Every finding on record at Menlo Park Post Acute

Based on interview and record review, it was determined the facility failed to follow physician orders for 1 of 3 sampled residents (#6) reviewed for medications. This placed residents at risk for unmet care needs. Findings include:Resident 6 admitted to the facility on [DATE] with diagnoses including end stage renal disease, unspecified conjunctivitis, perforated corneal ulcer, and dependence on renal dialysis.Resident 6's 2/8/26 comprehensive MDS assessment documented Resident 6 had a medically complex condition including perforated corneal ulcer in her/his right eye and conjunctivitis with bacterial agents as the disease. Resident 6's Care Plan initiated on 2/12/26 documented Resident 6 was at risk for complications related to a bilateral eye infection. Erythromycin (an antibiotic) eyedrops were initiated on 2/12/26. Resident 6's 2/12/26 Physician Orders included erythromycin ophthalmic ointment 5 mg to apply in left eye five times a day. Resident 6's 2/2026 MAR documented the following:-On 2/16/26 at 11:00 AM, medication was not given as resident was at dialysis by Staff 18 (CMA).-On 2/17/26 at 11:00 AM, medication was not given as resident was at dialysis by Staff 18.-On 2/18/26 at 11:00 AM, medication was not given as resident was at dialysis by Staff 18.-On 2/23/26 at 11:00 AM, medication was not given as resident was at dialysis by Staff 18.-On 2/23/26 at 1:00 PM, medication was not given as resident was absent from home by Staff 19 (CMA).-On 2/25/26 at 11:00 AM, medication was not given as resident was absent from home by Staff 19.-On 2/25/26 at 1:00 PM, medication was not given as resident was absent from home by Staff 19.-On 2/27/26 at 11:00 AM, medication was not given as resident was absent from home by Staff 19.There was no documented evidence Resident 6's provider was notified regarding the missed antibiotic eye medication.On 5/19/26 at 10:30 AM, Resident 6 stated she/he did not receive his/her eyedrops as ordered.On 5/21/26 at 11:06 AM, Staff 18 stated if any medications were due while Resident 6 was out of the facility for dialysis she would document on the MAR that Resident 6 was out of the facility. Staff 18 stated she did not communicate with the nurse about missing the antibiotic eye medication.On 5/21/26 at 12:01 PM, Staff 19 stated she could not recall if she notified the nurse the medications were due while Resident 6 was out of the facility for dialysis and was unsure whether the physician knew Resident 6 had missed doses of their antibiotic eye medication.On 5/21/25 at 1:00 PM and 5/22/26 at 9:34 AM, attempts were made to contact Staff 21 (LPN) were unsuccessful.On 5/22/26 at 10:19 AM, Staff 4 (LPN) stated Staff 18 and Staff 19 did not communicate with her on 2/16/26, 2/23/26 or 2/27/26 that Resident 6 had missed her/his antibiotic eye medication due to being out of the facility for dialysis. Staff 4 stated the medication aides should have communicated with her so she could contact the provider.On 5/22/26 at 10:48 AM, Staff 20 (RNCM) stated the CMAs should have communicated with the nurse about Resident 6 missing doses of the eye drops due to being out of the facility.On 5/22/26 at 11:14 AM, Staff 2 (DNS) stated the CMAs should have notified the charge nurse and charge nurse should have coordinated with the RNCM and provider to adjust Resident 6's medication schedule.

Based on observation, interviews and record review it was determined the facility failed to ensure dishwasher temperatures met the minimum requirements for 1 of 1 dishwasher and failed to ensure food was labeled and stored in a manner to minimize spoilage and cross contamination for 1 of 1 resident refrigerator reviewed for the kitchen. This placed residents at risk for food borne illnesses, communicable diseases, and un-sanitized dishware and utensils. Findings include: The facility's Dishwashing policy dated 8/2024 included the following:- Do not run dishes through until machine has reached proper temperature for your specific machine. This may take multiple cycles.- Check for proper temperatures and pressure. Log Temps, if deficient, tell FNS Manager and/or Maintenance Director. The facility's Resident Food from Outside Source policy dated 8/2024 included the following:- Refrigerated food items from an outside source is stored in a container with the following information on it: date product was received, name of product, resident name and room number. - Refrigerated foods that are unlabeled or undated, when noted, is discarded.- Homemade items, restaurant leftovers, take out items, milk, cottage cheese and similar type items is discarded on day three. 1. On 2/11/26 at 10:21 AM, the dishwasher temperature log was observed to be blank for 2/11/26. On 2/11/26 at 10:21 AM, the dishwashing machine's temperature gauge was observed to be at 110*F and Staff 20 (Dietary Aide) was observed rinsing dirty dishes and loading them onto a rack. He stated the machine was a low temperature machine and confirmed the machine's current thermometer read was 110*F. Staff 20 stated the temperature was supposed to be at 120*F and confirmed the log for 2/11/26 was blank. He stated he usually checked the temperature before washing dishes and after washing dishes. From 10:21 AM to 10:31 AM, the temperature gauge remained at 110*F, Staff 20 completed three loads of dishes and was preparing a fourth load into the dishwasher. On 2/11/26 at 10:32 AM, Staff 7 (Dietary Director) confirmed the dishwasher was a low temperature machine and required the temperature to be at or above 120*F in order for the dishes and utensils to be considered sanitized. She stated staff did not touch the machine and did not have the ability to adjust it.On 2/11/26 at 10:40 AM, Staff 20 continued to unload and load the dishwasher with dirty dishes while the thermometer gauge remained at 110*F.On 2/11/26 at 11:03 AM, Staff 21 (Dietary Aide) inserted a thermometer into the water of the dishwashing machine, which read 111*F. On 2/11/26 at 11:09 AM, Staff 7 inserted a thermometer into the water of the dishwashing machine, which read 118*F. She confirmed the dishwasher was not at the temperature needed in order for the dishes and utensils to be appropriately sanitized. She stated when the temperature was not at 120*F or above, staff were expected to let her know immediately.On 2/12/26 at 4:02 PM, Staff 1 (Administrator) stated he expected the dishwasher to be at the appropriate level for dishes and utensils to be sanitized. He stated he expected for staff to inform management immediately when the temperature of the dishwasher was below it's appropriate level. 2. On 2/11/26 at 8:41 AM, the inside of the resident refrigerator (a refrigerator designated for residents' food only) was observed to have a bag with a resident's name and room number on it, but no date.On 2/12/26 at 8:58 AM, the inside of the resident refrigerator was observed to have a bag with a resident's name and room number on it, but no date. Inside of the bag included a container of watermelon, cantaloupe and honey dew melon in a pool of liquid, but no date or expiration; a rotisserie chicken inside of a bag with no date or expiration; and two slices of processed cheese enclosed in plastic packaging with no date or expiration. On 2/12/26 at 9:05 AM, Staff 22 (Dietary Aide) stated he checked the resident refrigerator each day but did not throw away any of the contents inside of the resident refrigerator. He stated it was the responsibility of CNAs and housekeeping to throw away resident items in the refrigerator.On 2/12/26 at 10:12 AM, Staff 18 (CNA) stated when residents or family brought in food from outside of the facility, CNAs were responsible to put the resident's name, room number, and date it was received on the container. She stated CNAs threw away spoiled food or after the third day after it was received.On 2/12/26 at 10:17 AM, Staff 19 (CNA) stated when residents wanted to store their own food in the refrigerator, CNAs were responsible for putting the resident's name, room number, and date it arrived on the container. She stated CNAs were not supposed to throw away anything and dietary staff were responsible for cleaning and throwing away food. On 2/12/26 at 10:20 AM, Staff 17 (CNA) stated CNAs were responsible for putting a resident's name, room number, and the day it was received onto the container when residents bring food from outside of the facility. She stated CNAs did not throw away any food from the resident refrigerator and it was the responsibility of kitchen or housekeeping staff to do so.On 2/12/26 at 10:28 AM, Staff 7 (Dietary Director) confirmed the resident refrigerator had an undated bag that contained the undated container of melons, undated rotisserie chicken and two undated slices of processed cheese. She stated it was the responsibility of CNAs to receive a resident's food from outside and to put their name, room number, and day it was received onto the container. Staff 7 stated she expected for dietary staff, CNAs and housekeeping to work together to ensure unlabeled food, expired food, and food that has been in the refrigerator for three days to be thrown out. On 2/13/26 at 8:18 AM, Staff 1 (Administrator) stated he expected for dietary staff, housekeeping and CNAs to work together to ensure unlabeled food, expired food, or food that has been in the resident refrigerator for three days to be thrown out.

Based on interview and record review it was determined the facility failed to complete Quarterly MDS assessments in the required timeframe for 7 of 8 sampled residents (#s 12, 15, 26, 45, 51, 67 and 80) reviewed for resident assessment. This placed residents at risk for unassessed needs. Findings include:1. Resident 12 was admitted to the facility in 7/2022 with a diagnosis of pneumonia. Resident 12's 1/6/26 Quarterly MDS was listed as in her/his health record as in progress and was not completed or signed by the recertification survey exit date of 2/13/26. On 2/13/26 at 12:21 PM Staff 36 (RN, MDS Coordinator) acknowledged Resident 12's 1/6/26 Quarterly MDS Assessment was not completed within 14 days of the Assessment Review Date (ARD). Staff 36 stated there were still sections of the assessment that she needed to complete before she submitted it. On 2/13/26 at 1:10 PM Staff 1 (Administrator) acknowledged the resident's assessment was not completed timely and he knew it was also an issue for other residents. Staff 1 stated he expected all residents' MDS Assessments to be completed timely because they were an important factor in developing and maintaining resident-centered care plans. 2. Resident 15 was admitted to the facility in 6/2025 with a diagnosis of multiple rib fractures. Resident 15's 12/22/25 Quarterly MDS Assessment was listed in her/his health record as in progress and was not completed or signed by the recertification survey exit date of 2/13/26. On 2/13/26 at 12:21 PM Staff 36 (RN, MDS Coordinator) acknowledged Resident 15's 1/6/26 Quarterly MDS Assessment was not completed within 14 days of the Assessment Review Date (ARD). Staff 36 stated the assessment was partially completed and not ready to be submitted. Staff 36 stated the assessment was a priority but she did not know when she would be able to complete it and submit it. On 2/13/26 at 1:10 PM Staff 1 (Administrator) acknowledged the resident's assessment was not completed timely and he knew it was also an issue for other residents. Staff 1 stated he expected all residents' MDS Assessments to be completed timely because they were an important factor in developing and maintaining resident-centered care plans. 3. Resident 26 was admitted to the facility in 4/2019 with a diagnosis of combined systolic (congestive) and diastolic (congestive) heart failure (a type of heart failure characterized by the heart being unable to contract and relax properly). Resident 26's 12/16/25 Quarterly MDS Assessment was submitted on 2/12/26 (58 days after the Assessment Review Date). On 2/13/26 at 12:21 PM Staff 36 (RN, MDS Coordinator) acknowledged Resident 26's 12/16/26 Quarterly MDS Assessment was not completed within 14 days of the Assessment Review Date (ARD). Staff 36 stated it was not ideal that Resident 26's 12/16/25 Quarterly Assessment was completed more than 14 days after the ARD. On 2/13/26 at 1:10 PM Staff 1 (Administrator) acknowledged the resident's assessment was not completed timely and he knew it was also an issue for other residents. Staff 1 stated he expected all residents' MDS Assessments to be completed timely because they were an important factor in developing and maintaining resident-centered care plans. 4. Resident 45 was admitted to the facility in 6/2021 with a diagnosis of ataxic gait (an unsteady, uncoordinated walking pattern caused by brain damage). Resident 45's 12/17/25 Quarterly MDS Assessment was listed in her/his health record as in progress and was not completed or signed by the recertification survey exit date of 2/13/26. On 2/13/26 at 12:21 PM Staff 36 (RN, MDS Coordinator) acknowledged Resident 45's 12/17/25 Quarterly MDS Assessment was not completed within 14 days of the Assessment Review Date (ARD). Staff 36 stated a fair amount of the assessment was partially completed but it was not ready to be submitted. Staff 36 stated she did not know when it would be ready to submit. On 2/13/26 at 1:10 PM Staff 1 (Administrator) acknowledged the resident's assessment was not completed timely and he knew it was also an issue for other residents. Staff 1 stated he expected all residents' MDS Assessments to be completed timely because they were an important factor in developing and maintaining resident-centered care plans. 5. Resident 51 was admitted to the facility in 10/2022 with a diagnosis of hemiplegia and hemiparesis (neurological conditions causing one-sided body weakness or paralysis) following a stroke. Resident 51's 1/6/26 Quarterly MDS Assessment was listed in her/his health record as in progress and was not completed or signed by the recertification survey exit date of 2/13/26. On 2/13/26 at 12:21 PM Staff 36 (RN, MDS Coordinator) acknowledged Resident 51's 1/6/26 Quarterly MDS Assessment was not completed within 14 days of the Assessment Review Date (ARD). Staff 36 stated the interviews were done but the part she was responsible for completing was not done yet. Staff 36 stated she did not know when it would be ready to submit. On 2/13/26 at 1:10 PM Staff 1 (Administrator) acknowledged the resident's assessment was not completed timely and he knew it was also an issue for other residents. Staff 1 stated he expected all residents' MDS Assessments to be completed timely because they were an important factor in developing and maintaining resident-centered care plans. 6. Resident 67 was admitted to the facility in was admitted to the facility in 6/2019 with a diagnosis of dementia. Resident 67's 12/23/25 Quarterly MDS Assessment was listed in her/his health record as in progress and was not completed or signed by the recertification survey exit date of 2/13/26. On 2/13/26 at 12:21 PM Staff 36 (RN, MDS Coordinator) acknowledged Resident 67's 12/23/25 Quarterly MDS Assessment was not completed within 14 days of the Assessment Review Date (ARD). Staff 36 stated she was still waiting for additional data in order to submit the assessment. Staff 36 stated she did not have a timeline for the data or submission. On 2/13/26 at 1:10 PM Staff 1 (Administrator) acknowledged the resident's assessment was not completed timely and he knew it was also an issue for other residents. Staff 1 stated he expected all residents' MDS Assessments to be completed timely because they were an important factor in developing and maintaining resident-centered care plans. 7. Resident 80 was admitted to the facility in 5/2023 with a diagnosis of metabolic encephalopathy (a brain dysfunction caused by illness, organ failure or chemical imbalances that alter brain metabolism). Resident 80's 1/6/26 Quarterly MDS was listed in her/his health record as in progress and was not completed or signed by the recertification survey exit date 2/13/26. On 2/13/26 at 12:21 PM Staff 36 (RN, MDS Coordinator) acknowledged Resident 80's 1/6/26 Quarterly MDS Assessment was not completed within 14 days of the Assessment Review Date (ARD). Staff 36 stated the interviews were done but the part she was responsible for completing was not done yet. Staff 36 stated she did not know when it would be ready to submit. On 2/13/26 at 1:10 PM Staff 1 (Administrator) acknowledged the resident's assessment was not completed timely and he knew it was also an issue for other residents. Staff 1 stated he expected all residents' MDS Assessments to be completed timely because they were an important factor in developing and maintaining resident-centered care plans.

Based on interview and record review it was determined the facility failed to complete comprehensive MDS assessments in the required timeframe for 3 of 26 sampled residents (#s 30, 62 and 66) reviewed for resident assessment. This placed residents at risk for unassessed needs. Findings include:1. Resident 66 was admitted to the facility in 1/2021 with a diagnosis of an encounter for orthopedic aftercare following surgical amputation. Resident 66's 1/6/26 Annual MDS Assessment was listed in her/his health record as in progress and was not signed or submitted by the recertification survey exit date of 2/13/26. On 2/13/26 at 12:21 PM Staff 36 (RN, MDS Coordinator) acknowledged Resident 66's 1/6/26 Annual MDS Assessment was not completed within 14 days of the Assessment Review Date (ARD). Staff 36 stated the assessment was partially completed and not ready to be submitted. Staff 36 stated the assessment was a priority but she did not know when she would be able to complete it and submit it. On 2/13/26 at 1:10 PM Staff 1 (Administrator) acknowledged the resident's assessment was not completed timely and he knew it was also an issue for other residents. Staff 1 stated he expected all residents' MDS Assessments to be completed timely because they were an important factor in developing and maintaining resident-centered care plans. 2. Resident 30 was admitted to the facility in 5/2024 with a diagnoses including heart failure. Resident 30's 1/15/26 (Re-Admission) admission MDS assessed her/him as cognitively intact with little to no interest in doing things. The Activities CAA summary only addressed activities as to observe resident's acclimation to facility and will encourage and assist resident with activity programming as resident is accepting. No other information was documented as assessed for the reasons for little to no interest in recreational, diversional or leisure interest. On 2/13/26 at 924 AM Staff 9 (Activity Director) stated she did not complete or contribute information for Resident 30's leisure and recreational activity preferences for the MDS. On 2/13/26 at 12:42 PM Staff 2 (DNS) expected the triggered Activities CAA in Resident 30's 1/15/26 admission MDS to fully assess the resident's activity needs and preferences. No additional information was provided. 3. Resident 62 was admitted to the facility on [DATE] with diagnoses including third degree burns. The 2/1/26 admission MDS was completed and signed on 2/10/26, two days past the fourteen-day completion timeframe. On 2/12/26 at 1:44 PM Staff 4 (LPN Resident Care Manager) confirmed the late MDS completion date.

