that skin was more sensitive. On 2/21/24 at 10:44 AM, an interview was conducted with the Director of Nursing (DON). The DON stated they were unsure if resident 6 was able to make their needs known to staff and expected staff to check on resident 6 frequently. The DON stated they expected the CNAs to go in and check on resident 6 at least every two hours and that included incontinence care if needed. The DON stated if a resident was left in a soiled brief multiple times for a prolonged period, it affected the resident's skin integrity. The DON stated the outcome of compromised skin integrity included MASD which led to further skin break down and wounds if not treated appropriately. The DON stated staff had to be diligent on checking incontinent residents and applying barrier cream to prevent MASD. The DON stated resident 6 had MASD and was being followed by the wound care provider due to this. 22992 POTENTIAL FOR HARM 2. Resident 17 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease; dementia, moderate, with other behavioral disturbance; and diabetes. Resident 17's medical record was reviewed from 2/5/24 through 2/22/24. Resident 17's quarterly MDS assessment dated [DATE] indicated that resident 17 was frequently incontinent of urine and bowel. Resident 17's care plans were reviewed and revealed the following: a. On 10/21/22, a care plan was developed indicating that the resident has bowel and bladder incontinence and needs assistance with toileting cares r/t (related to) cognitive deficits. The interventions included to change resident 17's disposable briefs every shift and as needed, and check routinely during rounds and as required for incontinence. b. On 1/4/23, a care plan was developed indicating that the resident was at risk for skin breakdown related to incontinence, diabetes, and history of yeast infections and moisture associated skin damage. The interventions included to change reposition frequently as tolerated. c. On 10/11/22, a care plan was developed indicating that the resident had an ADL self-care performance deficit. Interventions listed indicated that the resident required partial/moderate assistance by one staff for toileting. A review of resident 17's Toilet Use Task in the electronic medical record on 2/14/24 indicated that during the previous 30 days the resident required varying degrees of assistance for toileting, including supervision, limited assistance, extensive assistance and total dependence. The Toilet Use Task information also indicated that the resident was only being assisted with toileting between one and three times a day. On 2/7/24, a continuous observation was made of resident 17, and revealed the following: a. At 9:45 AM, the resident was observed to be seated at a dining room table with other residents. b. At 10:15 AM, a strong smell of feces was noticeable in the dining room in the area where resident 17 was seated. c. At approximately 11:00 AM, the Activities Director (AD) asked a staff member to help resident 17 freshen up. d. At 11:59 AM, nearly one hour later, a staff member entered the dining room and walked with resident 17 to her room. e. At 12:02 PM, CNA 6 was observed to be wiping off the chair where resident 17 had been seated, using disinfectant wipes. CNA 6 stated that the other staff member had taken resident 17 to change her brief. f. At approximately 12:15 PM, resident 17 was observed to enter the dining room wearing a different shirt and pants. On 2/7/24 at 10:39 AM, an interview was conducted with CNA 4. CNA 4 stated that residents should be checked on and changed if needed every 2 hours. CNA 4 stated that staff did not document in the electronic medial record when brief changes were completed. 3. Resident 28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia, subarachnoid hemorrhage, muscle weakness, and generalized anxiety disorder. Resident 28's medical record was reviewed from 2/5/24 through 2/22/24. Resident 28's admission MDS assessment dated [DATE] indicated that resident 28 was frequently incontinent of bowel, and occasionally incontinent of urine, and required partial to moderate assistance with toileting hygiene. The MDS also indicated that resident 28 required substantial to maximum assistance to come to a standing position from sitting in a chair. Resident 28's care plans were reviewed and revealed the following: a. On 6/27/23, a care plan was developed that indicated resident 28 was at risk for skin breakdown related to incontinence, impaired mobility and cognitive impairment. b. On 7/19/23, a care plan was developed that indicated resident 28 required substantial/maximum assistance of staff for transfers and toileting. c. On 7/17/23, a care plan was developed that indicate resident 28 was at risk for pressure ulcer development related to cognitive impairment, impaired mobility, incontinence, impaired communication and malnutrition. The interventions on the care plan did not include any information regarding repositioning of the resident. On 2/7/24, a continuous observation was made of resident 28 and revealed the following: a. At 9:45 AM, resident 28 was observed to be seated in her wheelchair in the dining room. b. Between approximately 10:00 AM and 11:00 AM, resident 28 was observed to participate in an activity. c. At 12:10 PM, resident 28 was served lunch. d. At 12:31 PM, nearly three hours after the observation was initiated, resident 28 was wheeled out of the dining room. At no time during the 3 hour observation, was resident 28 repositioned or approached by staff regarding toileting. On 2/7/24 at 12:33 PM, an interview was conducted with Nursing Assistant (NA) 4. NA 4 stated that resident 28 was taken out of the dining room and to the shower room for toileting.

Based on observation, interview and record review it was determined, for 2 of 40 sampled residents, that the facility did not ensure that pain management was provided to residents who required such services. Specifically, two residents complained of uncontrolled pain and the pain medication follow up was documented as ineffective pain control, and the physician was not notified in a timely manner. A resident was also observed to vocalize pain during a wound treatment and was not provided pain medication prior to the treatment as was care planned, this will be sited at a harm level. Resident identifiers: 29 and 90. Finding Included: HARM 1. Resident 90 was admitted to the facility on [DATE] with diagnosis which included cellulitis of right lower limb, cellulitis of left lower limb, chronic venous hypertension with inflammation of left lower extremity, chronic venous hypertension with inflammation of right lower extremity, non-pressure chronic ulcer of unspecified part of left lower leg with fat layer exposed, non-pressure chronic ulcer of unspecified part of right lower leg with fat layer exposed, pain in unspecified limb, pain in unspecified foot, peripheral vascular diseases, diabetes type 2, and need for assistance with personal care. On 2/06/24 at 10:43 AM, an interview was conducted with resident 90. She stated that she tells the staff she was in pain from her legs to her feet. She stated that her pain was often at a 10 and that it was currently at a 10 and staff had not given her any pain medications that morning. She stated that when she tells staff she was in pain the staff will say they will get her something but never come back, and that it takes a lot of time to get somebody to help. Resident 90's medical record was reviewed from 2/12/24 thru 2/22/24. On 2/4/24, an admission Minimum Data Set (MDS) assessment was conducted. The functional ability of the MDS documented resident 90's functional limitation range of motion impairment for the upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) was impairment on both sides. Resident 90 required substantial/maximal assistance with mobility, upper and lower body dressing, toileting, and shower/bathe. On 2/5/24, an admission MDS assessment for pain was conducted. The pain interview documented, pain frequency as almost constantly. Resident 90 was asked, Please rate your pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine. The response was 10. Resident 90's care plan dated 2/3/24 indicated that the resident was at risk for pain related to wounds to bilateral lower extremities with infection. The interventions documented were the following: a. Administer analgesia per orders. Observe for efficacy and side effects. Give 1/2 (half) hour before treatments or care. b. Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. c. Monitor/record/report to nurse resident complaints of pain or requests for pain treatment. d. Resident 90's pain was aggravated by walking, movement, and wound treatment for foot wounds. e. Resident 90's pain was alleviated by pain meds, rest, and elevated legs. On 2/3/24, resident 90's physician orders revealed that resident 90 had the following orders: a. Oxycodone Hydrochloride (HCI) Oral Tablet 5 milligram (mg). Give 1 tablet by mouth every 6 hours as needed for Pain. b. Acetaminophen Oral Tablet 500 mg. Give 1 tablet by mouth every 6 hours as needed for Pain. On 2/4/24 at 2:22 PM, a pain level score was documented as 10 out of 10 (using a numerical scale from 0-10, 10 being the worst). On 2/4/24 at 2:22 PM, an administration note documented resident 90 received Oxycodone 5 mg for pain. On 2/4/24 at 5:06 PM, an administration note documented, oxyCODONE HCl Oral Tablet 5 MG[Miligrams] . Administration was: Ineffective. Follow-up Pain Scale was: 9. On 2/4/24 at 8:03 PM, an administration note documented Oxycodone was given for pain, resident reports pain 10/10. On 2/5/24 at 10:20 AM, a pain level score was documented as 8 out of 10. On 2/5/24 at 10:20 AM, an administration not documented resident 90 was given Oxycodone 5 mg for pain. On 2/5/2024 at 1:29 PM, an administration note documented, oxyCODONE HCl Oral Tablet 5 MG . Administration was: Ineffective. Follow-up Pain Scale was: 6. On 2/6/24 at 6:15 PM, an administration note documented resident 90 received Oxycodone 5 MG, pt [patient] c/o [complained of] px [pain] 8/10. On 2/6/24 at 9:10 PM, an administration note documented, oxyCODONE HCl Oral Tablet 5 MG . Administration was: Effective. Follow-up Pain Scale was: 3. On 2/7/24 at 3:19 PM, a nurses note documented, the nurse spoke with the physician about resident experiencing pain but not asking for pain medication. PCP [primary care physician] ordered to schedule 5 mg Oxycodone BID [twice a day] to help with pain management . On 2/7/24 at 7:00 PM, a physicians order documented, oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl). Give 1 tablet by mouth two times a day for Pain. [It should be noted that a physician was not contacted for 3 days regarding resident 90's documented uncontrolled pain and ineffective pain score after receiving medication.] On 2/14/24 at 10:34 AM, an observation was made of resident 90's receiving bilateral leg wound care. Resident 90 was observed to have her wound dressings already removed by the Wound Care Nurse Practitioner (WCNP). Resident 90 was observed to have her eyes tightly closed and eyebrows furrowed. The WCNP lifted each leg to observe the wounds, resident 90 stated ouch. At 10:46 AM, Registered Nurse (RN) 2 and RN 3 entered the room and stated they were giving resident 90 medication for pain. At 10:47 AM, WCNP and RN 3 lifted resident 90's left leg and continued wound care, while resident 90 cried out in pain stating ouch and crying. RN 2 stated resident 90 could hold her hand squeeze as hard as you need, I can take it. At 10:50 AM, Resident 90 cried louder stating, All of it hurts, the WCNP pressed on her