Based on interview and record review it was determined the facility failed to provide resident centered activities for 5 of 5 sampled residents (#s 2, 3, 20, 30 and 60) reviewed for activities. This placed residents at risk for diminished quality of life. Findings include: The facility's undated Activities policy included the following: - Activity programs are designed to meet the interests of and support the physical, mental and psychosocial wellbeing of each resident.- Activities are considered any endeavor, other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of wellbeing and to promote or enhance physical, cognitive or emotional health.- Activities are not necessarily limited to formal activities being provided only by activities staff.- Other facility staff may also provide the activities.- Scheduled activities are posted on the resident bulletin board. Activity schedules are also provided individually to residents who cannot access the bulletin board (e.g., bed bound or visually impaired residents).- Residents are encouraged, but not required, to participate in scheduled activities. 1. Resident 20 was admitted to the facility in 1/2026 with diagnoses including blindness in left and right eyes and dysphagia following cerebral infarction (difficulty swallowing following a stroke). The 5-Day Admissions MDS with an ARD of 2/2/26 revealed Resident 20 had a BIMS score of 15, which indicated the resident was cognitively intact. The resident required extensive assistance with all ADLs, including always needing assistance with reading written materials. Resident 20's 1/2026 Activity Profile revealed it was very important to listen to music she/he liked and to go outside for fresh air when the weather was good. It also revealed Resident 20 found it somewhat important to do things with groups of people. Review of Resident 20's Care Plan initiated 2/10/26 indicated for staff to encourage Resident 20 to attend activities and to provide assistance as needed. On 2/9/26 at 10:53 AM, Resident 20 stated she/he did not know the facility had activities and she/he had not been invited to any activities. Observations of the activities calendar for 2/10/26 included music and ice cream at 11:00 AM and a popcorn social at 2:00 PM. On 2/10/26 at 2:06 PM, Resident 20 stated she/he was not invited to music and ice cream or to the popcorn social and was not aware of the activities. Observations of the activities calendar for 2/11/26 included Bingo at 2:00 PM. On 2/11/26 at 2:35 PM, Witness 2 (Family Member) took a folder out of Resident 20's drawer. Observations of the contents inside of the folder included crossword puzzles, wordsearches, coloring pages, and colored pencils. Witness 2 stated Resident 20 was given the folder when she/he first moved into the facility as independent activities. Witness 2 stated she/he was not sure how Resident 20 could utilize the materials, as Resident 20 was visually impaired. On 2/11/26 at 2:35 PM, Resident 20 stated she/he did not know the facility was playing Bingo at 2:00 PM and stated, I love Bingo. On 2/12/26 at 9:27 AM, Staff 16 (CNA) stated residents were informed of activities when Staff 9 (Activities Director) announced the event on the overhead speaker and Staff 9 was the person who informed residents of activities that were available. Staff 16 stated Resident 20 liked to sleep all day. On 2/12/26 at 10:03 AM, Staff 17 (CNA) stated Staff 9 was responsible for giving out activities' schedules for the month and day to residents and Staff 9 informed residents by making announcements on the overhead speaker. Staff 17 stated if residents wanted to join an outing, residents would go to the front desk and sign their names on a sheet. Staff 17 was not aware of Resident 20's preferences but stated it could be found on her/his care plan. Observations of the activities calendar for 2/12/26 included an outing at 10:00 AM. On 2/12/26 at 3:12 PM, Resident 20 stated she/he did not know there was an outing for the activity. Resident 20 stated she/he would have liked to go if she/he knew about it. On 2/12/26 at 3:15 PM, Staff 9 stated she had informed Resident 20 to reach out to Staff 9 if she/he needed other activities. Staff 9 stated she passed out a reading material to residents each morning to inform residents of the day's activities, and she typically made an announcement on the overhead speaker 20-30 minutes before the start of the activity. Staff 9 stated she did not pass out the reading material to Resident 20, because she/he was typically asleep. Staff 9 acknowledged Resident 20 would not be able to see the reading material and stated she did not follow up throughout the day with Resident 20 to inform her/him of the day's activities. Staff 9 stated independent activities included crossword puzzles, newspapers, and coloring pages and were provided to residents, but acknowledged these items were inappropriate for Resident 20. Staff 9 stated she had not procured music or audiobooks for Resident 20 and had not spent much time with her/him. On 2/12/26 at 4:10 PM, Staff 1 (Administrator) stated he expected for Staff 9 and CNAs to inform residents of the activities for the day. Staff 1 stated he expected for residents to be provided with activities and supplied with items appropriate for their level of function. 2. Resident 2 was admitted to the facility in 2024 with a diagnoses including major depression. Resident 2's 10/14/25 Annual MDS assessed her/him as cognitively intact. Very important Activity preferences were identified as music, pets and going outside. It was important to do her/his favorite activities. On 2/9/26 at 4:01 PM Resident 2 stated she/he was very bored most of the time with only one activity offered in the morning for less than 30 minutes and sometimes an afternoon program. Resident 2 stated there was very little interaction or engagement in the activities offered. Resident 2 stated the facility had books available to read in the past but they had been removed. On 2/11/26 at 8:31 AM Resident 2 was observed in her/his room with the television on and she/he talked about the lack of planned activities today so she/he would figure out something to do today. On 2/12/26 at 1:16 PM Staff 17 (CNA) stated she/he read the Kardex care plan to get information to care for residents and acknowledged no activity preferences were on Resident 2's Kardex. A Kardex care plan dated 2/12/26 revealed Resident 2 had no activity interests or preferences on the Kardex care plan to inform staff of the resident's activity preferences. On 2/13/26 at 9:24 AM Staff 9 (Activity Director) confirmed Resident 2 had no information to direct staff to assist the resident with activity preferences. Staff 8 acknowledged the lack of resident centered activity programming for Resident 2. On 2/13/26 at 12:31 PM Staff 1 (Administrator) stated he expected all residents to have individual activity programs to meet their interests both from groups and individual activities. 3. Resident 3 was admitted to the facility in 2023 with a diagnoses including anxiety. Resident 3' s 3/13/25 Annual MDS assessed her/him as cognitively intact. Very important Activity preferences were identified as reading materials, music, pets, religion, doing things with groups of people, going outside, the news and doing her/his favorite activities. On 2/9/26 at 12:21 PM Resident 3 stated she/he was often bored and watched a lot of television for background noise. Resident 3 stated she/he missed the book cart and bookshelf to have access to reading materials. Resident 3 showed an Activity calendar for groups and stated the very little number of things offered were not engaging or interesting. On 2/11/26 at 11:33 AM Staff 9 (Activity Director) was observed to sit at a dining room table and put a puzzle together. Resident 3 nor any other residents were engaged in the puzzle. On 2/12/26 at 1:16 PM Staff 17 (CNA) stated she/he read the Kardex care plan to get information to care for residents and acknowledged no activity preferences were on Resident 3's Kardex. A Kardex care plan dated 2/12/26 revealed Resident 3 had no activity interests or preferences on the Kardex care plan to inform staff of the resident's activity preferences. On 2/13/26 at 9:24 AM Staff 9 (Activity Director) acknowledged the lack of activity programming for Resident 3 and the resident liked to sit outside and watch television. On 2/13/26 at 12:31 PM Staff 1 (Administrator) stated he expected all residents to have individual activity programs to meet their interests both from groups and individual activities. 4. Resident 30 was initially admitted to the facility in 2024 with a diagnoses including depression. Resident 30's 1/15/25 admission MDS assessed her/him as cognitively intact. Very important Activity preferences were identified as music, pets, news, to go outside and do her/his favorite things. Its was somewhat important for Resident 30 to have access to books, religion and doing things with groups of people. On 2/9/26 at 10:01 AM Resident 30 stated she/he was bored at times and was very upset her/his television remote control did not work all the time when she/he wanted to have the television available. Resident 30 was observed to click on buttons on her/his remote control and the television did not turn on. On 2/12/26 at 1:16 PM Staff 17 (CNA) stated she/he read the Kardex care plan to get information to care for residents and acknowledged no activity preferences were on Resident 30's Kardex. A Kardex care plan dated 2/12/26 revealed Resident 30 had no activity interests or preferences on the Kardex care plan to inform staff of the resident's activity preferences. On 2/13/26 at 9:24 AM Staff 9 (Activity Director) acknowledged the lack of activity programming for Resident 30 and she was not aware Resident 30 had difficulty with the television remote. Staff 8 stated the resident liked to talk some with her and watch television. On 2/13/26 at 12:31 PM Staff 1 (Administrator) stated he expected all residents to have individual activity programs to meet their interests both from groups and individual activities. 5. Resident 60 was initially admitted to the facility in 1/2026 with a diagnoses including spinal stenosis (narrowing of spinal canal causing pain). Resident 60's 1/19/25 admission MDS assessed her/him as cognitively intact. Very important Activity preferences were identified as reading/books, music, news, religion, going outside and doing things with groups of people. On 2/10/26 at 10:01 AM Resident 60 stated she/he was extremely bored and only had her/his cell phone for any distraction or entertainment. Resident 60 stated their family would come to visit to help break the boredom. Resident 60 stated she/he only went to therapy other wise she/he was in their room with no working television. On 2/10/26 at 3:18 PM Resident 60 was observed in her/his bed and looked at her/his person cell phone with no television on their side of room. Resident 60 had a small bag of popcorn which she/he received from the group activity which a person brought to her/him while in bed. On 2/12/26 at 1:16 PM Staff 17 (CNA) stated she/he read the Kardex care plan to get information to care for residents and acknowledged no activity preferences were on Resident 60's Kardex. A Kardex care plan dated 2/12/26 revealed Resident 60 had no activity interests or preferences on the Kardex care plan to inform staff of the resident's activity preferences. On 2/13/26 at 9:24 AM Staff 9 (Activity Director) acknowledged the lack of activity programming for Resident 60 and she was not aware Resident 60 did not have a working television in her/his room. Staff 8 stated Resident 60 liked to look at her/his phone, go to therapy balloon group and food groups sometimes. On 2/13/26 at 12:31 PM Staff 1 (Administrator) stated he expected all residents to have individual activity programs to meet their interests both from groups and individual activities.

Based on interview and record review it was determined the facility failed to provide a qualified professional to direct the activities program for 1 of 1 facility reviewed for activities. This placed residents at risk for unmet physical, mental and psychosocial needs. Findings include:On 2/12/26 at 3:15 PM, Staff 9 (Activities Director) stated she was recently promoted to Activities Director and was not aware of any certifications, trainings, or qualifications required for the position. Staff 9 confirmed she was the person who planned the group and individual activities for residents.On 2/13/26 at 8:13 AM, Staff 1 (Administrator) confirmed Staff 9 had been the Activities Director since 12/2025 and did not have the appropriate certifications, trainings, or qualifications for the role.

Based on observation and interview it was determined the facility failed to ensure waste was properly contained in dumpsters and garbage storage areas were maintained in a sanitary condition for 1 of 1 garbage area reviewed for kitchen sanitation. This placed residents at risk for exposure to pathogens related to the harborage and feeding of pests. Findings include: On 2/9/26 at 9:24 AM, the facility's dumpsters were observed to be very full and the doors did not close to enclose the trash.On 2/10/26 at 9:18 AM, the facility's dumpsters were observed to be very full and had trash overflowing from the top. Two inside out gloves were observed on the concrete where the dumpsters were and one large trash bag was placed in front of the dumpsters. On 2/10/26 at 3:30 PM, the facility's dumpsters were observed to be very full, trash overflowing from the top and four large bags were in front of the dumpsters. The ground around the dumpsters was observed to have miscellaneous trash items.On 2/11/26 at 5:00 AM, the facility's dumpsters were observed to be very full, trash overflowing from the top and more than four large bags placed in front of the dumpsters. The ground around the dumpsters was observed to have miscellaneous trash items including inside out gloves. On 2/11/26 at 6:44 AM, Staff 7 (Dietary Director) stated the dumpsters were shared by all of the employees of the facility.On 2/11/26 at 7:59 AM, Staff 10 (Maintenance Director) stated the garbage was supposed to be collected six times per week, Monday through Saturday. He stated the garbage company was also supposed to pick up the bags off the ground. Staff 10 stated he was not sure what happened on 2/9/26 and 2/10/26, but he did not get a phone call from the garbage company. Staff 10 acknowledged garbage should be contained in their receptacles and off the ground.On 2/13/26 at 8:20 AM, Staff 1 (Administrator) stated he expected the garbage to be contained in the receptacles and off the ground and for staff to notify management when the dumpsters became too full.

Based on observation, interview and record review it was determined the facility failed to ensure proper hand hygiene was completed for 1 of 1 sampled employee (#27) and 3 of 3 sampled residents (#s) reviewed for infection prevention and control practices. This placed residents at risk for infections. Findings include:The 8/1/24 Hand Hygiene policy and procedure specified hand hygiene was required before and after assisting a resident with personal care, after handling soiled or used linens, before applying gloves, and after removing gloves. 1.On 2/10/26 at 9:09 AM Staff 27 (CNA) was observed wearing gloves and providing cares to Resident 8 who was on contact precautions (infection-control measures used to prevent the spread of germs). These cares included touching the resident's gown, legs and bedding, and combing her/his hair. Staff 27 placed the resident's linens into a bag, removed her gloves, and exited the room using the gloves to carry the bag. Staff 27 was observed continuously as she dropped off the dirty linens, proceeded down the hall with the dirty gloves in hand, dropped the gloves into a garbage can, and then picked up clean gloves and started to put them on to enter a new room. At no point was hand hygiene performed. On 2/10/26 at 9:25 AM Staff 27 stated hand hygiene should be done as soon as gloves came off, but hand sanitizer was hard on her skin and she preferred to wear gloves instead of always using sanitizer. On 2/13/26 at 10:54 AM Staff 4 (Infection Preventionist) stated hand hygiene should be performed by staff after the removal of gloves and after disposal of garbage or dirty linens, before they went on to their next task. Staff 4 stated staff would need to wash their hands if they did not want to use hand sanitizer. 2. During an 2/11/26 at 10:00 AM Residents Council meeting the residents expressed a concern they were not offered hand hygiene during the dining room meal services. During a 2/11/26 dining room observation from 11:33 AM to 12:00 PM no hand hygiene was offered to the residents in the dining room prior to receiving lunch. On 2/11/26 at 12:01 PM Resident 2, Resident 28 and Resident 80 were observed eating lunch in the dining room. The residents all stated they were not offered hand hygiene prior to the meal service and would have liked to have had clean hands to eat with during the meal. On 2/12/26 at 11:40 AM Staff 18 (CNA) stated the residents usually wash their hands in the morning and were not offered hand hygiene prior to serving lunch unless a resident requested to have their hands washed. During a 2/13/2026 at 12:42 PM Staff 2 (DNS) state she would expect the residents to be offered hand hygiene prior to eating a meal in the dining room.

Based on interview and record review it was determined the facility failed to ensure adequate indications for medication use for 1 of 1 sampled resident (#10) reviewed for unnecessary medications. This placed residents at risk for adverse side effects. Findings include:Resident 10 was admitted to the facility in 1/2026 with diagnoses including paraplegia (paralysis of the legs and lower body) and wounds. The 1/10/26 Care Plan identified Resident's 10's pain would be relieved to a tolerable level as indicated by the resident. A 1/11/26 Physician's Order was in place for Morphine Sulfate 10 MG/5 ML every six hours as needed for pain. The 1/16/26 admission MDS revealed a BIMS score of 14 indicating the resident was cognitively intact. The resident received scheduled and PRN pain medications. The 1/2026 and 2/2026 MARs showed Staff 27 (CMA) administered PRN Morphine with a pain rating of zero seven times in the two-month period on 1/21/26, 1/22/26, 1/28/26, 1/29/26, 2/4/26, and 2/5/26.The 1/2026 and 2/2026 Progress Notes contained no additional assessment or justification for the dates associated with a pain rating of zero or why the morphine was administered to the resident. On 2/11/26 at 9:58 AM Staff 27 stated she was able to administer pain medications with no pain assessment or nursing oversight. She did not recall administering PRN Morphine to Resident 10 with a pain rating of zero. On 2/12/26 at 1:50 PM Staff 6 (RNCM) stated Resident 10 identified a pain level of four or five as tolerable. Staff 6 stated the resident was always in pain and would never be at a pain rating of zero. Staff 6 stated a pain rating assessment should always be conducted and reported to the licensed nurse when a resident requested pain medication. Administering PRN Morphine with a pain rating of zero was not appropriate.