heel and she cried out in pain, the WCNP asked the resident to state where she was feeling pain and where the WCNP was touching, resident 90 stated again, it all hurts, my heel. The WCNP stated she was sorry. At 10:52 AM, the WCNP began cleaning her wounds with gauze and wound cleanser, while the resident continued to have eyes shut tightly and crying while stating ouch multiple times. RN 2 stated for resident 90 to just squeeze her hand and that she could handle it. At 10:58 AM, resident 90's left leg was being wiped with gauze and wound cleanser, with each wipe of the gauze on the skin she would say ouch. At 11:03 AM, resident 90's legs were being wrapped in the outer layer of the wound dressing, she appeared calm, her eyes were no longer closed tightly and her eyebrows were not furrowed. [It should be noted that resident 90 did not receive pain medication a half hour prior to wound care and that it took approximately 30 minutes for her to look calm. It should be noted that after approximately 30 minutes the first 30 minutes of wound care included cleaning and directly touching the wounds and after the cleansing wound care consisted of wrapping resident 90's legs and no longer directly wiping the open wounds.] On 2/14/2024 at 10:45 AM, a physicians order documented, oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl). Give 5 mg by mouth every 24 hours as needed for pain with wound care. On 2/14/24 at 12:43 PM, an interview was conducted with RN 3. RN 3 stated when a resident received Oxycodone for pain, that it took about a half hour up to one hour for the pain relief to take effect. RN 3 stated that if a resident was receiving wound care that caused them pain, the resident should receive the medication before wound care so that it could help with and lessen pain during wound care. On 2/14/24 at 1:54 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that pain scores were considered one of the resident vitals and that if they were out of control the expectation was that staff would call the physician immediately to report if it was not being controlled with their current medication regimen. The DON stated that if a resident was taking oral Oxycodone for pain, it takes 15 to 30 minutes for it to become effective. The DON stated that if someone was getting wound care that was painful, she would expect the resident to receive the medication at least 15 minutes prior to wound care because the pain would be considerably less. The DON stated that if the resident did not receive pain medication prior to wound care, the resident would not have pain relief during wound care for the time it would take to become effective. She stated that resident 90 should have gotten the pain medication earlier, but that the nurses were busy and can only go so quickly. She stated that a wound care can be delayed or rescheduled in order for the resident to receive pain medication. The DON stated that during wound care when resident 90 was crying the WCNP did tell the resident they could stop wound care, but that the process of giving pain medication prior to wound care was to prevent pain during wound care, that ideally we do not inflict pain on the resident. 38031 2. Resident 29 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included a traumatic brain injury (TBI), hemiplegia and hemiparesis, major depressive disorder, panic disorder, anxiety disorder, low back pain, hepatitis C, seizures, insomnia, migraine, schizoaffective disorder, and history of suicidal behavior. 02/6/24 at 9:22 AM, an interview was conducted with resident 29. Resident 29 stated that he had pain in back and head. Resident 29 stated that he received Oxycodone for the pain, but it did not help. Resident 29 stated that his current pain level was 9/10. Resident 29 stated that he would like the pain to be non-existent, but he had to live with the pain. On 2/06/24, resident 29's medical records were reviewed. On 9/28/23, resident 29 had an order for Oxycodone Capsule 5 milligram (mg), give 1 capsule by mouth every 4 hours as needed for moderate to severe pain initiated. Resident 29's January 2024 Medication Administration Record (MAR) was reviewed. The Oxycodone 5 mg was documented as administered 22 times for reported pain scores of 2 through 9. On 1/26/24 at 7:56 PM, the Oxycodone 5 mg was administered for complaints of a headache. Resident 29 reported an initial pain score of 9/10. On 1/26/24 at 10:10 PM, resident 29's Oxycodone follow-up administration assessment was documented as Ineffective with a follow-up score of 7/10. No documentation could be found that the provider was notified of the ineffective pain control and no additional pain medication was administered. On 1/27/24 at 6:33 PM, the Oxycodone 5 mg was administered for complaints of bladder pain. Resident 29 reported an initial pain score of 9/10. On 1/27/24 at 8:22 PM, resident 29's Oxycodone follow-up administration assessment was documented as Ineffective with a follow-up score of 9/10. No documentation could be found that the provider was notified of the ineffective pain control and no additional pain medication was administered. On 12/21/23, resident 29's care plan for at risk for pain related to history of craniotomy, trauma and chronic migraines was initiated. Interventions identified included to anticipate the resident's need for pain relief and respond immediately to any complaints of pain; evaluate the effectiveness of pain interventions; review pain interventions for alleviation of symptoms, dosing schedules and resident satisfaction with results; monitor for side effects of pain medication and report occurrences to the physician; monitor/record/report any signs and symptoms of non-verbal pain; monitor/record/report to nurse loss of appetite, refusal to eat and weight loss; monitor/record/report to nurse resident complaints of pain or requests for pain treatment; and notify physician if interventions are unsuccessful or if current complaint was a significant change from past experience of pain. Review of the facility policy for Administering Pain Medications documented that pain management was defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. The policy stated that staff were to document the effectiveness of non-pharmacological interventions. The policy stated that staff were to re-evaluate the resident's level of pain 30-60 minutes after administering pain medication. The policy stated that staff should report information in accordance with facility policy and professional standards of practice. The policy was last revised in January 2024. On 2/12/24 at 12:37 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated resident 29 did not report pain. RN 2 stated that resident 29 would say that he had bladder pain and needed to urinate and wanted to be catheterized. RN 2 stated that resident 29 goes to the bathroom [ROOM NUMBER] times a day and his bladder was never full. RN 2 stated that resident 29 had as needed pain medication. RN 2 stated that he did not get the pain medication unless he asked for it. RN 2 stated that they would obtain a pain score and location of the pain prior to the medication administration and then they would evaluate the effectiveness 30 minutes after administration. RN 2 stated that if the pain medication was not effective, they should contact the physician. RN 2 stated that the notification to the physician would be documented in a progress note. On 2/13/24 at 7:56 AM, an interview was conducted with the Director of Nursing (DON). The DON stated for uncontrolled pain or pain that was not alleviated with pain medication the nurse should notify the physician. The DON stated the expectation for unresolved pain was to follow-up with physician immediately, and document in the nursing note that the physician was notified.

Based on interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not ensure that the resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, a resident with suicidal ideation, suicidal attempt, and homicidal ideation was assessed as requiring mental health services and those services were not provided. The deficient practice identified was cited at a harm Level. Resident identifier: 29. Findings include: Resident 29 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included a traumatic brain injury (TBI), hemiplegia and hemiparesis, major depressive disorder, panic disorder, anxiety disorder, low back pain, hepatitis C, seizures, hyperlipidemia, overactive bladder, benign prostatic hyperplasia, insomnia, migraine, schizoaffective disorder, lymphangioma, history of transient ischemic attack, and history of suicidal behavior. On 2/06/24 at 9:24 AM, an interview was conducted with resident 29. Resident 29 stated that he recalled previously sharpening a butter knife with the intent to stick his old roommate under the arm. Resident 29 stated that his old roommate, resident 99, was having sex with his old girlfriend and because of this he was going to stab resident 99. Resident 29 stated that resident 4 witnessed him sharpening the knife and asked him not to do it. Resident 29 stated that resident 4 liked resident 99 and did not want to see him hurt. Resident 29 stated that he never tried to hurt resident 99. Resident 29 stated that he never spoke to anyone at the facility about the incident and never spoke to the nurse about it. On 2/06/24 at 10:55 AM, an interview was conducted with resident 4. Resident 4 stated that she vaguely recalled another resident sharpening a knife. Resident 4 stated that she took the knife away and gave it to the nurse. On 6/22/23, resident 29's Patient Health Questionnaire (PHQ)-9 depression assessment documented a score of 17, which indicated moderately severe depression. On 9/21/23, resident 29's PHQ-9 depression assessment documented a score of 11, which indicated moderate depression. On 10/4/23, resident 29's PHQ-9 depression assessment documented a score of 7, which indicated mild depression. On 8/14/23, resident 29's Brief Interview for Mental Status (BIMS) assessment documented a score of 9, which indicated a moderate cognitive impairment. On 10/9/23, resident 29's BIMS assessment documented a score of 11, which indicated a moderate cognitive impairment. On 6/27/23, resident 29's PASRR Level II documented the resident's past medical history of a TBI due to assault that resulted in a craniotomy. Resident 29 then sustained a car accident that affected the right hemisphere with paralysis of the left upper extremity. On 4/28/23, resident 29 was hospitalized with increased extracranial fluid and periorbital cellulitis with Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Resident 29's history of psychiatric symptoms documented a history of depression and anxiety dating back to childhood. Resident 29 reported that his mother was abusive and neglectful and she forced him to go with a man who was a pedophile for money. Resident 29 endorsed a history of depressed mood, anhedonia, problems with sleep, problems with concentration, feeling of worthlessness and history of suicidal ideation. Resident 29 stated, I am depressed and I'm anxious and I have panic attacks. I feel like I'm absolutely no good. Resident 29 reported that he was hospitalized multiple times for mental health and attempted suicide at least twice. Resident 29 reported worsening of depression since accident and stated, I just wish life would be over. I just want to give this body back. Resident 29 stated he was depressed and very anxious. The assessment documented resident 29's mental illness diagnoses as major depressive disorder, panic disorder, and anxiety disorder. The assessment recommendations for specialized services for mental illness treatment were individual counseling and review of psychotropic medications. On 9/21/23, resident 29's PASRR level II documented the current psychiatric functioning was that resident 29 was struggling with feeling he needed to use the bathroom constantly and not being able to urinate. Resident 29 reported that this made him extremely anxious and he perseverated about this all the time. Resident 29 reported that his depression was less and he felt he was doing okay. The assessment recommendations for specialized services for mental illness treatment were individual counseling and review of psychotropic medications. Review of resident 29's physician orders revealed the following: a. On 5/10/23, an order was initiated for Clonazepam 1 milligram (mg) Oral Tablet, give 1 tablet by mouth as needed for Anxiety two times daily as needed. b. On 10/19/23, an order was initiated for Duloxetine Hydrochloride (HCL) Oral Capsule Delayed Release Particles 30 mg, give 30 mg by mouth one time a day related to major depressive disorder. c. On 1/30/24, an order was initiated for Duloxetine HCl Oral Capsule Delayed Release Particles 30 mg, give 30 mg by mouth one time a day related to major depressive disorder. d. On 5/10/23, an order was initiated for Escitalopram Oxalate Tablet 20 MG, give 1 tablet by mouth one time a day for depression. e. On 5/23/23, an order was initiated for Escitalopram Oxalate Oral Tablet, give 40 mg by mouth one time a day related to depression. f. On 1/30/24, an order was initiated for Escitalopram Oxalate Oral Tablet, give 40 mg by mouth one time a day for depression. g. On 5/19/23, an order was initiated for Hydroxyzine HCl Tablet 25 mg, give 1 tablet by mouth every 6 hours as needed for itching. h. On 9/12/23, an order was initiated for Hydroxyzine HCl Oral Tablet, give 25 milligram by mouth every 6 hours as needed for itching, agitation or anxiety for 30 Days. i. On 9/21/23, an order was initiated for Mirtazapine Oral Tablet, give 15 mg by mouth one time a day for depression for 30 Days. j. On 9/28/23, an order was initiated for Mirtazapine Oral Tablet, give 15 mg by mouth one time a day for depression for 30 Days. Resident 29's September 2023 Medication Administration Record (MAR) revealed the following: a. The Hydroxyzine 25 mg every 6 hours as needed was documented as administered with effectiveness on 9/14/23 at 11:29 AM, on 9/19/23 at 12:17 AM, on 9/22/23 at 11:21 AM, and on 9/23/23 at 7:56 AM. b. The behavior monitoring for the antianxiety medication for verbalization of anxiety had 28 episodes documented. c. The behavior monitoring for the antidepressant medication for negative statements to self and verbalized sadness had 6 episodes documented. Resident 29's progress notes revealed the following: a. On 9/14/23 at 2:56 PM, the Nurses Note documented, Resident was depressed about his ex-girlfriend. Stated that she was here this am and left and he need to tell her to bring him money. then worry about her getting into his money. He told [name omitted] in activities that he wanted to cut his wrist or kill himself. MD [Medical Director] notified. new order to transfer resident to ER [emergency room ] for eval. [evaluation] paramedic came and transported him to [local hospital name omitted] hospital at 14:56 [2:56 PM]. b. On 9/18/23 at 4:31 PM, the Interdisciplinary Team (IDT) Event Review note documented, resident sent to [local area hospital] for psych eval., returned today, mirtazapine started by [local area hospital] for increase in depression, all other least restrictive interventions in place, will continue to monitor. c. On 9/20/23 at 4:49 AM. the 72 Hour Event Charting note documented, Type of Event: Resident returned to facility on Monday after hospitalization for suicide threats. Interventions: Provided positive talk and encouragement, medication administration, and validation of feelings. Resident Reaction to Interventions: Resident compliant and expressive regarding his feelings of his current situation. Pain Management: Denied s/s [signs and symptoms] of pain, Improvement/Decline: Same, Notification(s): None d. On 9/20/23 at 2:03 PM, the Admission: 72 Hour Charting note documented, Primary Diagnosis: readmission for suicidal ideation. Focused Assessment: alert and oriented x [times] 3. stayed to himself sleeping and resting most of the day. required waking him up for meals and medications. verbalized needs when asked question. Adjustment to Admission: adjust well , ambulated to the bathroom. Pain Management: denied of pain this shift. Mental Status/Behavior: calm to self , quiet to self. Improvement/Decline: steady e. On 9/21/23 at 10:33 AM, the Social Service Note documented, [Resident 20] returned to the facility after going to hospital for suicidal comments and stating that he has a plan. He will be referred to [contracted behavioral health service] today. f. On 9/21/23 at 2:41 PM, the Admission: 72 Hour Charting note documented, Primary Diagnosis: suicidal ideation. Focused Assessment: alert and oriented x 3. He keep quiet in the room. appear tired. He keep stating that he cannot urinate. but found him in the bathroom urinate (sic) in toilet and still said he cannot urinate. water is pushed and then straight catheter him later. 30 cc [cubic centimeters] of urine came out. resident constantly use the bathroom. He went to f/u [follow-up] appt [appointment] with [name of provider omitted] today. ua [urinalysis] sample obtained and sent to the lab to rule out infection. Adjustment to Admission: compliant with medications. Pain Management: denied of pain. rest comfortably in bed. Mental Status/Behavior: quiet and sleep in bed mostly today. Improvement/Decline: stable g. On 9/22/23 at 1:42 PM, the Admission: 72 Hour Charting note documented, Primary Diagnosis: DIFFUSE TRAUMATIC BRAIN INJURY WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION, SUBSEQUENT ENCOUNTER. Focused Assessment: Due to SI [suicidal ideation] pt [patient] was transferred to psych [psychiatric] hospital for stabilization of mood. Pt readmitted on ce stable to. Admission: Adjusting well. No mention of any SI/depression at this time. Pt is out on the floor appropriately socializing. Pain Management: No c/o [complaints of] pain at this time. Mental Status/Behavior: Pt perseverates on needing to/unable to void/BM's [bowel movement]. Medication given as needed. Improvement/Decline: Pt's depression has improved. h. On 9/23/23 at 2:30 PM, the Social Service Note documented, Late Entry: Note Text: Clinical Status: [Resident 29] presents as stable. No psychiatric complaints are today expressed. Recent History: [Resident 29] described recent but not current thoughts of suicide. He today described brief, fleeting thoughts of suicide leading up to his recent hospitalization . He denied suicidal ideas or intentions following his return from the hospital. Denial is convincing. Mental Status Exam: [Resident 29] appears calm, attentive, communicative, casually groomed, and relaxed. He exhibits speech that is normal in rate, volume, and articulation and is coherent and spontaneous. Language skills are intact. Mood presents as normal with no signs of either depression or mood elevation. Affect is appropriate, full range, and congruent with mood. Associations are intact. There were no signs of psychotic symptoms this session. He denies having suicidal ideas. Homicidal ideas or intentions are denied. Cognitive functioning and fund of knowledge are intact and age appropriate. Short- and long-term memory are intact, as is ability to abstract and do arithmetic calculations. Vocabulary and fund of knowledge indicate cognitive functioning in the normal range. Insight into problems appears fair. Judgment appears fair. There are no signs of anxiety. There are no signs of hyperactive or attentional [sic] difficulties. [Resident 29] behavior in the session was cooperative and attentive with no gross behavioral abnormalities. Current risk appears to be LOW after returning from brief hospitalization . Resident currently denies any intent to carry out active self-harm while here under our care and supervision. Has committed to seek help and ask staff for support if risk elevates. i. On 9/24/23 at 2:50 PM, the Nurses Note documented, Nurses haven't been able to contact resident or get a hold of [name omitted] whom he was with. [Local] police dept called to do a well check on resident since he doesn't have his medications with him. They reported back that [resident 29] is fine and that he reports he is not returning to the facility. He expressed that he does want his belongings back, so we are working on that arrangement so he can get his medications and sign the necessary documentation. j. On 10/1/23 at 8:40 AM, the Nurses Note documented, Patient was angry in the middle o [sic] the night Had a fight with his girl friend [sic] and then he wanted to leave the facility and he started ramming his wheelchair into the front door. So this nurse went and got him and brought him down to the nurses station and talked with him for a bit. He wants his family in [name of stated omitted]. Patient returned to his room and was not seen for a bit. k. On 10/19/23 at 5:41 PM, the Psychotropic Note documented, Psychotropic meeting today, resident went to hospital last month for SI and was started on mirtazapine, however he continues to exhibit depressive symptoms, will start duloxetine 30 mg [milligrams]PO [by mouth] daily; provider agrees. Resident agrees with this plan. l. On 11/19/23 at 1:53 PM, the Nurses Note documented, It was brought to this nurses attention that resident was outside sharpening a butter knife to use to stab another resident. m. On 1/19/24 at 4:10 PM, the Social Service Note documented, Resident's referral re-submitted to [contracted behavioral health provider] for counseling. n. On 1/23/24 at 2:08 PM, the Social Service Note documented, Resident referred to [contracted behavioral health provider] program for (counseling and medication management). On 9/14/23 at 2:56 PM, the incident report documented, Resident made statements to several staff members today about wanting to kill himself, he told [name omitted] in Activities that he had attempted suicide this morning via cutting his wrists but was not successful. The resident stated, I just want to die. Immediate action taken was the resident was transferred to the hospital for a psychiatric evaluation. The report documented that the MD was informed on 9/14/23 at 3:03 PM. It should be noted that no documentation could be found of a facility investigation into the incident with the knife as documented in the nurse note on 11/19/23 On 5/10/23, the hospital History & Physical (H & P) documented, Suicidal ideation- may have been associated with his medical illness, and will need crisis eval at the time of discharge. On 9/14/23, the hospital H & P documented, Patient reports he has had chronic suicidality this year, he just finally voiced it today. His ex-girlfriend came to visit him today and did not say goodbye. He had a plan to cut his wrist with a butter knife he had access to. He reports he tried to do this but was unsuccessful. Does not have access to guns. Patient currently feels suicidal, hopeless. Says he can not continue living with chronic pain. Says he has a history of schizoaffective bipolar disorder, not currently on meds. Was formally on Ativan for anxiety but not currently. Denies HI [homicidal ideation] or AVH [auditory verbal hallucinations]. Has a history of previous mental health hospitalization and previous suicide attempts. Denies drug or alcohol use Says he would be willing to go back on psychiatric medication. The