Based on interview and record review it was determined the facility failed to ensure trauma informed care was assessed to ensure proper practices were provided for 2 of 2 resident (#s 3 and 10) reviewed for mood and behavior. This placed residents at risk for triggered responses and re-traumatization. Findings include: A facility Trauma-Informed Care policy dated 8/2024 included the focus of four areas when care interventions are developed and strategies to support resident with trauma history. Those four areas include: -Realize the prevalence of trauma through education and training of care staff, -Recognize how trauma affects individuals through evaluation and identification of triggers, -Responding and putting knowledge into practice through development of resident=centered care planning, and -Resisting re-traumatization through avoiding identified triggers and making empathetic, reasonable modifications to the care approach and environment. 1. Resident 10 was admitted to the facility in 1/2026 with diagnoses including post-traumatic stress disorder (PTSD) and anxiety. An admission MDS dated [DATE] revealed Resident 10 had a BIMS score of 15, which indicated the resident was cognitively intact. A Care Plan dated 1/12/26 stated Resident 14 had a diagnosis of PTSD but did not include resident specific information regarding triggers of her/his PTSD or what prevention techniques to address her/his PTSD if triggered. Review of Resident 10's records from 1/10/26 through 2/9/26 revealed a Trauma Informed Care assessment had not been performed to determine specific and potential triggers for PTSD, techniques to prevent a response if triggers occurred, or care intervention to implement for the resident after her/his PTSD was triggered. On 2/9/26 at 10:18 AM Resident 10 was observed in her/his room and stated she/he had experienced a startled reflex on multiple occasions at the facility due to staff loudly knocking on her/his door and also had experienced night terrors. Resident 10 stated she/he had verbally told staff her/his PTSD was triggered by loud sudden noises like knocking on the door and she/he wished for them to lightly tap on the door before they entered. On 2/10/26 at 2:32 PM a CNA was observed knocking loudly on Resident 10's door prior to entering Resident 10's room. Resident 10 was overheard verbally responding to the knocks in a louder than conversational voice level. On 2/12/26 at 11:23 AM Staff 18 (CNA) stated Resident 10 did not like staff loudly knocking on her/his door. Staff 18 stated this information was gained from talking with Resident 10 and was not included in her/his records. On 2/12/26 at 11:38 AM Staff 11 (LPN) stated he learned about Resident 10's PTSD triggers verbally from other staff members but did not have specific information on how to address Resident 10's PTSD. On 2/12/26 at 12:38 PM Staff 8 (Social Services Director) stated assessing a resident with a diagnosis of PTSD was important to know how to manage a resident's triggers and to prevent those triggers from impacting a resident. Staff 8 stated the information gained from a Trauma Informed Care assessment was to be included in a resident's care plan. Staff 8 confirmed a Trauma Informed Care assessment had not been completed on Resident 10. Staff 8 she was unaware of specific trigger related to Resident 10s PTSD. On 2/12/26 at 12:49 PM Staff 6 (RNCM) confirmed a Trauma Informed Care assessment had not been completed on Resident 10 to determine specific triggers and what action to take if Resident 10's PTSD was triggered. Staff 6 stated she was unaware a formal assessment was required to be completed for residents diagnosed with PTSD. 2. Resident 3 admitted to the facility in 3/2023 with diagnoses including Post Traumatic Stress Disorder (PTSD) and anxiety. Reviewed of Resident 3's health recorded revealed a Trauma Screen was completed on 8/22/24 and indicated the resident refused. No other Trauma Screen was found as completed. Resident 3's 3/13/25 Annual MDS assessed her/him as cognitively intact and the medical diagnoses included anxiety and PTSD. Review of Resident 3's health record revealed a 2/11/26 Care Plan with no indications to the PTSD triggers to ensure the resident, who was a trauma survivor, received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for the residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for Resident 3. No information was found in the health records to identify. On 2/11/26 at 5:45 AM Staff 36 (CNA) confirmed Resident 3 did not have any indications to triggers for possible re-traumatization or to escalate behaviors. Staff 36 could not provide triggers for the resident but stated Resident 30 would sometimes experience outbursts with yelling and throwing things. On 2/13/26 at 11:51 AM Staff 8 (Social Services Director) confirmed Resident 3 did not have any care plan interventions for possible re- traumatization. She was unaware of the need to assess and document trauma informed care prior to a week ago and had not been able to assess and care plan for all the residents. On 2/13/26 at 1:06 PM Staff 1 (Administrator) acknowledged Resident 3's care plan had not interventions related to her/his PTSD. Staff 1 expected residents care planned and staff to be aware of possible PTSD triggers to residents.

Based on observation, interview, and record review it was determined the facility failed to provide appropriate foot care for 2 of 5 sampled resident (#42 and 45) reviewed for ADL care. This placed residents at risk for complications and discomfort. Findings include: Resident 42 was admitted to the facility in 8/2025 with diagnoses including diabetes. The 11/24/25 Modified Quarterly MDS indicated Resident 42 had a BIMS score of 15 which indicated the resident was cognitively intact. The 9/5/25 Care Plan indicated the nursing staff completed nail trimming for Resident 42 and staff monitored skin conditions when care was provided and staff notified the nurse of any open areas or red skin areas. A review of Resident 42's Physician Orders on 2/2026 indicated the nurses checked fingernails and toenails once a week on bath days and trimmed the residents nails as needed. Resident 42 was scheduled for evening showers on Sunday and Wednesday. The 3/10/25 Skin & Wound Evaluation indicated Resident 42's right plantar foot wound was healed. An attached picture of Resident 42's right plantar foot indicated Resident 42's toenails were trimmed. The 2/2026 Documentation Survey Report indicated Resident 42 showered on 2/11/26. The 2/2026 MAR indicated Staff 29 (LPN) completed nail care on 2/11/26. The 2/2026 MAR indicated Resident 42 was not verbally or physically aggressive to other residents or staff. On 2/9/26 at 11:28 AM, Resident 42 was observed sitting in wheelchair and she/he was not wearing shoes. The resident had a left BKA (below the knee amputation) and on the right foot, the first three toes were amputated. Resident 42's foot was red, swollen and had a white substance around the foot and her/his two toenails were yellow and were overgrown and curved towards the bottom of her/his foot. Resident 42 stated staff didn't assess her/his foot and they didn't perform nail trimming. Resident 42 stated staff didn't care so why should she/he. On 2/12/26 at 9:35 AM, Resident 42 stated she/he showered yesterday evening and staff didn't offer to cut her/his toenails. Resident 42 stated she/he allowed staff to assist during showers and allowed staff to perform nail care when offered. On 2/12/26 at 1:26 PM, Staff 17 (CNA) stated the nurses perform nail care for residents with a diagnoses of diabetes. Staff 17 stated the nurses performed nail care after residents showered. On 2/12/26 at 1:50 PM, Staff 30 (CNA) stated Resident 42 showered, and he noticed Resident 42 had white stuff on her/his foot. Staff stated he tried to scrub it off with a towel, but the white substance didn't come all the way off. Staff 30 stated Resident 42's-foot didn't have too much redness but acknowledged Resident 42's toenails were deformed. Staff 30 stated he didn't report skin concerns because the foot didn't have discharge and open wounds. Staff 30 stated the nurses performed nail care after showers and was unsure if this was completed for Resident 42. On 2/12/26 at 3:48 PM, Staff 29, (LPN) stated he didn't assess Resident 42's foot because she/he refused weekly skin checks. Staff 29 stated he was unaware about any skin issues or concerns related to Resident 42's foot. Staff 29 stated he didn't perform nail care because Resident 42 refused. Staff 29 stated he did not report Resident 42's refusal of nail care or weekly skin checks to Staff 6 (RNCM). Staff 30 entered Resident 42's room and asked Resident 42 to assess her/his foot and she/he agreed. Staff 30 described Resident 42's nails overgrown but not having an ingrown nail. On 2/13/26 at 9:36 AM, Staff 6 stated residents had orders for weekly nail care. Staff 6 stated staff were expected to document nail care when it was completed and was unsure Resident 42 refused foot care. On 2/13/26 at 10:14 AM, Staff 2 (DNS) stated residents with a diabetic diagnoses received nail care by the podiatrist and the nursing staff. Staff 2 expected staff performed nail care on shower days. 2. Resident 45 was admitted to the facility in 2021 with diagnoses including peripheral vascular disease. The 12/17/25 Quarterly MDS revealed a BIMS score of 15 indicating Resident 45 had intact cognition. The Care Plan, last reviewed 1/14/26, indicated Resident 45 was seen by podiatry for routine toenail care as needed. No evidence was found in Resident 45's clinical record podiatry care was provided. In an interview on 2/11/26 at 10:18 AM, Resident 45 stated she/he needed podiatry services for toenail care. The resident reported the podiatrist who visited the facility declined to complete toenail care the most recent time they came in due to payor issues. Resident 45 stated her/his toenails were so long she/he worried about breakage and infections. On 2/11/26 at 10:39 AM, Staff 8 (Social Services Director) confirmed the mobile podiatrist used by the facility no longer accepted Resident 45's insurance plan. Staff 8 indicated all residents at the facility with that insurance plan had to begin going to podiatry appointments off site. Staff 8 confirmed on 2/12/26 at 12:18 PM she was unable to find documentation of podiatrist visits for Resident 45 from the past year. On 2/12/26 at 12:38 PM, Staff 34 (CNA) removed Resident 45's shoes and socks at her/his request. Resident 45's toenails on both feet were observed as thick, yellowed, and very long. The approximate length of most toenails was one half inch past the end of the toes. Staff 2 (DNS) acknowledged on 2/23/26 at 2:58 PM podiatry services had not been provided to Resident 45 per the care plan.

Based on interview and record review the facility failed to ensure a resident right to privacy was honored for 1 of 2 sampled residents (#64) reviewed for privacy. The placed residents at risk for exposure of personal information. Findings include:Resident 64 was admitted to the facility in 2025 with diagnoses including heart failure.Resident 64's 8/15/25 admission MDS assessed her/him to be cognitively intact.Review of the 11/2025 Resident Council Meeting minutes revealed the council had a concern of to much into personal business. The 11/18/25 written response by Staff 8 (Social Services Director) revealed Resident 64 was upset because call was placed to APS [Adult protective Services] regarding misappropriation of funds.On 2/13/26 at 9:24 AM Staff 9 (Activity Director) acknowledged she assisted the residents with the Resident Council meetings. Staff 9 confirmed she read the written responses from the meeting minutes to the Resident Council out loud, exactly as written. Staff 9 confirmed Resident 64's name was written in the 11/2025 Resident Council meeting minutes.On 2/13/26 at 11:45 AM Staff 8 acknowledged Resident 64's name was documented on the Resident Council meeting response she wrote. Staff 8 stated she was not aware the responses she wrote were read out loud to residents or that the residents had access to read her responses. On 2/13/26 at 11:32 AM Resident 64 stated she/he was at the 12/2025 Resident Council Meeting and felt angry that she/he heard her/his name read out loud to everyone in the meeting about the facility calling APS about her/him.On 2/13/26 at 12:16 PM Staff 1 (Administrator) stated he expected the Resident Council minutes to not include resident's personal confidential information and it should not have been read out loud to the resident group.

Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed to self-administer medications for 2 of 5 sampled residents (#s 13 and 47) reviewed for accidents. This placed residents at risk for unsafe medication administration. Findings include:The facility's Self-Administration of Medication policy dated 8/2024 included the following:- Medication at bedside is stored in closed, locked cupboards or drawers. This includes over the counter medications.- The RCM (Resident Care Manager) evaluates the resident's ability to self-administer medications using the Self Administration Evaluation form. No medications are stored at bedside nor self-administered until evaluation complete. - A physician order is obtained indicating the specific medications that resident is able to self-administer.- Drug storage is the responsibility of the nursing staff. - Medications are indicated on the MAR as self-administered. 1. Resident 13 was admitted to the facility in 10/2024 with a diagnosis of fracture of neck of left femur. The Quarterly MDS with an ARD of 12/2/25 revealed Resident 13 had a BIMS score of 15, which indicated the resident was cognitively intact. A review of Resident 13's clinical record revealed no self-administration of medication assessment was completed to determine the resident's ability to safely self-administer Senna (a laxative) and Tums (a chewable antacid). Observations on 2/9/26 at 12:57 PM and 2/10/26 at 9:33 AM revealed Resident 13 had one Tums tablet and one Senna pill inside of a small plastic cup on her/his bedside table. On 2/10/26 at 9:33 AM, Resident 13 stated staff had given her/him the Senna, but she/he did not want to take it and put it back in the plastic cup. Resident 13 stated she/he purchased Tums but also changed her/his mind about taking it. On 2/10/26 at 9:39 AM, Staff 12 (CMA) entered Resident 13's room and handed her/him a cup of medications with a cup of water. Observations revealed Staff 12 placed the cup of water next to the plastic cup containing the Tums and Senna and exited the room. On 2/10/26 at 1:56 PM, Resident 13 was observed exiting her/his room to use the restroom. At 2:00 PM, Resident 13 was observed walking with staff around the building. At 2:26 PM, Resident 13 was observed entering her/his room and the cup containing the Tums and Senna was still on her/his bedside table. On 2/10/26 at 2:51 PM, Staff 14 (CNA) stated she was unaware of Resident 13 being authorized to self-administer medications. She stated if medications were found on residents' bedside tables, she would inform the nurse. On 2/10/26 at 2:58 PM, Staff 15 (CNA) stated she was unaware of Resident 13 being authorized to self-administer medications. She stated if Resident 13 had medications at her/his bedside, she would let the nurse know. On 2/10/26 at 3:06 PM, Staff 13 (CMA) stated the process of giving medication to residents included ensuring residents completely swallowed oral medications safely prior to walking away from the resident. She stated if she saw any residents with a cup of medications on their bedside, she would inform the nurse. She was unaware of any residents who had authorization to self-administer their own medication. On 2/10/26 at 3:11 PM, Staff 11 (LPN) stated he expected staff to inform him of any resident who had medications at their bedside. He stated he did not know of any residents who had authorization to self-administer their own medication. At 3:16 PM, Staff 11 went into Resident 13's room and confirmed Resident 13 had one Tums and one Senna in a plastic cup on her/his bedside table. Staff 11 stated CMAs were expected to give medications and observe residents until all of the medications were gone and medications were not to be left unattended. On 2/12/26 at 4:02 PM, Staff 2 (DNS) stated she expected staff to remain with residents when residents took medications. She stated she expected staff to inform a nurse immediately if medications were found by a resident's bedside. 2. Resident 47 was admitted to the facility in 1/2026 with diagnoses including end stage renal disease. A 1/31/26 physician order included 5 ml of guaifenesin (Musinex) to be administered by a clinician as needed for coughing. On 2/9/26 at 10:19 AM three medication containers were observed at Resident 47's bedside table. No lock box was observed in Resident 47's room. Resident 47 stated she/he had those medications for a cough. Resident 47 stated other residents approached her/him and requested to receive a dose of those medications on multiple occasions. Review of Resident 47's records on 2/10/26 revealed no assessment for self-administration of any medications was performed for Resident 47. On 2/13/26 at 11:24 AM Staff 35 (LPN) stated a self-administration assessment was to be completed prior to a medication being left in a resident's room. If determined safe to self-administer a specific medication, new orders were placed by a physician, and the resident was provided a lock box and key for safe storage of medication. On 2/13/26 at 11:35 AM Staff 6 (RNCM) stated a medication self-administration assessment was done on residents to determine if there were safe to self-administer any medication. Staff 6 stated a medication self-administration assessment was not completed on Resident 47. Staff 6 entered Resident 47's room and confirmed Musinex, Musinex PM, and two saline nasal rinses were on Resident 47's bedside table and should not have been in Resident 47's room as she/he was not safe to self-administer those medications.