Specialized Rehabilitation Services (SRS) and Social Work Consultation notes documented under observations, findings, and recommendations the following: a. May 2023- Resident needs a social service care plan for depression and LTC [long term care] or Discharge b. June 2023- Resident needs a social service care plan for depression and LTC or Discharge. c. July 2023- no recommendations or notes documented. d. August 2023- Resident needs a quarterly note. e. October 2023- no recommendations or notes documented. f. November 2023- no recommendations or notes documented. g. December 2023- no recommendations or notes documented. h. January 2024 - Resident due for quarterly note. Resident 29's Kardex documented under Behavior/Mood the following: *Encourage and support resident when angry/wanting to leave by offering pleasant diversions, structured activities, food, conversation, television, book follow up with MD. *Monitor/record occurrence of for target behavior symptoms (verbizes [sic] anxiety) and document per facility protocol. *Observe for wandering or changes in cognition. Assess for changes as needed. It should be noted that the Kardex did not contain any safety or monitoring documentation on resident 29's suicidal ideation, suicidal attempt, or sharpening of a butter knife to use as a weapon. On 7/18/23, resident 29 had a care plan initiated for Level II PASRR determination for serious mental illness due to major depressive disorder, anxiety disorder, and panic disorder. Interventions identified included assist case worker with obtaining any needed information; coordinate services with habilitative coordinator; invite the habilitative coordinator and be responsible to the quarterly care plan meeting that discusses resident status; recommendations for services to be provided by the facility for physical therapy (PT), occupational therapy (OT), medication management and assist with activities of daily living (ADLs); monitor for increase in symptoms of depression; recommendations for specialized services for mental illness treatment: patient was in need of mental health services including individual counseling and a review of his psychotropic medications; and report any need to re-evaluate for additional specialized services. On 8/2/23, resident 29 had a care plan initiated for patient meets PASRR Level II level of determination secondary to major depression, generalized anxiety disorder, and panic disorder. The care plan documented that resident 29 had a history of recurrent depression, anhedonia, problems with sleep and appetite, fatigue, concentration, history of suicidal ideation and attempts. The care plan further documented that resident 29 had difficulty controlling worry, had a history of panic where he feels abrupt surge of fear, trembling, shaking, abdominal distress, fear of dying, feelings of light-headedness, numbness, tingling. Interventions identified included would receive appropriate specialized services as indicated on the PASRR Level II; refer to mental health Services as needed; arrange for PASRR re-evaluation if there was a significant change in status that results in new evidence of possible mental disorder, intellectual disability and/or related condition; coordinate and/or inform the appropriate agency to conduct the PASRR evaluation and obtain results if it was learned that Resident's/Patients PASRR was not completed or was incorrect; recommendation for specialized services for mental illness was mental health services needed including individual counseling and a review of his psychotropic medications; recommendations for services to be provided by the facility for physical therapy (PT), occupational therapy (OT), medication management and assist with activities of daily living (ADLs); and monitor for increase in symptoms of depression. On 9/15/23, resident 29 had a care plan initiated for at risk for suicidal impulsive/ideation's of self-harm related to psychiatric disorder and a history of suicidal statements. Interventions identified included to send to emergency department for suicidal ideation; medication changes made; allow time for expression of feelings; provide empathy, encouragement, and reassurance; encourage resident participation in activity preferences; ensure medications are swallowed after administering; keep resident representative(s) involved with status of resident condition and plan; listen to resident and try to calm; monitor and report to the Charge Nurse, Nursing Supervisor, and Physician/NP [nurse practitioner] any behavior changes (e.g., appetite/expression, excessive crying, etc.); SUICIDAL IDEATION RESPONSE: A staff member will remain with the resident until the Licensed Staff member arrives to assess the resident; SUICIDAL IDEATION RESPONSE: After performing a suicide assessment, the Licensed Staff member shall notify the resident's Attending MD and responsible party; SUICIDAL IDEATION RESPONSE: Immediately report to the Charge Nurse, Nursing Supervisor, and Physician/NP if resident verbalizes thoughts of hurting themselves; SUICIDAL IDEATION RESPONSE: Nursing personnel and other staff involved in caring for the resident shall be informed of the suicidal ideation and instructed to report changes in the resident's behavior immediately; and SUICIDAL IDEATION RESPONSE: Provide increased supervision of resident until the danger of imminent harm has passed or a transfer occurs. On 2/8/24 at 10:18 AM, an interview was conducted with the Certified Nurse Assistant Coordinator (CNAC). The CNAC stated that the facility provided behavioral training which covered de-escalation techniques for the residents. The CNAC stated that the techniques were resident specific and she along with the previous Director of Nursing (DON) would identify interventions and care plan them together. The CNAC stated that they had a Resident Advocate (RA) that had been at the facility for about a month. The CNAC stated that prior to that they had been without a social service worker for approximately 3 months. The CNAC stated that they had a local behavioral health provider that came to the facility to provide mental health services. The CNAC stated that they came to the facility weekly and as needed. The CNAC stated that resident 29's behavior was urination behaviors, believing he has to urinate all the time. On 2/12/24 at 9:06 AM, an interview was conducted with Nursing Assistant (NA) 1. NA 1 stated that resident 29 did not have any behaviors that she was aware of. NA 1 stated that on one occasion she witnessed resident 29 yelling from the bathroom. NA 1 stated that resident 29 stayed in his room a lot, and maybe was depressed. NA 1 stated that resident 29 did not have any restrictions that she was aware of. On 2/12/24 at 9:47 AM, a follow-up interview was conducted with the CNAC. The CNAC stated that resident 29 did not have any violent behaviors that she was aware of. The CNAC stated that resident 29 liked to sleep a lot. The CNAC stated that resident 29 reported sad thoughts and that he had some issues with his ex-girlfriend. The CNAC stated that resident 29 was suicidal a few months ago and it had to do with his girlfriend. The CNAC stated that resident 29 gets down when he was lonely. The CNAC stated that resident 29 needed to feel more valued as an individual. He may be a little depressed, a lot of the residents feel that way when they don't have 1:1. The CNAC stated that resident 29 reported to one of the employees, I'm down, I want to die. The CNAC stated that they took this statement seriously. He needed a bit more help. The CNAC stated that they transferred resident 29 to the hospital. On 2/12/24 at 11:57 AM, an interview was conducted with the Resident Advocate (RA). The RA stated that the Minimum Data Set (MDS) Coordinator was arranging the residents referrals to the contracted behavioral health provider but now they were training her on how to do it. The RA stated that a couple of weeks ago the MDS Coordinator provided her a list of residents that needed referrals to the behavioral health provider. The RA stated that the Director of Nursing (DON) stated that they were no longer using the previous contracted behavioral health provider and would need to send the referrals to the new mental health provider. The RA stated that she was still waiting for the new provider information. The RA stated that the facility had not had a social service worker (SSW) for awhile prior to her arrival on 12/19/23. On 2/12/24 at 1:12 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that she was in charge of referrals to behavioral health services for the time period between when the previous RA (PRA) left and when the new Resident Advocate arrived. The MDS Coordinator stated it was not clear that she should have been doing referrals, and she did not make any new referrals during this time. The MDS Coordinator stated that if the resident was receiving mental health services then the notes would be located in the electronic medical records under miscellaneous. On 2/12/24 at 2:00 PM, an interview was conducted with the Corporate Social Service Worker (CSSW). The CSSW stated that the Social Worker Consultant that documented the SRS notes did not come to the facility and see the residents, but instead conducted a chart review. The CSSW stated that the facility contracted with a behavioral health provider for mental health services, but they were in the process of obtaining a new contracted provider. The CSSW stated that residents were also able to use their own provider if they already had one. The CSSW stated that if the residents had not been seen by the contracted provider then they had not been seen for mental health services. The CSSW stated that they had identified that there was a need for residents to be connected with behavioral health services. The CSSW stated that for a lot of the residents they could not find documentation that mental health services had been provided. The CSSW stated that they reviewed all the residents two weeks ago and made a bunch of referrals. The CSSW stated that when they received a PASRR in the admission process that identified a mental illness they should be asking the resident about behavioral health services and if they have a provider. If the resident was open to services the CSSW stated that someone in the facility should be coordinating those services. The CSSW stated that the referrals and coordination of care should be documented in the resident progress notes. The CSSW stated that resident 29 would like to have counseling. The CSSW stated that resident 29 was sent to the hospital in September 2023 for suicidal ideation and the PRA was supposed to have made a referral for mental health services. The CSSW stated that her understanding was that it was a suicidal ideation and not a suicidal attempt. The CSSW stated that resident 29's care plan should address the suicidal ideation, PASRR and recommendations and any mental health issues. The CSSW stated that interventions to prevent future attempts should address removing any sharp objects from the room, monitoring for access to those objects and re-assessing upon return to the facility to determine safety needs. The CSSW stated that the monitoring should occur until the MD made a determination to discontinue. The CSSW stated that the staff should also be monitoring for the resident's access to any sharp objects and they should be putting in a progress note or alert charting for the monitoring. The CSSW stated it should also be in the Kardex as well. The CSSW stated that staff should be able to tell her that they were monitoring resident 29 for this and if he had any restrictions. The