Based on observation, interview and record review it was determined the facility failed to provide emergency dental services for 1 of 1 sampled resident (#42) reviewed for dental care. This placed residents at risk for acute dental pain and poor appetite. Resident 42 was admitted to the facility in 8/2025 with diagnoses including diabetes.The 9/5/25 Care Plan indicated Resident 42 had her/his own teeth and required assistance setting up when oral hygiene was performed. The 11/24/25 Modification of Quarterly MDS indicated Resident 42 had a BIMS score of 15 which indicated the resident was cognitively intact and Resident 42 did not have dental pain, discomfort and difficulty chewing. The 11/2025 Documentation Survey Report indicated Resident 42 was not verbally or physically aggressive to other residents or staff. A 11/21/25 Progress Note indicated Resident 42 was verbally aggressive with staff and reported toothache. A 11/25/25 Progress Note indicated Staff 31 (Social Services Assistant) called to make an emergent dental appointment but the clinic advised her to call back the following day and an appointment would be scheduled within 48 hours. On 2/9/26 at 11:28 AM, Resident 42 stated she/he felt neglected and felt the facility didnt care about her/him. Resident 42 stated she/he didnt have teeth on the top part of her/his mouth and had multiple missing teeth at the bottom part of her/his mouth. Resident 42 stated she/he had dental pain and discomfort back in 11/2025 and told staff. Resident 42 stated she/he was unable to chew her/his food. Resident 42 stated staff had not scheduled a dental appointment because they didn't care. Resident 42 stated she/he requested an emergent dental appointment in 11/2025 but staff didn't follow up. On 2/12/26 at 1:26 PM, Staff 17 (CNA) stated emergent dental appointments was scheduled quickly and residents were seen with in a couple of days. Staff 17 was unaware Resident 42 had dental concerns. On 2/12/26 at 1:50 PM, Staff 30 (CNA) stated he didn't provide oral care on 2/11/26 swing shift for Resident 42. 02/12/2026 3:48 PM Staff 29, (LPN) stated he didn't assess Resident 42's mouth to notice any dental concerns. Staff 29 stated Resident 42 had not expressed dental pain, discomfort or difficulty chewing. Staff 29 stated residents reporting dental pain and discomfort were scheduled an emergent dental appointment. Staff 29 stated social services scheduled emergent dental appointments within a couple of days. Staff 29 stated he encouraged oral hygiene and reminded residents to perform oral hygiene throughout the day and was unaware oral hygiene not occurring yesterday. On 2/12/26 at 3:57 PM, Staff 8 (Social Service Director) stated emergent dental appointments were scheduled within 24 hours upon request. Staff 8 stated dental concerns were discussed on a quarterly basis and she was unsure about the emergent appointment Resident 42 requested back in 11/2025. On 2/13/26 at 9:36 AM, Staff 6 (RNCM) stated she was unaware Resident 42 had dental pain and discomfort. Staff 6 stated she was not Resident 42's RCM back in 11/2025 so she didnt know about her/his dental concerns. Staff 6 stated staff helped Resident 42 set up supplies to perform oral hygiene. Staff 6 acknowledged Resident 42's request to see a dentist was not timely. On 2/13/26 at 10:14 AM, Staff 2 (DNS) stated residents who reported dental pain, discomfort and difficulty chewing were scheduled an emergent dental appointment immediately. Staff 2 acknowledged Resident 42's request to see a dentist was not timely.

Based on interview and record review it was determined the facility failed to ensure CNA staff received 12 hours of in-service training annually for 5 of 5 randomly selected staff members (#s 6, 7, 8, 9, and 10) reviewed for evidence of in-service training. This placed residents at risk for lack of quality care. Findings include: On 11/6/24 at 1:19 PM Staff 23 (Human Resources/Payroll) provided a list of annual training hours for CNA staff which revealed the following: -Staff 6 (CNA): 0 annual training hours; -Staff 7 (CNA): 8 annual training hours; -Staff 8 (CNA): 11 annual training hours; -Staff 9 (CNA): 0 annual training hours and -Staff 10 (CNA) 8 annual training hours. On 11/6/24 at 1:19 PM Staff 23 confirmed Staff 6, Staff 7, Staff 8, Staff 9 and Staff 10 did not complete the required 12 hours of annual in-service training. On 11/8/24 at 11:09 AM Staff 1 (Administrator) acknowledged CNA staff were required to have 12 hours of annual in-service training.

Based on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 5 of 5 randomly selected CNA staff (#s 6, 7, 8, 9 and 10) reviewed for sufficient and competent staffing. This placed residents at risk for lack of care by competent staff. Findings include: A review of personnel records on 11/6/24 at 12:01 PM with Staff 23 (Human Resources/Payroll) indicated the following employees had not received their annual performance evaluations: -Staff 6 (CNA), hire date 9/17/15: no annual performance review was completed. -Staff 7 (CNA), hire date 9/16/14: no annual performance review was completed. -Staff 8 (CNA), hire date 9/15/17: no annual performance review was completed. -Staff 9 (CNA), hire date 8/1/08: no annual performance review was completed. -Staff 10 (CNA), hire date 6/24/14: no annual performance review was completed. On 11/6/24 at 12:01 PM Staff 23 confirmed annual performance reviews for Staff 6, Staff 7, Staff 8, Staff 9 and Staff 10 were not completed.

Based on observation and interview it was determined the facility failed to ensure a homelike environment for 1 of 1 facility reviewed for dining. This placed residents at risk for a lessened quality of life. Findings include: Observations on 11/5/24 through 11/8/24 between the hours of 8:00 AM and 12:35 PM revealed meals were served with plastic spoons, plastic glasses and Styrofoam cups. On 11/5/24 at 12:38 PM Resident 66 was eating lunch. Resident 66 held up a plastic spoon and stated, they give us this crap to eat with. On 11/6/24 at 1:38 PM Staff 29 (CNA) stated residents usually received regular forks and knives but were given plastic spoons, plastic glasses and Styrofoam cups for at least the past month. Staff 29 stated this was not homelike. On 11/6/24 at 1:42 PM Staff 30 (Dietary Manager) stated the facility did not have enough glasses, cups or silverware for all of the meal service. Staff 30 stated plasticware and Styrofoam cups were not homelike. On 11/8/24 at 9:17 AM Staff 13 (Activities Director) confirmed multiple residents complained about paper and Styrofoam cups, plastic glasses and plastic utensils. Staff 13 reported the residents stated it feels like a fast food restaurant rather than a homelike environment when they received plastic and Styrofoam dishware and utensils.

Based on observation, interview and record review it was determined the facility failed to ensure the ice machine and ice machine scoop were cleaned adequately to maintain sanitary conditions in 1 of 1 kitchen reviewed for sanitary kitchen services. This placed residents at risk of foodborne illness. Findings include: 1. On 11/4/24 at 9:34 AM the ice machine adjacent to the kitchen was observed to have a pink/black substance on a plastic shield inside the machine. Condensation was observed dripping over the substance onto the ice. On 11/4/24 at 9:39 AM Staff 18 (Maintenance Director) stated the ice machine was cleaned every month. Staff 18 acknowledged the presence of the pink/black substance and confirmed the ice machine should be free of any debris or contaminants. On 11/4/24 at 9:58 AM Staff 1 (Administrator) acknowledged the existence of pink/black substance inside the ice machine and stated the ice machine needed to be cleaned. 2. On 11/4/24 at 9:34 AM the ice machine scoop located on the wall next to the ice machine was observed to be stored in a clear plastic container with a black substance and clear slime on the bottom of the container. On 11/4/24 at 9:49 AM Staff 18 (Maintenance Director) stated the ice machine scoop container needed to be cleaned and acknowledged the presence of a black substance and clear slime. On 11/4/24 at 9:58 AM Staff 1 (Administrator) acknowledged the existence of black substance and clear slime on the bottom of the ice scoop container and stated the container needed to be cleaned.

Based on observation and interviews it was determined the facility failed to ensure medications and biologicals were maintained within secured (locked) locations, accessible only to designated staff for 3 of 6 medication and treatment carts reviewed for safe medication storage. This placed residents at risk for unsafe access to medications and diversion of medication. Findings include: The facility's 1/2023 Storage of Medication Policy stated: In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medications supplies should remain locked when not in use or attended by persons with authorized access. 1. On 11/6/24 at 1:38 PM a treatment cart was observed to be unlocked on Hall 1. The nurse was not in view of the cart. On 11/6/24 at 1:47 PM Staff 12 (LPN) confirmed the cart was unlocked. 43691 2. On 11/7/24 at 9:53 AM a medication cart was observed to be unlocked and unattended on Hall 3. On 11/7/24 at 9:57 AM Staff 32 (LPN) confirmed the cart containing perscription medications and inhalers was left unlocked and unattended. 50926 3. On 11/5/24 at 8:07 AM the treatment cart in Hall 1 was observed to be unlocked and unattended. Staff 19 (LPN) returned to cart within one minute. He explained the contents of the cart included wound treatment supplies, equipment for checking blood sugar levels, and residents' insulin (an injectable medication). He also confirm the treatment cart had been left unlocked and unattended. On 11/8/24 at 11:03 AM Staff 2 (Interim DNS) was notified of the findings. No additional information was provided. 4. On 11/6/24 at 8:55 PM the treatment cart and the Hall 1 medication cart were observed near the south entrance. The treatment cart was unlocked and the computer on the medication cart open to a resident's medical record. Both were unattended. At 9:00 PM Staff 17 (RN) confirmed the cart had been unlocked and the computer had been unsecured. On 11/8/24 at 11:03 AM Staff 2 (Interim DNS) was notified of the findings. No additional information was provided.

Based on interview and record review it was determined the facility failed to inform residents and/or the residents' responsible party of the risks and benefits, and to ensure consent was obtained for the use of psychotropic medications for 2 of 5 sampled residents (#s 34 and 66) reviewed for unnecessary medications. This placed residents at risk for lack of informed consent. Findings include: The facility's Psychoactive Medications policy, dated 8/1/24, indicated risks and benefits of drug use and revealed informed consent was to be obtained from the resident/resident representative prior to administration of any psychoactive medication. 1. Resident 34 was admitted to the facility in 3/2023 with diagnoses including major depressive disorder. Resident 34's 10/2024 MAR revealed the resident received the following psychotropic medications as ordered by her/his physician: -Buspirone (a medication to treat anxiety), three times a day for anxiety. -Sertraline (a medication to treat depression), one time a day for major depression. -Clonidine (a medication to treat anxiety), every 6 hours as needed for anxiety. Review of Resident 34's health record revealed no documentation to indicate the resident or her/his representative were informed of the risks and benefits of buspirone, sertraline or clonidine and no evidence the resident consented to receive the medications. On 11/6/24 at 11:51 AM Staff 2 (Interim DNS) stated it was her expectation nursing staff reviewed the risks and benefits of psychotropic medications with residents prior to the residents taking the medications and confirmed Resident 34 received buspirone, sertraline and clonidine without consent being obtained. 2. Resident 66 was admitted to the facility in 10/2024 with diagnoses including major depressive disorder. Resident 66's 10/2024 MAR revealed the resident received the following psychotropic medication as ordered by her/his physician: -Quetiapine (a medication to treat major depressive disorder), one time a day at bedtime. Review of Resident 66's health record revealed no documentation to indicate the resident or her/his representative were informed of the risks and benefits of quetiapine and no evidence the resident consented to receive the medication. On 11/6/24 at 11:51 AM Staff 2 (Interim DNS) stated it was her expectation nursing staff reviewed the risks and benefits of psychotropic medication with residents prior to the residents taking the medication and confirmed Resident 34 received quetiapine without consent being obtained.

Based on interview and record review it was determined the facility failed to ensure residents were free from physical abuse for 1 of 7 sampled residents (#28) reviewed for abuse. This failure resulted in Resident 28 sustaining a broken jaw, which required surgery and necessitated a diet texture modification, after the resident was struck by another resident. Findings include: Resident 28 admitted to the facility in 3/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 28's 4/1/21 care plan indicated the resident required extensive assistance with ambulation, bathing, bed mobility, dressing, grooming, toileting, and transferring. Resident 28's 7/8/21 Quarterly MDS indicated the resident was [AGE] years old, 67 inches tall and weighed 140 pounds. Resident 18 admitted to the facility in 5/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 18's 8/15/21 Quarterly MDS indicated the resident was [AGE] years old, 70 inches tall and weighed 225 pounds. Resident 18's care plan, updated 9/5/21, indicated the resident was independent with ambulation, bathing, bed mobility, dressing, grooming, toileting and transferring. Facility investigative documents for an incident on 10/7/21 indicated Residents 18 and 28 were in a verbal altercation with Staff 41 (CNA) present in the room. Staff 41 left to get help and then nursing staff heard Resident 18 yell out for assistance because Resident 28 was not doing well. Staff 26 (LPN) found Resident 28 slumped back in her/his wheelchair, bleeding and unresponsive. Resident 28 told staff she/he struck Resident 18. Resident 28 was sent to the Emergency Department and was diagnosed with a broken mandible (jaw). Police responded to the facility and arrested Resident 18. The facility determined Resident 18 physically abused Resident 28. A 10/7/21 hospital note indicated Resident 28 was punched in the jaw and diagnosed with a left mandible fracture, dislocation and intracranial bleed. The note indicated Resident 28 was referred for necessary surgical repair and was ordered to have a puree diet for six weeks. No evidence was found in Resident 28's medical record to indicate the resident experienced sustained emotional distress. Attempts to contact Resident 18 on 2/14/22 and 2/15/22 were unsuccessful. On 2/15/22 at 9:42 AM Staff 31 (Social Services) stated Resident 28's baseline behaviors did not change after the incident. On 2/15/22 at 9:53 AM Staff 41 stated the two residents were arguing about taking a shower when she left the room to get a blanket for one of the residents. Within seconds of leaving the room she heard the nurse call for help. Staff 41 saw Resident 18 standing outside the room and saw Resident 28 bleeding, confused and looking very bad. Staff 41 stated Resident 18 admitted to striking Resident 28. On 2/15/22 at 10:18 AM Staff 26 stated Resident 18 told him Resident 28 needed help. Staff 26 found Resident 28 tilted back in a wheelchair, unresponsive, bleeding, not breathing and with her/his legs up in the air. Staff 26 put the resident's wheelchair back on the ground and the resident began breathing again. Staff 26 stated Resident 18 admitted to striking Resident 28. Staff 26 said Resident 18 hit a disabled, elderly [resident] in a wheelchair who weighed half [her/his] weight. During interviews with Staff 3 (DNS) and Staff 40 (Regional Director of Operations) from 2/15/22 through 2/17/22 the staff stated the facility investigated the incident and concluded Resident 18 physically abused Resident 28. Facility nursing staff and administrative staff were inserviced regarding abuse policies and procedures after the incident, and no additional instances of abuse were identified since the 10/7/21 incident. This incident was determined to be past noncompliance based on corrective measures put in place by the facility after the incident. As a result of the incident on 10/7/21 the facility instituted the following: - A complete investigation related to the 10/7/21 incident. - In-service trainings from 10/11/21 through 11/1/21 for nursing staff related to abuse definitions, as well as abuse incident policies and procedures. - In-service trainings from 10/11/21 through 11/1/21 for administrative staff related to abuse incident reporting, investigations and documentation. No evidence was found to indicate additional abuse incidents occurred after 10/7/21. The facility was determined to be back in compliance with this regulation as of 11/1/21.

Based on observations, interview and record review, it was determined the facility failed to ensure residents were appropriately supervised while smoking for 6 of 7 sampled residents (#s ,3, 4, 5, 6, and 7) reviewed for smoking. This failure, determined to be an Immediate Jeopardy situation, resulted from residents who were supervised smokers observed to be smoking with no supervision by staff. This placed all residents at risk for injury from fire hazards throughout the facility. This facility was found to be providing Substandard Quality of Care in the area of: CFR 483.25 Free of Accident Hazards/Supervision/Devices Findings Include: The facility's 3/2019 Smoking Policy for Independent and Supervised Smokers indicated: Residents who wish to smoke will be assessed for their ability to smoke safely and appropriately manage their smoking materials. Residents who do not meet the established criteria to smoke independently will be provided assistance/supervision during all smoking activities. For residents requiring assistance/supervision with smoking, the facility will establish designated smoking times, and post them near the smoking area. Supervision for smoking is to be provided solely by facility staff. Visitors and other residents may not supervise resident smoking. 1. Resident 3 was admitted to facility on 1/2018 with [DIAGNOSES REDACTED]. Resident 3's BIMS score was obtained from the MDS Annual assessment dated [DATE] and was 12 out of 15, indicating moderate cognitive impairment. On 9/16/20 at 12:02 PM, Resident 3 was observed to be smoking with no supervision in the smoking area. No staff were observed in the smoking area or by the exit doors from inside the facility to the smoking courtyard. On 9/16/20 from 12:51 to 12:57 PM, Resident 3 was observed to be smoking with no supervision in the smoking area. Resident 3 was interviewed at 12:55 PM and stated she/he always kept her/his cigarettes in her/his jacket pocket. Resident 3 denied her/his smoking materials had been removed by facility staff from her/him in the past couple of days. Immediately after the interview, Resident 3 was observed to leave the smoking area with a pack of cigarettes and lighter in her/his jacket pocket. Resident 3 then walked back to her/his room with the smoking materials still in her/his jacket pocket. On 9/16/20, Resident 3's Bedside Kardex Report indicated she/he was placed on alert for change to supervised smoking status due to violation of smoking policy and safety hazard 9/15/20. Interventions were to keep smoking materials stored in a locked box located in the courtyard. On 9/16/20 at 1:21 PM, Staff 5 (CNA) stated Resident 3 was not a supervised smoker. Staff 5 stated facility staff had a list of supervised smokers. If a resident was added to the list, the Activity Director would notify the staff of the change. On 9/16/20 at 2:05 PM, Staff 5 acknowledged she was not aware that Resident 3 had been placed on alert on 9/15/20 and added to the list of supervised smokers. Resident 3's smoking evaluation dated 9/16/20 was not updated to reflect she/he was changed to a supervised smoker. The facility risk management report dated 9/16/20 indicated Resident 3 was seen coming into facility from the courtyard with a lit cigarette. The resident turned around after she/he entered the building and put her/his cigarette out on the door frame on the inside of the door. Resident 3 stated she/he realized she/he was walking in with the cigarette and knew she/he couldn't have the cigarette inside so she/he put it out. 2. a. Resident 2 was admitted to facility on 1/2020 with [DIAGNOSES REDACTED]. Resident 2's BIMS score was obtained from the MDS Quarterly assessment dated [DATE] and was 8 out of 15, indicating moderate cognitive impairment. Resident 2's smoking evaluation dated 8/7/20 indicated Resident 2 did not have the cognitive skills or adequate memory recall for smoking safety. Resident 2 was not able to demonstrate the ability to safely store smoking materials. The Interdisciplinary Team (IDT) noted Resident 2 was safe to smoke with supervision. Resident 2's Bedside Kardex Report dated 9/16/20 and care plan identified the resident as a supervised smoker, requiring supervision by staff. Resident 2 had a history of [REDACTED]. due to history of smoking in facility, ensure resident was not smoking and did not have any smoking materials in her/his room and ensure Resident 2 was brought to the front desk for smoke break time. b. Resident 4 was admitted to facility on 2/2018 with [DIAGNOSES REDACTED]. Resident 4's BIMS score was obtained from the MDS Annual assessment dated [DATE] and was 9 out of 15, indicating moderate cognitive impairment. Resident 4's smoking evaluation dated 6/2/20 indicated the resident did not have the cognitive skills or memory recall for smoking safety. Resident 4 was not able to demonstrate the ability to properly store smoking materials and the resident had a history of [REDACTED]. Resident 4's Bedside Kardex Report dated 9/16/20 and care plan indicated she/he was to be monitored for behaviors that included unsupervised smoking, keeping smoking materials on her/his person, refusals to turn over cigarettes and lighter to staff and going into other resident rooms seeking cigarettes. Interventions were to instruct the resident about the facility smoking locations, times, safety concerns, notify the charge nurse immediately if it was suspected the resident had violated safety policy, to observe clothing and skin for signs of [MEDICAL CONDITION] that resident required supervision while smoking. Staff were to put a disposable cigarette holder in place for Resident 4 prior to giving her/him a cigarette. If smoking supplies were observed within resident's room, staff were to notify the charge nurse immediately, remind resident where smoking supplies are to be stored and placed in a supervised lock box. c. Resident 5 was admitted to facility on 9/2019 with [DIAGNOSES REDACTED]. Resident 5's smoking evaluation dated 7/16/20 indicated she/he did not have the cognitive skills or adequate memory recall for smoking. Resident 5 had a history of [REDACTED]. Resident 5 was found safe to smoke with supervision. Resident 5's Bedside Kardex Report dated 9/16/20 and care plan indicated she/he was to be monitored for supervised smoking. Interventions were to instruct resident about the facility smoking locations, times, safety concerns, notify the charge nurse immediately if it was suspected resident had violated safety policy, to observe clothing and skin for signs of [MEDICAL CONDITION] that resident required supervision while smoking. After supervised smoking was completed, a staff member was to remind/assist resident back into the facility to either continue to read her/his book or engage in other facility activities as desired. All smoking materials were to be stored and locked in the assigned smoking box. Staff were to check Resident 5's room every shift as needed assuring the room was free from any smoking materials (tobacco, cigarettes, lighters, rolling papers). d. Resident 6 was admitted to facility on 6/2015 with [DIAGNOSES REDACTED]. Resident 6's BIMS score was obtained from the MDS Annual assessment dated [DATE] and was 9 out of 15, indicating moderate cognitive impairment. Resident 6's smoking evaluation dated 3/11/20 indicated she/he did not have the cognitive skills or adequate memory recall in assessing her/him for smoking safety. Resident 6 was not able to demonstrate the ability to safely store smoking materials, resident's belongings and clothing were not free from burn holes, and the resident had a history of [REDACTED]. Resident 6 was found safe to smoke with supervision. Resident 6's Bedside Kardex Report as of 9/16/20 and Care Plan indicated she/he was to be monitored for supervised smoking. resident had a history of [REDACTED]. Interventions were to instruct the resident about the facility smoking locations, times, safety concerns, notify the charge nurse immediately if it was suspected the resident had violated safety policy, to observe clothing and skin for signs of [MEDICAL CONDITION] that resident required supervision while smoking. e. Resident 7 was admitted to facility on 9/2014 with [DIAGNOSES REDACTED]. Resident 7's BIMS score was obtained from the MDS Annual assessment dated [DATE] and was 4 out of 15, indicating severe cognitive impairment. Resident 7's smoking evaluation dated 8/25/20 indicated the resident did not have the ability to safely store smoking materials per facility policy and Resident 7 was found safe to smoke with supervision. Resident 7's Bedside Kardex report as of 9/16/20 and care plan indicated she/he was to be monitored for supervised smoking. Interventions were to instruct resident about the facility smoking locations, times, safety concerns, notify the charge nurse immediately if it was suspected resident had violated safety policy, to observe clothing and skin for signs of cigarette burns, resident required supervision while smoking, to set resident up with two cigarettes every odd hour during waking hours and to store the cigarettes in the locked box located in the smoking section of the courtyard with the keys stored in a labeled box in cart one. On 9/16/20 from 12:51 to 12:57 PM, residents 2, 3, 4, 5, 6 and 7 were observed to be in the facility smoking area. All residents were observed to be smoking and no staff were observed in the smoking area or inside the facility at the exit doors leading to the smoking courtyard. On 9/16/20 at 4:42 PM, Resident 6 was observed to be smoking unsupervised in the smoking area with no staff observed in the smoking area or by the exit doors. Staff 1 (Administrator), who had accompanied the surveyor outside to inspect the smoking area, confirmed Resident 6 was a supervised smoker and it was an expectation of facility policy she/he would be supervised by staff while smoking. . On 9/16/20 at 1:21 PM, Staff 4 (CNA) stated she came out to supervise the smokers at 1:00 PM. Staff 4 stated there had been four or five residents in the smoking area previously. Staff 4 acknowledged she was not supervising the smokers during the noon hour. On 9/16/20 at 3:10 PM, Staff 3 (Social Services Assistant) confirmed upon the surveyor's request, she had identified residents 2, 3, 4, 5, 6 and 7 at 12:51 PM. Staff 3 confirmed she had observed the residents smoking unsupervised in the smoking area. On 9/16/20 at 4:35 PM, Staff 8 (RCM) confirmed that it was an expectation staff should be present with residents who required supervision while smoking. On 9/16/20 at 4:42 PM, Staff 1 stated supervised smokers had been assessed as not safe to smoke independently. Smoking materials were located in locked boxes in the courtyard area and staff were responsible for supervising those residents. Staff 1 confirmed it was an expectation staff should be present with supervised smokers at all times while in the smoking area. On 9/16/20 at 6:10 PM, the facility administrative staff, including Staff 1 was notified of the immediate jeopardy (IJ) situation and provided a copy of the IJ template related to the facility's failure to ensure the residents were adequately supervised during smoke breaks, which placed all residents at risk of fire hazards. An immediate plan of correction (POC) was requested. On 9/16/20 at 6:57 PM the facility submitted a plan of correction which was accepted by the survey team. The IJ Removal Plan included: -The facility will put a key pad lock in the internal court yard so supervised smokers will get assisted to the smoking area. -The facility will provide independent smokers with the key code to enter the courtyard. -The facility will distribute letters to current smokers to advise them of the change in operations. -Maintenance director will install the key pad lock 9/16/20. -The facility will re-educate staff on supervised smoking times. On 9/16/20 at 7:30 PM, Staff 1 provided a copy of the in service education related to smoking policy that had been signed by staff on the evening shift. On 9/17/20 at 2:30 PM the courtyard doors were found to have working key pad locks on the doors to the courtyard smoking area and signage displayed notifying residents of the new policy. On 9/17/20 at 2:34 PM, Staff 14 (LPN) verified she had received in service training regarding the new smoking policy per POC. On 9/17/20 at 3:15 PM, Staff 13 (CNA) verified she had received in service training regarding the new smoking policy per POC. On 9/17/20 at 3:25 PM, Staff 7 (Maintenance Director) confirmed he had changed the key pad locks to the smoking area on 9/16/20 per POC. On 9/18/20 at 5:24 AM, Staff 9 (CNA) verified she had received in service training regarding the new smoking policy per POC. On 9/18/20 at 5:29 AM, Staff 10 (CNA) verified she had received in service training regarding the new smoking policy per POC. On 9/18/20 at 6:17 AM, Staff 11 (CNA) verified she had received in service training regarding the new smoking policy per POC. On 9/18/20 at 6:25 AM, Staff 12 (CNA) verified he had received in service training regarding the new smoking policy per POC. On 9/18/20 at 7:13 AM the smoking area was observed to have five residents smoking and one staff member supervising the smokers.

Based on interview and record review it was determined the facility failed to ensure a resident at risk for aspiration was supervised during a meal. Resident 1 choked on food, the resident's airway was obstructed and required Cardiopulmonary Resuscitation (CPR). Findings include: Resident 1 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The [DATE] Speech Language Pathology and Plan of Treatment form indicated the resident was assessed to determine the safest least restrictive diet for the resident. The resident coughed when the resident swallowed thin liquids. The resident was identified to need close supervision and was on aspiration precautions. On [DATE] at 11:15 am Staff 18 (Rehabilitation Director) indicated Resident 14 was assessed on [DATE] and therapy made recommendations that included staff were to provide close supervision when the resident ate. Staff 18 indicated close supervision meant staff were to be within line of site of the resident. The In Room Care Plan updated on [DATE] indicated Resident 14 was at risk for aspiration. The resident could have thin liquids, was to be upright, take small sips and stop if the resident coughed. The resident was to eat in the Assist Dining Room and was to be provided supervision and verbal cues. The [DATE] Progress Note by Staff 10 (LPN) indicated Resident 14's room mate reported Resident 14 was in respiratory distress. Resident 14 was found to be at the side of the bed, gasping for air and the resident's face and lips had a blue tint. Staff 10 instructed another nurse to call emergency services (EMS) and Staff 10 attempted to perform the Heimlich maneuver (intervention to clear airway). The Heimlich maneuver was not effective. The resident started to lose consciousness and was moved to the floor and CPR was initiated. EMS arrived eight minutes later and took over the care of the resident. The resident was transported to the hospital. On [DATE] at 11:15 am Staff 10 (LPN) indicated at times the resident refused to eat in the dining room. If the resident did not want to eat in the dining room the CNAs were to report to the nursing staff. The resident had a right to eat in her/his room, but required staff to stay with the resident in her/his room when the resident ate. Staff 10 indicated on [DATE] the CNAs did not report the resident refused to eat in the dining room. The [DATE] Witness Report by Staff 19 (CNA) indicated she was assigned to work with Resident 1 on [DATE]. At approximately 5:20 pm Resident 1 refused to go to the dining room to eat. The statement indicated Staff 19 had to monitor the residents in the dining room during the meal time and did not provide Resident 1 her/his meal. On [DATE] at 10:38 am Staff 19 (CNA) indicated she was Resident 1's CNA on [DATE] but was assigned to monitor the residents in the dining room during dinner. Staff 19 indicated Staff 20 (CNA) passed the meal trays to the residents that chose to eat in their rooms. Staff 20 provided Resident 1 her/his meal and did not provide supervision to Resident 1 after Staff 20 delivered Resident 1 her/his meal. The Witness Report dated [DATE] by Staff 20 (CNA) indicated Resident 1 refused to eat in the dining room on [DATE]. The note indicated Staff 20 was not aware the resident had any problems and the resident was her/his own responsible party. The report indicated at approximately 6:20 pm Staff 20 was at the nurses station. Staff 20 heard call [DATE]. Staff 20 went to Resident 1's room and assisted as directed by the nurses. On [DATE] at 10:41 am Staff 20 (CNA) indicated on [DATE] she was assigned to pass dinner trays to the residents that chose to eat in their rooms. Staff 20 indicated Resident 1 had a history of [REDACTED]. On [DATE] Resident 1 did not want to go to the dining room to eat. Staff 20 indicated she provided Resident 1 her/his meal and left the room to answer another resident's call light. Staff 20 indicated she was not able to just sit with Resident 1 because she was responsible to answer call lights for the residents that did not go to the ding room to eat. On [DATE] at 1:00 pm Staff 9 (RNCM) indicated Resident 1 had a swallow evaluation in February 2017. Resident 1 coughed when she/he ate and was to eat in the dining room. At times Resident 1 chose not to eat in the dining room. Staff 9 indicated if Resident 1 chose to eat in her/his room staff were to stay in the room to supervise the resident. Staff 20 indicated staff were not with the resident on [DATE] when the resident chose to eat in her/his room. The [DATE] EMS report indicated the EMTs (Emergency Medical Technicians) arrived to Resident 1's side at 6:26 pm. Staff were observed performing CPR. The facility staff reported Resident 1 did not have any complaints that day. The EMTs used a scope to look into Resident 1's airway. The EMTs removed a large piece of food from the resident's airway. CPR was resumed and Resident 1 was transported to the hospital for additional care. The primary impression was cardiac arrest and the secondary impression was full airway obstruction. The [DATE] Emergency Department Report indicated Resident 1 could have had a primary respiratory arrest. The resident was provided a total of 40 minutes of CPR before the resident was pronounced dead.