CSSW stated that it would be concerning if resident 29 had repeat access to sharp objects again. On 2/12/24 at 2:52 PM, a follow-up interview was conducted with the CSSW. The CSSW stated that resident 29 was referred to the contracted behavioral health provider on 1/19/24 and again on 1/23/24. The CSSW stated that resident 29 was not referred for mental health services prior to this. On 2/13/24 at 8:18 AM, an interview was conducted with Registered Nurse (RN) 2 and RN 3. RN 2 stated that the Director of Nursing (DON) updated the resident's care plan. RN 2 stated that they could view the care plan and they informed the DON of any new interventions that they had identified. RN 3 stated that the aides had a Kardex that would inform them of the identified interventions for the residents. On 2/13/24 at 8:20 AM, an interview was conducted with the DON. The DON stated that the MDS Coordinator updated the resident care plans, and the information was communicated in the morning stand up meetings. The DON stated that if the nurses notified her of any new care plan interventions or care areas she would discuss it in the morning meeting. The DON stated that they did not have a behavioral group. The DON stated that the facility used a psychiatric NP in the past. The DON stated that she felt like they needed a psychiatrist involved with the care to resolve any behavioral health plans. The DON stated that they had been consulting with a contracted behavioral health service. The DON stated that resident 29 needed behavioral health services as soon as possible. Just because he hasn't had any recent issues doesn't mean he doesn't need one. The DON stated that she would send a referral to the contracted behavioral health service today for resident 29. The DON stated that the new behavioral health group was not yet implemented but that they had planned to transition to new providers. On 2/13/24 at 8:39 AM, a follow-up interview was conducted with the MDS Coordinator. The MDS Coordinator stated that they identified care plan interventions through the IDT meetings and morning standup meeting. The MDS Coordinator stated that she and the DON went through the 72 hour report, checked the resident dashboard for medication changes, and each department would discuss issues with resident care. The MDS Coordinator stated that she was currently handling the PASRR Level II evaluation referrals. The MDS Coordinator stated that resident 29's current PASRR care plan was initiated on 12/21/23 and the SI care plan was initiated on 12/21/23. The MDS Coordinator stated that resident 29 was readmitted to the facility on [DATE]. The MDS Coordinator stated that they would have had to redo the PASRR if resident 29 was discharged to the community for greater than 2 days. The MDS Coordinator stated that they received resident 29's PASRR letter of determination on 9/28/23 and he was reassessed.

Based on interview and record review, the facility did not provide and document sufficient preparation to 2 of 40 sampled residents to ensure safe and orderly transfer or discharge from the facility. Specifically, one resident with cognitive impairment was discharged to a hotel room, but was subsequently seen at a local emergency room after becoming lost. This resulted in a finding of harm. In addition, one resident left on a leave of absence, and was not oriented for discharge upon return to the facility. Resident identifiers: 94 and 97. Findings include: HARM 1. Resident 94 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Wernicke's encephalopathy, dementia, major depressive disorder, other amnesia, and history of traumatic brain injury (TBI). Resident 94's medical record was reviewed from [DATE] through [DATE]. An admission Minimum Data Set (MDS) assessment dated [DATE] for resident 94 was reviewed. The MDS indicated that a Brief Interview for Mental Status (BIMS) was completed. The BIMS indicated that the resident was unable to report the correct month and year. The resident received a score of 8 on the BIMS, indicating that the resident was moderately cognitively impaired. Resident 94's care plans were reviewed and included the following: a. On [DATE], resident requires long term care services related to: TBI w/ (with) major neurocognitive DO (disorder). b. On [DATE], resident was admitted to facility with diagnoses of Severe cognitive dysfunction, inability to take care of himself, dementia, wernick's (sic) encephalopathy, amnesia, hx (history) of traumatic brain injury . c. On [DATE], resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) TBI with major neurocognitive disorder. d. On [DATE], resident has limited physical mobility r/t TBI with major neurocognitive [disorder). e. On [DATE], resident has a behavior problem, making inappropriate comments to female resident's (sic) r/t poor impulse control s/t (secondary to) TBI. f. On [DATE], resident is an elopement risk/wanderer r/t TBI Impaired safety awareness. g. On [DATE], resident has impaired cognitive function/dementia or impaired thought processes. h. On [DATE], resident has a communication problem r/t Expressive Aphasia, Head Injury, Neurological symptoms, Receptive Aphasia. i. On [DATE], resident is at Low, Moderate Risk for Falls per standardized fall scale Cognitive deficits, Confusion, Gait/balance problems, Incontinence, Psychoactive Drug Use, Unaware of Safety needs, Wandering. j. On [DATE], resident is at risk for bladder incontinence and requires assistance with toileting cares r/t Confusion, Neurogenic disorder, Poor toileting habits s/t TBI . There was no discharge care plan in resident 94's medical record. Resident 94's emergency room (ER) notes from a local hospital dated [DATE] were reviewed. The ER notes documented that the resident presented to the ER after an apparent altercation at a previous facility and was not aware of circumstances as to why he came here. The ER notes documented that resident 94 was diagnosed at that time with violent behavior and frontal lobe and executive function deficit. The ER notes documented that The patient does not have the mental capacity to be discharged from the ER and there is no place to discharge him safely. He therefore unfortunately remains in the emergency department for lack of any other viable options. The Behavioral Consultation notes from the ER stay during [DATE] were reviewed and documented the following: resident 94 . is a [AGE] year-old male with past psychiatric history significant for major current cognitive disorder, history of TBI, history of Warnicke (sic) Korsakoff syndrome, frontal lobe and executive function deficit, who was brought to the [name of local ER] after episode in which he assaulted his roommate . Patient has a well documented history of major neurocognitive disorder that is likely multifactorial given history of alcohol use and history of TBI, as well as frontal lobe and executive function deficit, and recently documented diagnosis of major neurocognitive disorder via neuropsychological testing. On my evaluation, patient was oriented to himself, though had difficulty articulating the events leading to ED (Emergency Department) presentation, as well as not being aware of the date or place that he was currently in. I suspect that this is reflective of his baseline cognitive abilities given the previous mentioned diagnoses. The patient's behavior is certainly concerning, though I do suspect that his assaultive behavior and threats of homicide are likely manifestations of his underlying neurocognitive disorder as well as TBI. I suspect that both of these disorders are contributing to frontal and executive function deficits, which are likely impairing his judgment. The Behavioral Consultation notes from the ER also indicated that in [DATE], resident 94 had been residing in skilled nursing facility . until recently when he self-discharged . According to family, patient has been calling frequently with bizarre request including request to talk to his father and mother who have both been deceased for 5 and 3 years respectively. Additionally, patient talked to sister about his son who is now 22 as if he is [AGE] years old still. With concern, family was initially unable to locate [resident 94]. After searching the city, they found him in his old neighborhood from [AGE] years prior when he owned to house (sic). He was trying to meet up with old friends and was clearly confused. Patient has furthermore exhibited wandering behavior, inappropriate gestures toward female staff and poor short-term recall. Accordingly patient is not deemed to have decision-making capacity . Patient has not demonstrated decision-making capacity, which has been corroborated by several physician evaluations as well as neuropsychiatric testing during this hospital admission. the role of an Alzheimer's fronto-temporal dementia process cannot be ruled out at this point but either way a neurodegenerative disorder is apparent. Resident 94's Level II PreAdmission Screening Resident Review (PASRR) dated [DATE] was reviewed. The PASRR indicated that resident 94 was brought to a local ER by law enforcement on [DATE]. The PASRR evaluator documented that during one of his hospital stays, resident 94 underwent this evaluation and it was evident that he is not able to make informed decisions on his own and requires the assistance of a facility to provide the appropriate care on a daily basis. Testing results indicate that [resident 94] is not able to reside in a less restrictive environment and will likely require not only skilled nursing services ongoing but a memory care unit. The PASRR evaluator also documented that resident 94 struggled to answer questions, was a poor historian, was unable to remember that his parents passed away, and has no level of insight into the fact that he has not owned [his] home for over [AGE] years. The PASRR evaluator concluded that resident 94 would continue to benefit from skilled nursing services. He will require this on an ongoing basis and he is not able to perform several of his ADLs without assistance. He would benefit from cognitive stimulation, support, encouragement and group activities with socialization. He would have the greatest benefit in a memory care unit. He would also benefit from someone having guardianship to ensure that his needs are met. Resident 94's progress notes indicated the following: a. On [DATE] at 1:30 PM, a physician note documented, Spoke with patient this morning. He answers some questions but refuses to answer some, says frustrated with being woken up and asks to leave the facility. More communicative through the day: he explains he can go to the rescue mission and will follow up with other doctors he's had. He wants to stay at a hotel after discussion. Also given options for the [name of local homeless shelter]. He has capacity to make decisions for himself and has a logical discharge plan. Communicated to facility to arrange discharge when able. [Note: This is in direct conflict with multiple specialist assessments from resident 94's previous hospitalization s and evaluations.] b. On [DATE] at 5:34 PM, Resident educated on following the prescribed doses on the medication cards. Resident stated understanding. c. On [DATE] at 6:15 PM, Resident discharged from facility today at 1815 (6:15 PM). Drive to destination by administrator. [Note: It should be noted that resident 94's medical record did not discuss any discharge plans prior to [DATE].] On [DATE], resident 94 was seen at a local ER. The ER notes documented that resident 94 was brought to the ED after found wandering streets in the rain knocking on his old childhood home door. He has significant neurocognitive deficits and resided in care of (sic) facilities for approximate (sic) last 3 [plus] years. he does not have capacity for decision making/to leave against medical advice. He will require supervision for nutrition and medication management as well as protection from potential exploitation (to which he would be vulnerable if he were not in a secured setting.[resident 94] lacks capacity to make decisions on his own behalf regarding his living situation. It is my professional opinion that [resident 94] requires a secure and structured environment for his own safety. The resident was diagnosed with alcohol-induced persisting amnestic disorder. On [DATE] at 4:05 PM, an interview was conducted with the previous Administrator (PADM). The PADM stated that resident 94 wanted to discharge from the facility, stating we knew he didn't want to be there (at the facility) and I talked to him and said 'do you want to be here?' and he said 'no I want to go'. The PADM stated that he then had a conversation with the doctor to see if he was well enough to go out on his own, and the doctor said we can't keep him here. The PADM stated that he then spoke with resident 94 again and told the resident that the facility would pay for a hotel for several nights. The PADM stated that he drove resident 94 to the local homeless shelter to show him and talk to him about the fact that they have people that can help him out. The PADM stated he provided resident 94 with food and printed a map to make sure he was fine getting there. The PADM acknowledged that resident 94 had cognitive impairment but stated that resident 94 was experiencing increasing behaviors, and the PADM relied on the physician's opinion that the resident was capable of making his own decisions. POTENTIAL FOR HARM 2. Resident 97 was admitted to the facility on [DATE] with diagnoses that included cardiomyopathy, severe protein-calorie malnutrition, viral hepatitis C, generalized anxiety disorder, muscle weakness, adjustment disorder with anxiety, major depressive disorder, dysphagia, and insomnia. Resident 97's medical record was reviewed from [DATE] through [DATE]. Resident 97's quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident's BIMS score was 9, indicating moderate cognitive impairment. Resident 97's progress notes indicated the following: a. On [DATE] at 4:00 PM, a nurses note read, Resident approached nurses' station and resident informed nurse that he was going to look at apartments with a friend. Resident had walker with him when leaving. Resident signed LOA (leave of absence) book and resident assisted to front door and visitor waiting at front door for resident. Resident did not return as of midnight and informed oncoming nurse he had not come back from LOA. b. On [DATE] at 8:18 PM, a social services note read, Resident 97 left with someone around 4:00pm signed out and said he was going to look for apartment. Hasn't returned yet. discharged him on LOA. c. On [DATE] at 11:55 AM, a nurses note read, Got a call from a lady by the name of [name deleted]. she was calling to check on [resident 97]. explained [resident 97] hasnt returned from LOA Visit. [name deleted] stated she brought him back at [DATE] around [8:00 PM]. stated she wound (sic) call his family but was adamant she dropped him off last night. per records [resident 97] checked himself out with [name deleted] but never checked back after his visit. d. On [DATE] at 9:30 PM, a nurses note read, Received (sic) a call from a female asking if resident is here at the facility. Says that she dropped him off around 830pm but did not watch him come inside of facility. Staff went outside and searched the premises for him but he was not there. Was not at ,d+[DATE] either. Notified DON [Director of Nursing] of situation. Also mentioned this to [name of physician]. e. On [DATE] at 3:50 PM, a nurses note read, [Resident 97] showed up this afternoon and stated he was here to pick up his personal items. he appeared impaired and was arguing with staff. explained to him is admission required which was to go to the ER for readmission (sic). pt refused. told staff to get his electronic (sic) wheelchair and pack his electronics in his back pack. stated he will come back on Monday to pick up the rest of his items. The facility filed an Initial Entity Report with the State Survey Agency (SSA) on [DATE], approximately 6 days after resident 97 left the facility. The report documented that resident 97 signed the leave of absence (sic) book on Wednesday ,d+[DATE] at around 4:30pm and left with a friend to go look at appartmnets (sic). It was our understanding that he would be back later that day however he has left with friends before, stayed at their place and not come back for a couple days. On Friday ,d+[DATE] at around 8:45pm the friend he left with reported that she had dropped him off in front of our building. He hadn't come in to the building at that time and so we sent some people out to search for him because he only had his walker. After we couldn't find him we thought that he must have called another friend and so we dediced (sic) to give him the weekend. We talked with the original friend he originally left with multiple times through the weekend and tried to reach out to the cell phone number we had for him as well in attempt to find him. The following Monday he still hadn't come back and so we reached out to the police to file a missing person's report. The Alleged Abuse Verification of Investigation Report form completed by staff on [DATE] for resident 97 was reviewed. The report indicates that on [DATE] one staff member was interviewed. The staff member stated that resident 97 signed our Leave of Absence book stating that he was going to look at apartments and would be back later that evening. He left with a friend who came to pick him up. He left with his walker and the clothes on his back. He never came back that night or several nights later. No other interviews were documented on the report. The Alleged Abuse Verification of Investigation Report form also documented that resident 97 has been at our facility for the better part of a year. He has progressed in all his care measures to the point that we have been trying to help him transition out to living on his own. The doctor was prepared to discharge him as soon as we found a safe discharge location. On [DATE] at 4:05 PM, an interview was conducted with the Previous Administrator (PADM). The PADM stated that resident 97 was often drunk or high due to a drug problem. The PADM stated that resident 97 would often leave for longer than a day, so we were telling him this wasn't a hotel. If he's there he has to follow the regulations in order to get care. The PADM stated that he attempted to reach out to resident 97 but that resident 97 was under the influence of whatever it was. The PADM stated that when it was evident he wasn't coming back after what we had done to try and get him back, the facility discharged resident 97. The PADM was unable to explain why the resident was not reported missing sooner, why no other staff were interviewed during the investigation, and why the resident was not appropriately oriented for discharge once he returned to the facility.

Based on interview and record review, the facility did not ensure that 1 of 40 sampled residents had the right to refuse medical treatment and formulate an advance directive. Specifically, one resident with an advanced health care directive received treatment that was documented as against the resident's wishes. This resulted in a finding of harm. Resident identifier: 39. Findings include: Resident 39 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, interstitial pulmonary disease, acute and chronic respiratory failure, severe protein calorie malnutrition, pulmonary fibrosis, endocarditis, transient ischemic attack, end stage heart failure, atrial fibrillation, pulmonary hypertension, abnormal weight loss, delirium, benign prostatic hypertension, pneumonia, pressure ulcer on sacrum, and history of skin cancer. Resident 39's medical record was reviewed from [DATE] through [DATE]. Resident 39's medical record included a document entitled Utah Advance Health Care Directive. The document included resident 39's initials next to the statement, I choose not to receive care for the purpose of prolonging life, including food and fluids by tube, antibiotics, CPR (Cardio Pulmonary Respiration), or dialysis being used to prolong my life. I always want comfort care and routine medical care that will keep me as comfortable and functional as possible, even if that care may prolong my life. The document was signed by resident 39 and a witness, and was dated [DATE]. Resident 39's medical record also included a Provider Order for Life-Sustaining Treatment (POLST). The POLST indicated that resident 39 did not want staff to attempt or continue any resuscitation and wished to have a status of Do Not Resuscitate (DNR). The POLST was signed by the physician on [DATE], and there was a note on the POLST that said the resident wanted to speak to his son before signing this POLST. On [DATE] at 1:57 PM, a nurses note for resident 39 documented that Patient DNR code status, facility to complete POLST paperwork. On [DATE] at 3:58 AM, a nurses note for resident 39 documented that Resident passed away. MD [Medical Doctor] and family notified. Resident discharged from facility. On [DATE] at 8:16 AM, a nurses note for resident 39 documented that Residents O2 (oxygen) saturation was not recording on pulse ox (oximeter) for CNA (Certified Nursing Assistant) and notified nurse. Nurse assessed situation and had CNA turn-up residents O2 to 5 L's (liters). Resident was having labored breathing. Nurse notified DON (Director of Nursing) to check code status and DON stated that that information was not signed so to start CPR. Aids started CPR and nurse called 911 per DON's request. On [DATE] at 9:47 AM, an interview was conducted with the Previous Director of Nursing (PDON). The PDON stated that she was the DON at the time that resident 39 passed away. The PDON stated that approximately 24 hours before the resident's death, resident 39 was experiencing some respiratory distress. The PDON stated that facility staff provided a nebulizer treatment, but resident 39 crashed quickly. The PDON stated that when resident 39 was found to not have any oxygen saturations, facility staff contacted her by phone. The PDON verified that she had instructed staff to perform CPR on the resident, because although resident 39 had expressed verbally that he wanted to be a DNR status, the resident also wanted his son to look at the POLST document prior to him signing. The PDON stated that she was not aware that resident 39 had a previous signed advanced directive on file indicating he did not want CPR. When asked about the process for completing advanced directives, the PDON stated that it was a collaborative thing. The PDON stated that there was a POLST binder at the nurses station, where the residents' advanced directives were kept. The PDON stated that the nurse working the night that resident 39 was an agency nurse so that's why he called me. When asked how agency staff were trained about the advanced directives of residents, the PDON stated that we have a binder for agency but he was not a nurse that came to our facility very often. I think he only came twice, including that night [that resident 39 passed away]. He was not as familiar with the facility and where everything was. The PDON stated that the nurse going off shift should have oriented the agency nurse coming on shift about where to locate resident information.