1. Based on interviews and record review it was determined the facility failed to provide non-pressure ulcer dressings as ordered for 1 of 4 sampled residents (#1) reviewed for wound care. Resident 1's dressing changes for her/his wounds were not completed as ordered and maggots developed in her/his wound. Findings include: Resident 1 was admitted to the facility in April 2015 with [DIAGNOSES REDACTED]. The 7/8/16 physician's order for bilateral lower extremity wound care was for the facility staff to wash legs with soap and water. Pat dry, apply zinc oxide cream to open area. Add Calcium Alginate between toes to wick moisture. [MEDICATION NAME] to peri-wound contact/dry skin. Wrap with Kerlix. Apply [MEDICATION NAME] Size G, one layer to bilateral lower extremities 24/7. Then apply circaids. Change daily and PRN The July 2016 TAR documented the resident refused wound care treatment on one occasion from 7/8/16 through 7/17/16. The resident was hospitalized from [DATE] through 7/25/16. The 7/8/16 physician's order for wound care remained in effect. The 7/29/16 progress notes documented there was a foul odor on the resident's dressing on her/his legs. The 7/29/16 wound care nurse's notes documented the resident's toe wound was a full thickness venous ulcer. There were no signs and symptoms of infection and no drainage. The July 2016 TAR documented the resident refused wound care treatment on one occasion from 7/17/16 through 7/30/16. The 7/30/16 physician's order for bilateral lower extremities and left 2nd toe for zinc oxide applied to 20 percent. Continue with the resident of the dressings. [MEDICATION NAME] should cover from base of toes up to below the knees. The dressing were to be done once a day and as needed The August 2016 TAR contained both the 7/8/16 and 7/30/16 physician's orders for wound care. The TAR contained documentation the resident refused wound care treatments on 8/1/16, 8/2/16 and 8/3/16. There was no documentation the facility staff attempted to provide wound dressing changes or reported to the next shift nurse the dressing change needed to be accomplished. On 8/4/16 there was documentation the wound care was provided. The 8/5/16 progress notes documented at 1:36 am by Witness 3 (Former LPN) wound dressing was done at the request of the resident. Witness 3 documented there was a foul odor from the wound bed. The 8/5/16 progress notes documented by Witness 2 (Nurse Practitioner/NP) maggots in wound did not cause any harm and most probably were beneficial in debridement. Educated patient in length of necessity to be compliant with wound care and dressing changes as well as routine bathing to prevent re-occurrence The 8/5/16 Incident Investigation indicated Resident 1 asked Witness 3 (night shift charge nurse) to change her/his dressings on her/his right leg because it had not been changed for 2-3 days. When the old dressing was removed the nurse noticed between her/his big toe and second toe on the right foot there was sanguineous drainage. When the wound bed was assessed there appeared to be maggots in the wound bed. Resident 1 had no complaints or discomfort. Staff 2 (DNS) also assessed the right great and second toe by removing the entire dressing to reveal numerous tiny, clear maggots emerging from between her/his toes. The investigation documented Staff 2 (DNS) interviewed the two nurses who were assigned to provide wound care for Resident 1 from 8/1/16 through 8/4/16. Staff 2 discovered the wound dressings were not changed for four days instead of two to three days as reported. The investigation concluded Witness 4 (Former LPN) failed to provide goods or services necessary to prevent harm, mental anguish or illness. Staff 2 determined neglect was substantiated and the facility completed a self-report to the local protective services agency. Interviews conducted 12/5/16 at 10:00 am through 12/8/16 at 4:15 pm revealed the following: On 12/5/16 at 10:00 am Witness 1 (Complainant) stated Resident 1 developed maggots in her/his wound. Staff 2 (DNS) stated the State Board of Nursing was not contacted about the incident as Witness 4 (Former LPN) decided to quit. Staff 2 stated she wrote disciplinary action against Witness 4 and reported the incident to the local protective services agency. Staff 2 stated when the resident refused the wound dressing to be changed she expected the nursing staff to continue to approach the resident about the dressing change and report the next shift nurse. Witness 3 (Former LPN) stated Resident 1 asked her to conduct a dressing change on the night shift. Witness 3 stated it was dark in the room and she asked Staff 4 (CNA) to assist her with dressing change. Witness 3 stated the bandage stuck to the resident's foot and appeared the dressing had not been changed for a few days. Witness 3 stated when the dressing was removed she notice there were items falling out of the wound. Witness 3 stated she obtained a flash light and determined there were maggots falling out of the wound. Witness 3 stated she saw more maggots in the wound. Staff 4 (CNA) stated she was in Resident 1's room when Witness 3 (Former LPN) changed the wound dressing. Staff 4 stated she saw what looked like worms falling out of the resident's wound. Witness 4 (Former LPN) stated she had been off of work for the first three days of August 2016 and returned to work on 8/4/16. Witness 4 stated she was not aware the resident refused wound treatments on 8/1/16 through 8/3/16. Witness 4 stated on 8/4/16 she documented in the computer she completed the wound dressing change. Witness 4 stated she checked the resident's blood sugars and gathered the supplies for the wound dressing change. The resident refused to have wound dressing change and she did not document the resident refused the dressing change. Witness 4 stated she made a stupid mistake by not correcting the documentation to indicate the dressing change was not accomplished. Witness 4 stated nurses were expected to reapproach the resident three times during the shift and if the resident continued to refuse the nurse on the next shift was to be informed the dressing change was not done. Witness 4 stated she chose to leave employment at the facility and was no longer working as an LPN. Staff 5 stated the resident often refused dressing changes. Staff 5 stated when the resident refused the dressing changes it was expected the nurses approached the resident three times during the shift for a dressing change. If the resident continued to refuse the dressing change the nurse on the next shift was to be informed of the need to approach the resident for a dressing change. Staff 5 stated the nurses would document contact with the resident on the TAR or in the progress notes. 2. Based on interviews and record review it was determined the facility failed to follow physician's orders regarding the provision of [MEDICATION NAME] (medication to treat fluid build-up due to heart failure) and to contact the physician when the resident had a weight gain for 1 of 3 sampled residents (#1) reviewed for [MEDICAL CONDITION]. The resident had a 41 pound weight with [MEDICAL CONDITION] and was treated at the local hospital for [MEDICAL CONDITION] and fluid overload. Findings include: Resident 1 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. a. The 6/30/16 local hospital discharge orders indicated the resident's [MEDICATION NAME] dose was decreased from 80 mg to 60 mg twice a day. The local hospital physician indicated the [MEDICATION NAME] dose can be uptitrated per house provider The resident's record contained no physician's order for 60 mg of [MEDICATION NAME] to be provided twice a day. The July 2016 MAR indicated [REDACTED]. The 7/5/16 Nutritional Risk Review progress notes documented the resident weighed 330 pounds on 6/27/16 and current weight was recorded as 381 pounds. The progress note stated the weight was reported to the Nurse Practitioner and the resident was started on [MEDICATION NAME] 40 mg BID. The progress notes also indicated the reason for the weight gain was the diuretic ([MEDICATION NAME]) order was reduced from 80 mg to 20 mg. On 12/6/16 at 6:27 pm Staff 2 (DNS) verified there was no order for [MEDICATION NAME] and no [MEDICATION NAME] was provided to the resident from 7/1/16 through 7/4/16. Staff 2 verified the resident's [MEDICATION NAME] was started on 7/5/16. b. On 7/5/16 nursing protocol was put in place for the resident to be weighed daily. The facility staff were to notify the physician when there was a weight gain of two pounds in one day or five pounds in one week. The 7/12/16 Nurse Practitioner (NP) notes documented the resident's weight was 377 pounds. The July 2016 MAR indicated [REDACTED]. On 7/15/16 the resident weight was recorded as 346 pounds, this constituted a weight gain of six pounds. There was no documentation the resident's physician was notified of the resident's weight gain. The 7/15/16 progress notes documented the resident had complaints of shortness of breath when resting. The July 2016 MAR indicated [REDACTED]. There was no documentation the resident's physician was notified. The 7/16/16 progress notes documented the resident's legs were draining and the right lower pants were soaked. The resident had increased complaints of shortness of breath when resting and increased weeping [MEDICAL CONDITION] in her/his legs, arms and abdomen. The July 2016 MAR indicated [REDACTED]. The 7/17/16 progress notes documented the resident had [MEDICAL CONDITION] over all limbs and torso. The nurse noticed the resident had over a 41 pound weight gain in four days with a 6.8 pound weight gain overnight. The physician was consulted and the resident agree to be hospitalized to remove fluids from her/his body. On 12/8/16 at 7:38 pm Staff 2 (DNS) provided documentation the facility staff were expected to follow physician's orders to notify when the resident's weight gain was above parameters. Staff 2 stated she reviewed the resident's progress notes and the physician was aware of the resident's weight from 7/5/16 through 7/12/16. On 12/14/16 at 2:00 pm Staff 1 (Administrator) and Staff 2 (DNS) were asked to review the record of the resident's weight and if the physician needed to be informed. No additional information was provided.

Based on observations, interviews and record review it was determined the facility failed to provide assistance and supervision when she/he was readmitted to the facility for 1 of 3 sampled residents (#16) reviewed for falls. Resident 16 sustained a right hip fracture and required hospitalization . Findings include: Refer to Form CMS 2567, dated 6/1/16, F-323 Event ID# JVHB12.

Based on interview and record review it was determined the facility failed to provide interventions and supervision for a resident identified to be a potential threat to others for 1 of 3 residents (#1) reviewed for resident to resident incidents and failed to ensure a resident did not continue to elope through a window and failed to ensure a resident identified as an elopement risk was accompanied out of the facility with a family member or responsible party for 2 of 4 residents (#s 5 and 9) reviewed for elopement. This placed residents at increased risk for injury. Findings include: 1. Resident 1 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The 9/11/15 Nursing Admission Database (initial assessment upon entering the facility) indicated the resident was independent with walking. The resident's 9/25/15 admission MDS and associated CAAs indicated the resident was an immediate threat to self. The resident became agitated if confronted by staff. The resident was verbally abusive to staff and others. The resident's behavior was assessed to put the resident at risk for poor interactions with others. The Care Plan created on 10/5/15 included the resident had ineffective coping related to frequent use of foul language, angry outbursts and blaming others for adverse feelings. Interventions included staff were to acknowledge the resident and assess if the ineffective coping endangered the resident and/or others and the staff were to intervene if necessary. The Progress Notes from 9/25/15 through 10/13/15 indicated on 9/26/15 Resident 1 was observed to yell at other residents. The resident was taken to her/his room and the resident's aggression/yelling decreased. The 10/2/15 note indicated the resident had extreme difficulty with aggression and agitation toward caregivers. The 10/6/15 note indicated a geriatric medical referral for counseling was made with Witness 3 (Licensed Clinical Psychologist). The 10/6/15 note included the resident was at baseline showing signs and symptoms of aggression and agitation toward staff. The 10/13/15 notes included the resident threw a container of food in the hall and screamed at staff and the resident had severe agitation/aggression and staff attempted to redirect the resident. The 10/13/15 note by Staff 1 (Administrator) indicated the resident made threatening remarks toward Witness 3. See GeroMedical notes attached. The resident was issued a 30 day notice to move due to the resident's aggressive behaviors towards staff and residents. The 10/13/15 Psychological Assessment by Witness 3 included Resident 1 was referred for evaluation because the resident displayed verbal outbursts and aggressive behavior. The resident was reported to be seen throwing objects at other residents, staff and walls with force. The summary of the report included the resident was offensive to most staff and residents. The resident was reported to throw pliers at the occupational therapist. The resident was assessed to not respect others and would gladly harm them if it suits (her/him) The assessment ended after the resident threatened to harm Witness 3. Treatment objectives included the resident was a threat to other residents, staff and professionals. Safety Measures should be put into place including pt (patient) never to be left alone unsupervised, staff to work in pairs with the resident. On 3/11/16 at 11:47 am Witness 3 indicated he assessed Resident 1 on 10/13/15. The resident assessment ended after Resident threatened to harm him. Witness 3 indicated he immediately spoke with Staff 1 (Administrator), Staff 15 (Business Office Staff) and Staff 5 (SSD) after the interview with Resident 1 and discussed the potential threat Resident 1 was to other people in the facility, including residents. The facility understood the potential threat. Witness 3 also indicated it was the facility responsibility to provide interventions to keep other residents safe. On 3/9/16 at 11:00 am Staff 1 (Administrator) indicated Witness 3 assessed resident 1 on 10/13/15 but Witness 3 did not immediately talk with staff and did not provide the report until after Resident 1 was discharged from the facility on 10/16/15. On 3/21/16 at 8:40 am Staff 5 (Social Service Director) indicated Resident 1 had behaviors from the first day the resident was admitted to the facility. The resident threw food at staff and tried to trip staff. Staff were encouraged to not walk too closely to the resident. The resident made another resident lick an ashtray in order to earn a cigarette and threatened residents. Staff 5 indicated Witness 3 discussed findings immediately after he evaluated Resident 1. Staff 5 indicated