Based on interview and record review, it was determined the facility did not ensure that each resident received adequate supervision and services to prevent accidents for 1 of 18 sampled residents. Specifically, a resident with an assessed elopement risk and a history of wandering away from the facility, eloped from the facility and sustained frost bite injuries to his lower extremities related to exposure. Resident identifier: 90. Findings include: Resident 90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/28/19, resident 90 eloped from the facility at approximately 2:00 PM. Resident 90 was not located and returned to the facility until 11/29/19 at approximately 11:00 AM. Facility staff documented the following regarding resident 90's elopement: a. 11/28/19 at 4:00 PM, a facility nurse documented, Patient missing since approx. 1400 (2:00 PM) today having escaped facility. DON (Director of Nursing) notified. No family. Police responded to RN (Registered Nurse) call. Multiple officers searching for this patient Picture ID of patient given with medications, [DIAGNOSES REDACTED]. He is apparently on foot and has possibly one shoe off. Police are out still searching for patient at 1830 (6:30 PM). All managers are updated and protocols followed. Police continue intensive search at this time. All information passed on in report to oncoming shift RN at 1830 (6:30 PM). b. On 11/28/19 at 4:08, a facility staff member documented the following in an incident report, .Searched (resident 90's) room to see if could find wander guard taken off and found none. Wander guard placement is checked every shift and was noted to be on this day. Wander guard rounds are done weekly to ensure equipment is working properly. c. On 11/28/19 at 8:57 PM, a facility nurse documented, It was reported to this nurse at approximately 1600 (4:00 PM) that (Resident 90) was missing. Intensive search of building, grounds and surrounding areas was done to locate (Resident 90.) MD notified, he is his own responsible party, no family or friends to notify. (Resident 90) was last seen approximately 1420 (2:20 PM) walking in hallway. Police were notified at 1605 (4:05 PM), missing person report completed. (Resident 90's) probation officer was notified as well at this time. Staff continued to drive surrounding areas for several hours to assist looking for (Resident 90). Police reported 2030 (8:30 PM) to this nurse they have performed an extensive search of area checked all open businesses and all surrounding hospitals. Police did a press release to ask for public assistance in search. d. On 11/29/19 at 8:16 AM, a facility nurse documented, (Resident 90) left the building yesterday around 2 in the afternoon. He has not come back. The police were called and it has been in the news. Hospitals, homeless shelters and his probation officer have been called. Staff has been searching for him since as well. e. On 11/29/19 at 11:19 AM, (Resident 90) has been found. He is currently being treated at the facility. Paramedics came to assess him and said that he could be treated at the facility. Referrals have been made for wound care etc. to treat him. f. On 11/29/19 at 11:57 AM, a facility staff member documented the following Incident Note: .He (resident 90) was wearing warm clothing, coat, socks shoes and sweats. His wander guard was on his lower extremity and functioning Red areas noted on toes and feet. Some skin peeling off bottom of both feet. Wet clothing was removed and replaced with warm dry clothing, warm blankets provided. Paramedics called and came into perform assessment and felt he did not need to go to hospital as his vitals were all stable and within range. Staff one on one with (Resident 90) to ensure safety. Notified MD and wound team and to ensure safety and advised it would be best for him to be sent out to ER (emergency room ) for a full work up and evaluation. Paramedics called and sent to ER. Nurse to nurse report given to (name of local hospital) and stressed to nurse he cannot be left alone as he is one on one with staff here in the facility. Gave them cell phone number to contact as well as facility phone number. Probation officer, the state survey agency, APS (Adult Protective Services), ombudsman, hospitals all involved searching for him were notified of his safe return. On 11/29/19, resident 90 was admitted to a local hospital. He remained in the hospital until his discharge to another nursing home on 12/3/19. The hospital discharge orders included the following History of Present Illness, .presented with a chief complaint of exposure. Patient come (sic) from a secure care facility, paitent (sic) has extensive psychiatric history was able to get out of his facility last night. Patient not a good historian, reports he went out and wrestled with someone. Patient was located by police this morning with one shoe, appeared to have frostbite to his lower extremities. ER workup consistent with rhabdomyolysis likely secondary to exposure. On 12/17/19 at 11:53 AM and again on 12/18/19 at 10:02 AM, interviews were conducted with the Administrator. The Administrator stated facility staff were not able to determine how resident 90 was able to leave the building on 11/28/19. The Administrator said resident 90 has his wander guard ankle bracelet on when he left the building. The Administrator stated that although the facility utilized a wander guard system, it was not 100% effective. The Administrator suspected a visiting family member of another resident likely held the door open for resident 90 on 11/28/19, as well as when the resident previously eloped. The Administrator stated the wander guard code was changed after resident 90's first elopement, but a visitor may have still held the door open for the resident on 11/28/19. The Administrator stated staff were reminded, When the (wander guard) alarm goes off, find the resident that is making the alarm go off. The Administrator stated that resident 90 does not fit into this type of facility, and therefore the resident was admitted to another nursing home following his hospitalization . On 12/17/19 at 2:06 PM, an interview was conducted with facility's DON. The DON stated that after resident 90 eloped on 9/18/19, the facility started performing regular wander guard checks. The DON stated when staff recognized resident 90 was missing on 9/18/19, they were able to locate him within 30 minutes; however staff did not know how long he had been away from the facility before it was determined he was missing. The DON stated after the elopement on 11/28/19, they checked the sensitivity of the wander guard system more closely. The DON stated that signs on the doors informing the public not to let residents out of the building had been in place approximately four years. The DON was unable to state how the sensitivity of the wander guard system prevented resident 90 from leaving the building. Resident 90's medical record included the following documentation regarding his assessed risk for elopement or wandering: a. 7/30/19, Elopement Risk Assessment: Low risk for elopement. b. On 8/7/19, facility staff completed an admission Minimum Data Set (MDS) assessment, which included a Brief Interview for Mental Status (BIMS). Per the MDS assessment, resident 90 had a BIMS score of 9, which indicated he had moderately impaired cognitive functioning. Additionally, facility staff assessed resident 90 had experienced hallucinations and delusions. c. On 9/1/19, facility staff completed a wander risk assessment for resident 90. Facility staff assessed that resident 90 was a high risk to wander. d. On 9/18/19 at 10:49 AM, a wandering risk scale was completed for resident 90. Resident 90 was assessed as a high risk to wander with a score of 11 Unsure how he got out suspect followed visitor out. Resident 90's medical record included the following care plan interventions and physician orders [REDACTED]. a. 9/1/19, check wander guard every shift and function every Sunday. Note: Resident 90 wandered away from the facility on 9/1/19 and was returned to the facility by law enforcement. b. 9/5/19, Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. c. 9/5/19, assess for fall risk. d. 9/5/19, Wander Alert: Wander guard to lower extremity on 9/1/19. e. 9/5/19, a physician's orders [REDACTED]. f. 9/18/19, fifteen-minute location checks were initiated. Note: On 9/18/19, resident 90 wandered away from the facility. g. 9/19/19 at 12:30 PM, a facility nurse documented, Okay to discontinue 15 minute checks at this time. h. 9/20/19, resident 90 was moved closer to the nursing station. i. 9/25/19, an All Staff inservice record included documentation that staff were reminded to listen for the wander guard alarm. The record included documentation that staff were directed, When alarm goes off - Be sure resident is safe - Redirect the resident to a safe area - Resolve the alarm. j. 10/4/19, resident 90's elopement care plan of 9/19/19 was updated with, Check sensitivity of wander guard system. Facility staff implemented a weekly wander guard focus round in which staff were to take resident 90 close to the front door to ensure the alarm signaled and the door locked. Facility staff documented completion of the wander guard focus round on 9/18/19, 9/26/19, 10/1/19, 10/9/19, 10/15/19, 10/22/19, 10/28/19, 11/7/19, 11/13/19, 11/20/19, and 11/29/19. Prior to resident 90's elopement on 11/28/19, he had wandered away from the facility on two other occasions; 9/1/19 and 9/18/19. Resident 90's medical record included the following documentation relating to these two incidents: a. On 9/1/19 at 12:36 PM, a facility nurse documented, Pt (patient) left campus unaccompanied approx. (approximately) noon today. DON notified promptly. Police notified approx. (1:30 PM) and given details and description, after CNA (certified nursing assistant) and (name of dietary manager) searched area around facility. No sign of patient as of (4:00 PM) today. Listed as missing person with police. DON kept updated. b. On 9/1/19 at 4:56 PM, a facility nurse documented, Patient returned to unity by police at (4:50 PM) uninjured. c. On 9/18/19 at 6:56 PM, a facility nurse documented that resident 90, walked away from the facility, apparently before shift had begun. Resident not seen as shift was starting. Resident was wearing a deterrent on ankle. d. On 9/18/19 at 11:36 PM, a facility nurse documented a late entry that documented, Had all available personnel search grounds and building. 15 minutes after noticed missing received phone call saying they had patient, aides were sent to get patient. No visible injuries on patient on skin check. Wander guard in place to lower extremity. Frequent checks initiated. MD was notified . e. 9/18/19 at 6:43 PM, a facility staff member documented on an incident report that, aides reported to nurses that resident was missing. Aides were sent on search of grounds. To no avail. Called DON and MD. Received call within 30 minutes from someone (who lived approximately 8 blocks away). Aide was sent to pick him up. After returning to the facility, resident 90 had no injuries and was placed on 15 minute checks to determine the resident's location. The sensitivity of the wander guard was tested and adjusted. A review of nursing note entries for resident 90, between (MONTH) 21, 2019 and (MONTH) 29, 2019 was completed. Facility nursing staff repeatedly document that resident 90 experienced frequent hallucinations and delusions, wandered throughout the facility, including into other resident rooms, and was increasingly difficult to redirect. On 10/15/19, facility staff requested an order from the facility's Medical Director to discharge the resident to another facility that was smaller, with more security. Although the Medical Director signed the order, the resident was not transferred as the other facility had no beds available. No other attempts were made to transfer resident 90 to another facility.

Based on observation, interview, and record review it was determined that the facility did not ensure that the environment remained as free of accident hazards as was possible for 3 of 24 sample residents. Specifically, a resident experienced 6 falls before interventions were initiated; there were unlocked and unattended chemicals in the laundry room, shower room, two resident rooms, and a housekeeping cart. Resident identifier: 22. Findings include: 1. Resident 22 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 22 was interviewed on 3/31/14 at 9:28 AM. During the interview, resident 22's bed was observed to be without side rails. There was a pressure alarm pad placed on a wheelchair in resident 22's room. An interview was conducted with RN (Registered Nurse) 1 on 3/31/14 at 10:44 AM. RN 1 stated that resident 22 had multiple falls recently. RN 1 stated that 2 falls were without injury. RN 1 stated one of resident 22's falls resulted in a hospital admission. Resident 22's medical record was reviewed on 4/1/14. A Fall Risk assessment dated [DATE] and updated 3/19/14 revealed a score of 16. The form revealed a score of, ". . .10 or above represents HIGH RISK." Resident 22's nurses notes revealed the following: a. On 12/15/13 at 12:30 AM, "Res (resident) (with) noted fall risk ....However spoke (with) res about low bed, et (and) blue mat. Res worried would trip up & be worse. Adjusted bed to safe level. BR (bathroom) door left open, cane within reach et oriented on how to use call light. Frequent (checks) done. " b. On 12/18/13 at "6a-6p" (6:00 AM until 6:00 PM) documented that, "Pt (patient) has told 2 staff members & MD (medical doctor) that she rolled out of bed last pm (evening). State (No) injury but (L) (left) shoulder a bit tender et there is a purple/red spot above (L) eye. (No) limits in ROM (range of motion) or movement." c. On 3/12/14 at 3:00 PM, "Pt was found by staff seated on floor with her back against the chair calling for help. Pt was assisted to seated and (no) injury apart (sic). Vss (vital signs stable). Pt stated she attempted to sit in her chair and aet (and) (sic) fell instead (sic)." d. On 3/20/14, "Fall this am (morning). Pt was seen to fall aganst (sic) her heater in her room. Pt fell back et hit her back et (R) (right) hip on heater. Pt landed on her backside." e. On 3/20/14, "Another fall this pm. Res was attempting to get out of bed to go to the bathroom and slid from the side of the bed onto her buttocks. Nurse was in next room and was able to assist res to her bed. Assessment showed (no) signs of injury." f. On 3/21/14, "C/o (complained of) fall (at) lunch time (no) injures (sic). Vs (vital signs) wnl's (within normal limits). Stat (immediate) labs rx'd (prescribed). CBC (complete blood count), CMP (complete metabolic panel)." g. On 3/22/14, "Res told aide this a.m. that her (L) wrist was sore. Oncoming nurse and this nurse assessed Res and noted pain/some bruising to top of hand. X-ray ordered to r/o (rule out) fracture." h. On 3/23/14, "Res fell again at 0500 (5:00 AM) this am. While trying to ambulate alone et w/o (without) walker to the bathroom from her bed. Fall was unwitnessed but nurse heard et arrived shortly after. Res may have hit head; neuro (checks) (neurological check) sheet started. (No) apparent injuries noted during initial assessment." i. On 3/24/14 at 9:00 AM, "pt had a fall this am in fell ow pt room fully backwards and strikg (sic) head on the edge of door way. Laceration was bandaged (no) other physical injury. Mentel (sic) status (change). Pt hearing things 'in head' or 'in room' family notified pt sent to E.R. (emergency room )." A Plan of Care dated 12/15/13 revealed a problem of, "Potential for complications r/t (related to) osteoporosis." One approach listed was ". . . 3) Ensure safety and decrease fall risk by: a. keeping room clean and uncluttered b. keeping bed in low position with half side rails up for mobility and wheels locked. . ." The facility Incident/Accident Reports were reviewed and revealed the following: a. On 12/18/13, "Pt stated she rolled out of bed in the night . . " The "type of injury" documented was "slightly tender L shoulder." The "steps taken to prevent recurrence:" revealed the following intervention, "will cont (continue) to monitor res." b. On 3/12/14, "Pt was found seated on floor with back against her recliner chair. . ." There was a bruise documented on her right arm. The interventions documented were, " . . .Will cont to monitor res." c. On 3/20/14, "Res was standing in her room with her back to her heater et she fell back towards heater et fell on the floor. She fell on her buttocks." The section marked "steps taken to prevent recurrence" revealed "(check) hydration, res enc. (encouraged) to drink. Stated felt fine." d. On 3/20/14, "Res was trying to get out of bed to go to the bathroom and slid off edge of bed to floor onto her buttocks. (No) apparent injuries noted." The, "steps taken to prevent recurrence: spoke (with) res stated (at) x's (times) just looses (sic) balance." e. On 3/21/14, "Res fell with walker, by her recliner to the floor. She fell on her back/side L arm/wrist hurt, but (no) bruising/swelling. Able to move limb w/o difficulty. . ." The section marked "steps taken to prevent recurrence" revealed an intervention of, "Labs ordered CBC, CMP." f. On 3/23/14, "Res fell while trying to walk to the bathroom alone w/o walker, unwitnessed, neuro (checks). (No) apparent injuries." The "steps taken to prevent recurrence: continue with neuro (checks). g. On 3/24/14 at 9:00 AM, "Pt bent over to give another resident encourgemt (sic) she became dizzy, lost balance and fell backward striking head on the wall. Staff immediately attended to her and assisted." The "Type of injury" revealed, "Laceration." The "Steps taken to prevent recurrence:" was blank. The form further revealed that resident was taken to the hospital. A Physician's Telephone order dated 3/27/14 revealed, "D/c wander guard. Pressure alarm while in bed, d/t (due to) (increased) falls. " An observation was made on 3/31/14 at 9:28 AM. There was no pressure alarm on resident 22's bed or beneath her on her recliner chair. There was a pressure alarm sitting in an empty wheelchair next to the wall. An observation was made on 4/1/14 at 1:08 PM. There was no pressure alarm on resident 22's bed or beneath her recliner chair. There was a pressure alarm sitting in an empty wheelchair next to the wall. An interview was conducted with CNA (certified nursing assistant) 1 on 4/1/14 at 1:02 PM. CNA 1 stated that facility staff did not have an order for [REDACTED]. On 4/1/14 at 10:24 AM, an interview was conducted with the facility Director of Nursing (DON). The DON stated that laboratory work was completed for resident 22 after the fall on 3/21/14. The DON stated no other interventions were initiated after the other falls resident 22 experienced. On 4/1/14 at 1:42 PM, a follow up interview was conducted with the DON. The DON stated that after resident 22 was admitted that facility staff tried a tab alarm for less than a day. The DON stated that resident 22 did not have side rails, low bed, or fall mats because those were all accident hazards to resident 22. The DON stated that there was no documentation about resident 22 refusing a tab alarm. The hospital records dated 3/26/14 were reviewed and revealed resident 22 sustained a "head injury." 2. An observation was made on 3/31/14 at 6:55 AM. The room marked "Shower Room 2" was unlocked and the room was unattended. There was a cabinet on the wall which was unlocked. The cabinet contained a spray bottle of "NADC" (Non-Acid Disinfectant Cleaner). The label revealed, "Hazardous to humans & animals". 3. On 3/31/14 from 6:58 AM to 7:07 AM, an observation was made of a housekeeping cart in the front hallway/lobby area. It was unlocked and unattended. Inside it was a spray bottle of "NADC" The label revealed the warning, "Hazardous to humans & animals". There was also a spray bottle of "409 Glass and Surface Cleaner". The label revealed a warning of, "Keep out of reach of children". There was also a canister of "Comet Powder with Chlorinol". The warning revealed, "Keep out of reach of children". A housekeeping staff member returned to the cart at that point, retrieved some supplies, and left again. 4. On 3/31/14 at 6:59 AM, an observation was made of the laundry room. The laundry room was unlocked and unattended. The linen room and the laundry room were connected inside the door way by an archway. The linen room was unable to be locked. The washer and dryer were between two locked doors that were unlocked and unattended during the observation. On the floor in the laundry room was a bottle of germicidal ultra bleach. The label indicated to "keep out of the reach of children and to contact poison control if ingested." On 4/1/14 at 1:30 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that the laundry room attendant was always in the laundry room from 6:00 AM until 2:00 PM. The DM stated that the laundry room attendant never left the laundry room unattended. The doors to the laundry room were always locked so the residents could not get in the laundry room. 5. On 3/31/14 at 7:12 AM, during the initial tour of the facility, a bottle of Non-Acid Disinfectant Bathroom Cleaner (NABC) was observed on the night stand in resident room 8. The label on the bottle stated "Caution: Keep out of reach of children. Causes moderate eye irritation. Harmful if absorbed through skin." 6. On 3/31/14 at 7:16 AM, during the initial tour of the facility, a bottle of Non-Acid Disinfectant Bathroom Cleaner (NABC) was observed on the night stand in resident room 4. The label on the bottle stated "Caution: Keep out of reach of children. Causes moderate eye irritation. Harmful if absorbed through skin."