other residents were afraid of Resident 1. Staff tried to alter behaviors by providing activities but interventions were ineffective. Staff 5 acknowledged the resident was able to walk independently through the facility and one staff was not assigned to monitor the resident at all times to ensure the other residents were safe from Resident 1. On 3/22/16 at 12:30 pm Staff 16 (Business Office Staff) indicated, after Witness 3 evaluated Resident 1, he discussed his concerns with Staff 1 and Staff 5. Witness 3 informed them Resident 1 threatened him. Witness 3 was concerned Resident 1 was a threat to staff and other residents. Staff 15 indicated during the meeting with Witness 3 it was discovered Resident 1 had a history of [REDACTED]. Staff 15 was not aware one specific staff member was to monitor the resident at all times to ensure Resident 1 did not threaten others. The Progress Notes indicated on 10/14/15 at 11:14 am the resident continued to yell at staff and other residents the entire shift and the resident was noncompliant with cares. The 10/14/15 at 6:08 pm note indicated the resident threatened another resident with a knife and the knife was confiscated. The Resident to Resident Altercation and Incident Report initiated on 10/14/15 indicated Resident 1 threatened another resident with a knife. The knife was immediately confiscated. The summary indicated the care plan was undated to 2 person assistant at all times and the care plan was updated to include the resident had aggressive and threatening behavior. The conclusion indicated the facility was able to substantiate verbal abuse towards another resident and the behavior caused harm to the victim for fear for his life. On 3/22/16 at 3:00 pm Staff 12 (LPN) indicated a CNA was in the courtyard with a another resident that was a supervised smoker. Staff 12 was called to the courtyard when Resident 1 threatened the other resident with a knife. Resident 1 did not want to release the knife so she obtained assistance from Staff 1 (Administrator). Staff 1 was able to obtain the knife. Staff 12 indicated Resident 1 was independent to walk throughout the facility. The resident was not assigned constant supervision before or after the knife incident. The 10/15/15 In Room Care Plan, developed two days after Resident 1 threatened another resident with a knife, indicated staff were not to care for Resident 1 alone. Two CNAs were to be present to provide Care. The staff were to report if the resident had a weapon and the weapon was not to be taken from the resident without additional staff present. The care plan did not include how the staff were to ensure other residents were to be kept safe from Resident 1. The 10/16/15 at 5:18 am note by Staff 14 (LPN) indicated the resident in room 135-2 reported Resident 1 was outside and was yelling threats to the resident in 135-3. Resident 1 was instructed to leave other residents alone. On 3/11/16 at 11:08 am Staff 14 indicated the resident was verbally abusive to other residents. Resident 1 was directed to leave the other resident's alone. Staff 14 indicated he did not stay with the Resident 1 after Resident 1 was reported to threaten the resident in room 135. After the incident Resident 1 watched television in the common area. Other residents stayed away from Resident 1 because of Resident 1's behaviors. Staff 14 indicated one CNA was not assigned to monitor the resident at all times, but staff were instructed to not provide care to Resident 1 without another staff present. The 10/16/15 note indicated the resident had escalating behaviors toward other residents and the resident was discharged from the facility to a hospital for evaluation. The Care Plan created on 10/16/15, the day the resident was discharged from the facility, included when Resident 1 was in the general population the staff were to be present. On 3/23/16 at 1:00 pm Staff 6 (DNS) acknowledged Resident 1 had aggressive behaviors toward staff and residents and was able to walk independently through the facility. Staff 6 acknowledged the care plan had interventions to ensure staff were safe during cares but there were no specific interventions to ensure other residents were safe if alone with the resident. A request was made to Staff 6 to provide documentation the facility had interventions in place to ensure all residents in the facility were protected from Resident 1 after the resident was assessed by Witness 1 to have threatening behaviors to others. No additional information was provided. 2. Resident 5 was admitted to the facility in 2016 with [DIAGNOSES REDACTED].>The facility Elopement/Wandering Policy and Procedure dated 1/2014 indicated residents were assessed for potential elopement during the admission process. After a resident was identified as an elopement risk the resident was to be assessed for the use of wander guard (a device placed on the resident wrist or wheelchair and activates an alarm if exit doors were exited). Residents identified to be at risk for elopement or had a cognitive deficit were to be accompanied by family, responsible party or a facility staff when the resident left the facility for appointments or outings. The 2/11/16 Admission Nursing Database (initial assessment upon entry the facility) indicated the resident was alert and oriented to self and was confused. The assessment indicated the resident was at risk for elopement. The chart did not have an assessment for the use of a wander guard. On 3/23/16 at 1:00 pm a request was made to Staff 6 (DNS) for the wander guard assessment. No additional information was provided. The resident's IRCP (In Room Care Plan) initiated on 1/11/16 indicated the resident was a high risk for falls and was confused. The care plan indicated the resident did not remember her/his current location. The care plan had an area to indicate if the resident was an elopement risk. The IRCP was copied at an angle and the area to mark if the resident was at risk for elopement was not visible. An e-mail dated 3/10/16 at 8:25 pm from Staff 6 (DNS) to this surveyor indicated an IRCP not copied at an angle to identify if the resident was an elopement risk was not found in the resident's chart. The 1/14/16 at 10:19 pm Progress Note indicated the resident was compliant with medications and was in bed. The 1/15/16 note by Staff 7 (LPN) at 2:44 pm indicated the resident was alert and oriented and cooperative with care. The note indicated the resident was in bed in the morning and the resident participated with therapy. On 3/8/16 at 12:45 pm Staff 7 indicated she worked the day shift on 1/15/16 and the shift ended about 2:00 pm. Prior to the end of the shift Staff 7 saw Resident 5 work with therapy. The 1/15/16 Physical Therapy Notes electronically signed at 1:57 pm indicated the resident participated in therapy Client seen this am for transfer sit/stand with walker and was assisted back to the resident's room after therapy. On 3/8/16 at 9:30 am Staff 8 (Physical Therapy Assistant) indicated the therapy note was signed on 1/15/16 at 1:57 pm but the exact time of the therapy was not documented. The 1/16/16 at 12:36 am note by Staff 9 (LPN) indicated at on 1/15/16 at 6:00 pm Resident 5's fiance called the facility to speak with the resident but the resident was out of the facility. At 6:20 pm Witness 2 (Family) called the facility and was concerned the resident left the facility. Staff 9 informed the family the resident was alert an oriented and was able to leave the building at will. The police were notified and a search for the resident was initiated. The note also indicated the day nurse (Staff 7) reported the resident was out for lunch. On 3/22/16 at 12:45 pm Staff 9 indicated she worked the evening shift on 1/15/16. Staff 7 (LPN) reported the resident left the building for lunch. Staff 9 was not concerned the resident was not in the building in the evening because Staff 7 indicated the resident was out with visitors. On 3/22/16 at 12:49 pm Staff 7 stated she did not notify Staff 9 the resident was out for lunch because she saw the resident before she left the facility at 2:00 pm. Staff 7 was not aware the resident left with visitors until the next day. Resident 5's room mate told her the resident left with visitors and did not come back. A telephone call was placed to Staff 11 (Day CNA) on 3/22/16 at 12:56 pm. A return call was not received. On 3/10/16 at 5:00 pm Staff 10 (CNA) indicated she worked on 1/15/16 evening shift. She did not see the resident at dinner and told the nurse. The nurse reported the resident was out for lunch and Staff 10 indicated she was not concerned because the resident left the building with visitors. On 3/9/16 at 9:30 am Resident 11 (Resident 5's Room Mate/Assessed to be cognitively intact on the 12/13/15 Quarterly MDS) stated the resident left with two visitors after the lunch was brought to the room. The 1/15/16 Police Report indicated Witness 2 (Family) filed a missing persons report for Resident 5. The report indicated Staff 13 (RN) saw the resident at 1:30 pm during medication administration. On 3/23/16 at 3:23 pm Staff 13 indicated he worked the evening shift on 1/15/16. Staff 13 arrived at approximately 1:30 pm and started to administer medication to the residents. Staff 13 saw Resident 5 working with therapy at approximately 1:30 pm. Staff 13 indicated that was the last time he saw the resident. The CNA staff did not report the resident was not in the facility, therefore he did not look for the resident. The staff realized the resident was not accounted for and did not look for the resident until approximately 6:30 pm. The police came at approximately 8:30 pm. The 1/17/16 progress note indicated Resident 5 was found in room 115. The resident indicated she/he did not remember where she/he went or when she/he returned. The resident indicated she/he was OK. The resident was showered and provided food. The 1/17/16 note indicated the resident was confused, blood pressure was 158/88 (normal is 120/80), pulse was 124 (normal is 60-80) and the residents temperature was 99.7. The resident was administered prescribed medications including blood pressure medication. The 1/18/16 note indicated the resident returned on 1/17/16 and was assessed. The resident's physician was notified and the physician did not want the resident to be evaluated at the emergency room . The resident's family arrived on 1/18/16 and requested the resident be evaluated at the hospital. The physician was notified the family wanted the resident to be evaluated and the physician provided orders to send the resident to the hospital for evaluation. The Resident's family called emergency transport and the resident was sent to the hospital for evaluation. The 1/18/16 Emergency Department dictation indicated the resident was awake, alert and in no acute distress. The resident was admitted for dehydration and was identified to have a urinary tract infection. The resident was admitted for monitoring due to the concern the facility lost the resident. The Investigation Summary completed on 1/18/16 by Staff 1 (Administrator) indicated at approximately 6:00 pm on 1/15/16 she was notified Resident 5 was not in the building . Staff 1 was informed the family called the facility to speak with the resident. The day shift nurse reported the resident was seen at approximately 1:30 pm and the evening shift nurse did not see the resident on her shift. The resident was missing for 5 hours and it was too early to file a missing person report. A police officer arrived to the facility at 7:24 pm to obtain information. The summary indicated Resident 5 had many visitors. The report indicated facility security tapes were reviewed. The resident was observed with therapy at 9:27 am and at 10:05 am a visitor came in and out of the resident's room. The report indicated the resident was found in an empty facility room on 1/17/16. The resident was assessed to not be in distress. On 3/8/16 at 12:45 pm and 3/23/16 at 1:00 pm Staff 6 (DNS) indicted if a resident left the facility the resident was to sign out and write the anticipated time of return. If the resident was not alert and oriented, the family or responsible party identified in the resident's chart were to sign the resident out. Staff 6 indicated the staff did not know who left with the resident on 1/15/16 and the resident did not sign out. Resident 5's room mate indicated Resident 5 left with a visitor but the resident did not know who the visitor was. Staff 6 indicated the staff did not look for the resident until the family called the facility. On 3/9/16 at 11:00 am Staff 1 (Administrator) indicated the facility security camera video tapes were reviewed and the facility was not able to identify the time the resident left the facility and did not know who the resident left with. 3. Resident 9 was admitted to the facility with [DIAGNOSES REDACTED]. The resident's 2/4/16 Elopement Risk Evaluation indicated the resident was at risk to elope due to a history of elopement, was cognitively impaired and was at risk to elope to an unsafe location. The resident's 2/4/16 IRCP (In Room Care Plan) included the resident was independent with transfers, was a high risk for elopement and the resident had a wander guard (Device attached to wrist/leg or wheelchair. The device activates an alarm if the resident opens an exit door). The 2/6/16 at 6:15 am Progress Note indicated the resident eloped through the bathroom window at 5:40 am and was found in the front of the facility without clothes on. The resident was to be checked every thirty minutes. The 2/4/16 Care Plan did not direct the staff to check the resident every 30 minutes. On 3/8/16 at 2:00 pm Staff 4 (LPN Resident Care Manager) indicated she was aware the resident climbed out the resident's room window and the bathroom window. Staff 4 acknowledged the resident's care plan did not alert staff the resident tried to leave through windows and did not have interventions in place to ensure the resident did not exit through windows. The 2/6/16 at 11:31 am note indicated the resident tried to leave the bedroom window and the 2/8/16 note indicated the resident tried to break through the bathroom window but was stopped by the CNA. The 2/10/16 note indicated at 12:00 am the CNA found the resident in her/his room and the resident removed the screen off the window. The 2/11/16 note indicated the resident continued to leave out the bedroom window but returned to the facility. On 3/22/16 at 1:23 pm Staff 12 (LPN) indicated she was aware the resident left the building through windows, but it did not occur on her shift. If a resident left the building through a window it should be reported and investigated to find out why the resident tried to leave and what interventions were to be tried to prevent the resident from exiting the windows. On 3/23/16 at 1:00 pm Staff 6 (DNS) acknowledged the resident exited through bedroom or bathroom windows on four different days. Staff 6 acknowledged the facility did not put in place interventions to prevent the windows from opening all the way or a system to alert the staff if the windows were opened. A request for an assessment/investigation to address how to prevent the resident from leaving the facility through window was requested from Staff 6. No additional information was provided.

Based on observation, interview and record review it was determined the facility failed to respond to a change in condition and inform/follow up with physicians in a timely manner, complete alert charting, follow physician orders, review/revise an ineffective pain management program and assess and track wounds for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 & 6) reviewed for changes in condition and skin breakdown. Residents 1, 2, 3, 4, 5 and 6 were at risk for continued decline in conditions and worsening skin breakdown. Resident 2 experienced prolonged, unaddressed pain. Findings include: The facility's Policy and Procedure for Skin At Risk/Skin Breakdown included: Upon discovery of newly identified skin impairment .the Licensed Nurse will document skin impairment that includes measurements of size, color, presence of odor and exudates (fluid). Document presence of pain associated with the skin impairment. Notify the physician and obtain a Treatment Order if needed, document on the TAR after implemented .Document findings on the Skin Grid for Pressure, Venous, Arterial, and Diabetic Ulcers or the Skin Grid for Non-Pressure Related Skim Impairment .Weekly Wound Rounds are to be completed by a team consisting of the Director of Nursing Services (DNS)/Designee and Resident Care Manager's (RCM's). Arterial, Pressure, Status, Venous Ulcers and Surgical Wounds are to be assessed, measured and documented on the Skin Grid . 1. Resident 2 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. a. The 4/2015 and 5/2015 physician orders [REDACTED]. [MEDICATION NAME] was to be applied to the left heel wound at dressing changes. Staff were directed to administer pain medication 20-30 minutes prior to changing dressings, once daily. The 4/1/15 at 11:35 pm Progress Note disclosed Resident 2 reported being in a lot of pain as a result of dressing changes done that day. The 4/2/15 Wound physician progress notes [REDACTED]. The physician noted the resident had improved compliance with dressing changes and offloading and the nutritional status seemed to be steadily improving given healing at that time. Resident 2 had more severe pain in the left leg, which was described as 10 out of 10. The 4/8/15 Progress Note indicated the [MEDICATION NAME] was out of stock. The resident stated the insurance no longer paid for it. The 4/9/15 Wound physician progress notes [REDACTED]. Resident 2 wants the surgery consult to get done soon. The resident complained of increased pain over the left hip over the previous several weeks. Wounds were described as mostly showing slow steady improvement. The right calf wound was the most concern due to an area of necrotic muscle/tissue, which the resident continued to defer sharp debridement, especially when the resident felt the pain was under treated. Ultimately still planning on pursing surgical evaluation for multiple flaps, possible amputation of the right lower extremity, but need to improve (Resident 2's) nutritional status before most clinics will consider an appt. In the interim, should work on getting a better handle on (Resident 2's) pain control . The 4/16/15 Wound physician progress notes [REDACTED]. Wounds remained a variable improvement/worsening in several places. The physician ordered physical therapy for a wheelchair cushion evaluation/replacement and pressure mapping, which was added to the TAR. At the time of the survey there was no documented evidence the physical therapy referral was done as ordered. The 4/20/15 at 1:30 pm Progress Note revealed Resident 2 reported pain that was 10 out of 10 and radiated all over her/his body. The resident refused dressing changes. The 4/23/15 Wound physician progress notes [REDACTED]. The wounds continued to mostly show some mild improvement and the resident's nutritional status had improved significantly, allowing a referral to plastic surgery. Pain remained in the left lower extremity and hip. The physician directed staff to follow up with the resident's primary care physician regarding referrals to a pain clinic and surgery. Staff 33, Former RNCM documented in the 5/1/15 at 10:43 am Progress Note that Witness 7, Physician stated Resident 2 was able for flap surgery. The 5/8/15 at 4:06 pm Progress Note indicated maggots were found in Resident 2's wounds during dressing changes. The wounds appeared to be getting worse due to the resident's refusals of wound care so many times in the past month. The resident stated she/he no longer wanted to be treated by the wound physician. The 5/11/15 at 10:09 am Progress Note disclosed the Nurse Practitioner was contacted regarding the maggots and to inquire of a possibility of surgical consult or Hospice services for the resident. The 5/14/15 at 11:50 pm Progress Note indicated Resident 2 agreed to see the wound physician. After the physician left the LN attempted to redress the resident's wounds and the resident was administered pain medications. When the LN attempted later to redress the wounds, the resident stated she/he was in too much pain to finish the treatment. The 5/14/15 Wound physician progress notes [REDACTED]. The right lateral leg was noted to have maggots in the necrotic tissue over the weekend and had expanded significantly. Really needs extensive debridement of the wounds to reduce necrotic burden, but (Resident 2) remains resistent (sic) to this due to ongoing pain control concerns. At the time of the survey there was no documented evidence the facility followed up on the pain clinic referral and the surgical referral was not followed up until 5/11/15, 18 days later. The 5/22/15 at 2:13 pm Progress Note indicated Resident 2 was admitted to Hospice services. The 5/26/15 Hospice Progress Note indicated Resident 2 allowed partial wound care and complained of constant pain. The 5/29/15 Hospice Progress Note again noted the resident declined wound care due to pain. The resident requested a change to the pain management orders, which was done. At the time of the survey, there was no documented review or revision of the resident's pain management program until the resident was admitted to Hospice services. The 8/26/15 Progress Note revealed Resident 2 passed away. In interview on 9/24/15 at 3:01 pm Staff 34, RN stated Resident 2 did not think her/his pain medication was enough prior to going to hospice and decided the only way to get enough pain medication coverage was to go on Hospice. In interview on 9/24/15 at 3:20 pm Witness 7, Physician stated Resident 2's nutrition improved enough to be seen by a plastic surgeon for the wounds. There was a lack of follow up from the facility on orders and labs. Pain control was the biggest concern for the resident, which was handled through the resident's primary care physician. Witness 7 stated he recommended the pain clinic because the pain medications were not prescribed at the level the resident required. In interview on 9/25/15 at 9:11 am Staff 7, LPN stated in 4/2015 and 5/2015 Resident 2 had a lot of pain. If the resident did not let staff change the wound dressings the physician was going to discontinue the resident's pain medications. Once the resident was up in the chair the resident did not want to be transferred back to bed as it was uncomfortable. The resident went on Hospice for pain medication. In interview on 9/25/15 at 10:26 am Staff 15, LPN stated Resident 2 was tired of being in pain, wanted it all to end and thought Hospice was a way to get more pain medication. Staff 15 stated staff informed the physician the resident had increased pain but thought the physician wanted the resident to be more compliant with accepting care. Staff 15 did not know if the resident's pain management was changed. In interview on 9/28/15 at 9:44 am Staff 20, CNA stated Resident 2 always stated she/he was in pain and every little movement would hurt the resident's legs. The resident did not like it anymore and was tired of the pain. In interview on 9/30/15 at 11:16 am Staff 36, RN stated Resident 2 needed a lot of pain medication and was still in pain after being treated. Staff 36 attempted to obtain more pain medication for the resident, however, the Nurse Practitioner refused to increase the medication. In interview on 9/3/15 at 10:39 am Witness 4, Hospice RN stated Resident 2 had significant wounds when she/he was admitted to Hospice. The resident was not well medicated, had significant anxiety due to having so much pain for so long and Hospice initiated pain medication changes. The lack of documented follow up of pain clinic and surgical referrals and review/revision of Resident 2's pain management program was shared with Staff 1, Administrator, Staff 2, DNS and Staff 32, Corporate RN on 9/23/15 at 1:13 pm. No additional documentation was provided. b. Resident 2's multiple pressure and traumatic wounds were assessed and tracked by a wound physician during weekly visits from 4/2/15 to 4/23/15. There was no documented weekly physician visit nor wound assessment on 4/30/15 and 5/7/15. The resident's wounds were assessed on 5/14/15. The 5/22/15 at 2:13 pm Progress Note indicated Resident 2 was admitted to Hospice services. At the time of the survey, there were no further documented assessments of the resident's pressure and traumatic wounds. On 9/2/15 at 5:10 pm Staff 3, RCM/LPN stated when Resident 2 was placed on Hospice services, the previous interim DNS told her to not worry about getting measurements of the resident's wounds. Staff, 1, Administrator, Staff 2, DNS and Staff 32, Corporate RN were interviewed on 9/23/15 at 1:13 pm. Staff 32 stated there was nothing in the facility's policy that directed staff to no longer assess, track and documented wounds once Resident 2 was placed on Hospice. c. Resident 2 had the following 4/2/15 wound care physician orders: Wound #2 with skin prep, iodine swabs and leave open to air daily; Wounds #s 11, 12, 15, 20, 24, 27, 28 and 30 cleanse with saline, apply silver [MEDICATION NAME] impregnated gauze and cover with ABD daily and PRN soiling/saturation/loss of dressing; Wound #25, cleanse, apply moderate layer of [MEDICATION NAME] gel then silver [MEDICATION NAME] cream and cover with gauze daily. On 4/9/15 the physician added the treatment of [REDACTED].#31. On 4/16/15 the physician added the treatment of [REDACTED].#32. On 4/23/15 the physician changed the treatment for [REDACTED]. The 4/2015 TAR lacked documented treatment of [REDACTED]. After 4/11/15 there was no documented treatment for [REDACTED]. For Wound #s 2, 11, 12, 15, 20, 25, 27, 29 there were multiple blank entries during the month. For example: Wound 12 lacked documented evidence the wound was treated on 19 out of 30 days and Wound 27 lacked documented evidence the wound was treated on 21 out of 30 days. On 5/14/15 the physician added the treatment of [REDACTED].#s 33 & 34. The 4/2015 and 5/2015 TARs noted the resident consistently refused treatment of [REDACTED]. The 5/22/15 at 2:13 pm Progress Note indicated Resident 2 was admitted to Hospice services. The 5/2015 TAR lacked documented treatment for [REDACTED]. For the remaining wounds, there were multiple blank entries during the month. For example: Wound #s 2, 15, 20, 25, 27 and 29 lacked documented evidence the wound was treated on 7 out of 31 days. The 6/1/15 Hospice wound care orders directed staff to apply [MEDICATION NAME] treated talfa or other nonstick pad to all wound bases, cover with ABD or other absorbent pad and secure with gauze wrap or tape as needed. Hospice staff would attempt wound care on Mondays and Thursdays and the facility was to offer daily on other days. From 6/1/15 to 6/14/15 the 6/2015 TAR lacked documented evidence on 8 out of 10 occasions that the resident's wounds were treated on days other than the Monday and Thursday Hospice treatments. The 6/30/15 at 3:52 pm Progress Note indicated Resident 2 was transferred to a different Hospice agency. The 6/30/15 Hospice wound care orders continued the daily treatment of [REDACTED]. On 7/1/15 Hospice added Dakins Solution quarter strength to necrotic wounds during care. The 7/2015 TAR did not include the 7/1/15 Dakin's treatment to the wounds. The [MEDICATION NAME] treatment was not completed as ordered for 9 out of 31 occasions. For example: On 7/4/15 the treatments were not done due to ran out of time. On 7/10/15, 7/15/15, 7/19/15 and 7/21/15 it documented the treatment was not administered as the wound care was done the previous day. On 7/26/15 the treatment was not administered as the wound care was scheduled for the next day. The 8/2015 TAR did not include the 7/1/15 Dakin's treatment to the wounds. The [MEDICATION NAME] treatment was not completed as ordered on 11 out of 25 occasions. On 8/8/15, 8/13/15 and 8/25/15 the treatments were not administered as the wound care was done yesterday. On 8/9/15, 8/10/15, 8/11/15, 8/15/15, 8/18/15, 8/20/15, 8/22/15 and 8/23/15 the treatments were not done as wound care was not scheduled for those days. In interview on 9/24/15 at 3:20 pm Witness 7, Physician stated there was a lack of follow up from the facility on orders and documentation of wound treatment was an on-going problem with the facility. The lack of following wound treatment orders from 4/2015 to 8/2015 was shared with Staff 1, Administrator, Staff 2, DNS and Staff 32, Corporate RN on 9/23/15 at 1:13 pm. No additional documentation was provided. 2. The facility's Policy and Procedure for Managing Acute Condition Change included: Alert charting will be initiated by the charge nurse or RCM for any change in the resident's condition that necessitates frequent observation and recording . Procedure for Alert Charting: 1. Assess the resident experiencing an acute change.2. Notify the physician and family/responsible party without delay. 3. Document the current status of the resident in the nurses' notes . Resident 1 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The 6/8/15 (Monday) Physical Therapy Treatment Encounter Note(s) disclosed Resident 1 reported severe exacerbation in pain on the weekend following mild improvement on Friday throughout the day. Saturday and Sunday pt (patient) reports severe pain- sharp and deep in R groin, hip joint and knee, but also into lower leg and shin. The 6/8/15 Physical Therapy Discharge Summary noted in the setting of potential return of joint infection, the resident demonstrated marked increase in pain and joint immobility. The 6/9/15 at 3:12 pm Progress Note indicated Resident 1 received pain medication for sharp pain in the right groin. The resident stated she/he had more pain and sharper pain in that area since a physical therapy session a few days ago. The resident stated she/he had reported the increased pain to physical therapy and Staff 32, RN. The 6/12/15 at 12:46 pm Progress Note indicated Staff 33, Former RNCM contacted the physician regarding the resident's increased right hip and right lower extremity pain, increased [MEDICAL CONDITION], induration (hardening of tissue), redness and temperature to the right hip. The physician ordered an x-ray and ultrasound. The 6/12/15 hip x-ray noted marked [MEDICAL CONDITION] of the right hip and deformation of the femoral head. The ultrasound found no acute or chronic blood clot. The 6/13/15 (Saturday) at 9:24 pm Progress Note revealed Resident 1 complained of left hip pain and was concerned with it possibly being infected. Site is [MEDICAL CONDITION], [DIAGNOSES REDACTED]tic (redness) and warm to the touch. Informed patient that MD would be notified Monday . The 6/14/15 (Sunday) at 1:28 am Progress Note disclosed Resident 1 still complained of right hip pain which was warm to the touch and erythemic, appearances consistent with infection. The physician was faxed with a request for antibiotic treatment. The 6/14/15 at 2:41 pm Progress Note indicated the resident's hip was warm to touch. The resident reported there was discharge coming out but none was found upon assessment. On top of the old incision scar a reddish purple discoloration was noted. The physician was contacted, who directed staff to call the resident's surgeon. The 6/14/15 at 11:41 pm Progress Note revealed Resident 1 complained of right hip pain over the last few days. The area had progressively reddened, more [MEDICAL CONDITION] and remained hot. When inspected, the area was still hot to touch, the leg had become very [MEDICAL CONDITION], and was still very [DIAGNOSES REDACTED]tic. Also a change in condition was noted as the appearance of a large blister was present. Discussed with the patient at that time of possible need to be transported to the hospital due to a high potential of infection. When attempting to clean the blister area, the blister open, spilling out copious amounts of yellow pus. Discussed very important need to send patient to ER. Resident 1 was sent to the hospital at 7:30 pm. The 6/14/15 - 6/20/15 Hospital History and Physical and Discharge Summary noted this was Resident 1's third admission for the right hip [MEDICAL CONDITION]/abscess/osteo[DIAGNOSES REDACTED], likely due [MEDICAL CONDITION] again. The resident was diagnosed with [REDACTED]. The 6/21/15 at 3:10 pm Progress Note disclosed Resident 1 was readmitted to the facility. At the time of the survey, there was no documented evidence of alert charting. Resident 1's continued complaints of increased pain and her/his signs and symptoms indicating a possible infection were not communicated to the physician in a timely manner and there was no documented evidence the surgeon was contacted as directed by the resident's primary care physician. On 9/2/15 at 9:40 am Resident 1 was alert and oriented and observed lying in bed. Resident 1 stated she/he had problems with infections in her/his leg and in 6/2015 she/he told staff for a couple of weeks about signs of another infection. Resident 1 stated she/he showed the area to Staff 33, Former RNCM, who described the leg as pretty angry. Resident 1 told Staff 33 about the concern for infection, however, felt Staff 33 pretty much ignored her/him, stating it was not an infection and wanted to check for a blood clot. Resident 1 stated Staff 33 was notified about Resident 1's changes by both her/him and other staff on at least three occasions. Resident 1 stated she/he showed the leg to another former LN over the weekend, however that LN stated there was nothing they could do about it as it was the weekend. Another LN called the primary physician, who directed staff to call the surgeon. The LN did not call the surgeon because it was the weekend and the resident was sent to the hospital the next day. On the day she/he was sent to the hospital, there was a small amount of clear liquid coming out of a small area on the hip. The resident informed a LN and put a dressing on it herself/himself. The liquid soaked through the dressing and when a former LN did the dressing change a big hole opened up on the skin and the resident was sent to the hospital. In interview on 9/15/15 at 11:15 am the lack of timely response to Resident 1's change of condition and alert charting was shared with Staff 1, Administrator and Staff 2, DNS. No additional documentation was provided. In interview on 9/16/15 at 1:31 pm Staff 35, Director of Rehab, PT stated Resident 1's pain progressively worsened over the course of therapy, however the resident's pain on 6/8/15 was different, more intense than before. The resident was concerned of the return of an infection as the pain now went into the lower leg. Staff 35 stated there was on-going conversation with Staff 33, RNCM regarding the resident's pain and concern regarding the right lower leg, including during weekly utilization review meetings. In interview on 9/24/15 at 3:01 pm Staff 34, RN stated regarding the resident's report of increased pain on 6/9/15, the resident complained of pain every day, the pain was always the same and he wondered if the resident was drug seeking. Staff 34 could not recall if the resident reported any concerns of a possible hip infection. In interview on 9/24/15 at 2:40 pm Staff 33, Former RNCM stated he could not recall when the resident started complaining of increased pain, about the resident's discharge from therapy related to pain and possible infection, nor about contacting the physician on 6/12/15 regarding the resident's change in condition. In interview on 9/24/15 at 4:15 pm Staff 24, CNA stated prior to Resident 1's 6/14/15 hospitalization the resident had increased pain, had difficulty transferring and did not get out of bed due to pain in the leg. The right leg was more swollen than the left, which the LN noticed as well. Resident 1 reported to the LN she/he was having a hard time because the pain medications were not working for her/him per usual. Staff 24 stated both she and Resident 1 told nursing staff that something was wrong, but staff wanted to wait until Monday (6/15/15) to talk to the physician. In interviews on 9/28/15 at 5:05 am and 5:21 am Staff 13, LPN stated Resident 1 complained of pain and possible infection two days prior to the 6/14/15 hospitalization . Staff 13 spoke with a couple of nurses about getting antibiotics for what seemed to be a recurrent infection, then faxed the physician himself. Per Staff 13, faxes can be answered in days, but a phone call was more expedient. When asked why he faxed the physician on Sunday, 6/14/15 rather than call the physician, Staff 13 stated it was to make sure he had done something to get the resident some help due to challenges in reaching the physician at night. In interview on 9/3/15 at 4:17 pm Staff 2, DNS stated the physician should have been called rather than faxed on 6/14/15 (Sunday). In interview on 9/24/15 at 12:16 pm Staff 8, RN stated on 6/14/15 the resident's hip was painful and there was a small elevated area on top of the hip scar. The resident reported drainage, none was there, however, the area was reddish-purple. Staff 8 stated she called Resident 1's primary physician before lunch, trying to obtain antibiotics for the resident. The physician directed her to call the surgeon. Staff 8 stated she called the surgeon's office but was not sure if she left a voice mail for the surgeon and endorsed it to the next shift nurse. 3. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 7/14/15 3:05 pm Social Services Progress Note indicated Resident 3 came to the Social Services office and stated up all night puking. The resident did not use the call light for help. Resident 3 smelled of sour vomitus. At the time of the survey there was no documented evidence nursing staff was notified of the resident's report of emesis, vital signs obtained, nor of the physician being notified. On 9/21/15 at 9:42 am Staff 5, Social Services Director stated she asked Resident 3 if she/he had reported the emesis to nursing, which the resident stated no. Staff 5 stated her typical behavior was to report this information to nursing staff, however, she could not recall who she reported it to. In interviews on 9/29/15 at 11:01 am with Staff 8, Day Shift RN and at 11:54 am with Staff 15, Evening Shift LPN, they stated they did not receive report of Resident 3's emesis. On 9/3/15 at 4:17 pm Staff 2, DNS stated the physician should have been notified regarding the resident's emesis. 4. Resident 4 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. On 6/5/15 the physician increased [MEDICATION NAME] (a medication to treat [MEDICAL CONDITION]). A 6/23/15 Progress Note indicated Resident 4 experienced a [MEDICAL CONDITION] at around 7:55 am, with tremors [MEDICATION NAME] until about 8:15 am. The resident became nauseous and vomited and stayed in bed, complaining of not feeling well. There was no alert charting related to the resident's post [MEDICAL CONDITION] status, nor documented evidence the physician was notified. A 7/10/15 Progress Note revealed at approximately 5:20 pm Resident 4 had a [MEDICAL CONDITION]. There was no alert charting documented until the following day at 6:06 pm. On 7/14/15 the physician increased [MEDICATION NAME] (a medication to treat [MEDICAL CONDITION]). A 7/17/15 Progress Note disclosed at 7:00 am Resident 4 experienced four [MEDICAL CONDITION], [MEDICATION NAME] about 30 seconds a piece, five minutes apart. There was no documented evidence the physician was notified of the resident's [MEDICAL CONDITION] activity. There was no alert charting regarding the resident's post [MEDICAL CONDITION] status until the next day at 8:56 pm. On 7/21/15 labs noted the [MEDICATION NAME] was in the therapeutic range for [MEDICAL CONDITION]. An 8/4/15 Progress Note revealed Resident 4 went into [MEDICAL CONDITION] activity at 3:35 pm to 3:39 pm. There was no documented evidence the physician was notified. There was no alert charting documented until the next day at 12:41 pm. 8/11/15 Progress Notes indicated Resident 4 had a [MEDICAL CONDITION] at 12:45 pm, which lasted for about 20 minutes. The resident experienced another [MEDICAL CONDITION] at 7:40 pm. There was no documented evidence the physician was notified regarding the resident's [MEDICAL CONDITION] activity until after the second [MEDICAL CONDITION] occurred. There was no alert charting of the resident's post-[MEDICAL CONDITION] status until the next day at 1:30 pm. On 8/13/15 the resident was sent to the hospital for follow up of [MEDICAL CONDITION]. In interview on 9/24/15 at 12:06 pm Staff 10, LPN stated she notified the physician regarding [MEDICAL CONDITION] and document [MEDICAL CONDITION] that occurred during her shift. In interview on 9/24/15 at 4:31 pm Staff 6, RN stated he always notified the physician regarding [MEDICAL CONDITION] but did not document it. In interview on 9/16/15 at 2:30 pm Staff 1, Administrator stated if alert charting was not documented in the progress notes, there was no further documentation available. In interview on 9/30/15 at 10:32 am Staff 3, RCM/LPN stated staff were expected to notify the physician. Staff were to complete alert charting during the shift and the next shift regarding the resident's post [MEDICAL CONDITION] status. 5. Resident 5 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The 6/8/15 at 11:05 pm Progress Note indicated Resident 5 had a wound behind the left ear with moderate amount of light green fluid visible in the ear canal in front of the wound. The physician was notified by fax. There was no documented alert charting regarding the wound, no further tracking or assessment of the wound status and no documented follow up with the physician regarding possible treatment of [REDACTED]. The 8/13/15 at 11:35 pm Progress Note disclosed Resident 5 had a bloody left ear. The left ear had a quarter sized wound that a CNA stated had been there for at least a couple of years. The blood had a foul smelling dump of what appeared to be possibly hard pus. Upon treating the ear, the outer ear was filled with some bodily sort of material blocking the entrance to the middle ear. Again, there was no documented alert charting regarding the wound, no further tracking or assessment of the wound and no documented follow up with the physician regarding possible treatment of [REDACTED]. On 9/23/15 at 9:42 am Resident 5 was observed to have a large growth on the back of the left ear with a treatment in place. In interview on 9/30/15 at 10:17 am Staff 4, RNCM stated the facility identified the lack of assessing and tracking wounds. Staff 4 stated alert charting should have been completed and the physician should have been notified. 6. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 8/21/15 at 3:16 pm Progress Note indicated Resident 6 complained of right foot pain. The foot was red, warm to touch and a small dry scab was noted on the side of the foot. The physician was notified, Waiting for any change of plan of care. There was no documented alert charting related to the foot status except for 8/24/15 at 3:29 pm. There was no follow up with the physician until 8/27/15, six days later, when the resident was examined by a Nurse Practitioner. At that time Resident 6 reported the right foot went completely numb when ambulating and was very painful after sitting down. In interview on 9/24/15 at 12:16 pm Staff 8, RN stated she faxed the physician regarding the resident's foot status on 8/21/15. Staff 8 reviewed the resident's record and stated she did not see a response from the physician from 8/21/15 until 8/27/15. Staff 8 stated if there was no response from the physician staff should call the physician for follow up. In interview on 9/30/15 at 10:32 am Staff 3, RCM/LPN stated nursing staff needed to keep calling the physician regarding Resident 6's foot status until they heard something from the physician. Staff should have completed alert charting regarding the change with the resident's foot.

1. Based on interview and record review it was determined the facility failed to evaluate the need for bowel care and provide services for the highest well being for 1 of 1 (#99) residents reviewed for quality of care. This resulted in the resident being admitted to the hospital with [REDACTED]. Resident 99 was admitted to the facility in April 2015 with [DIAGNOSES REDACTED]. The May 2015 physician order [REDACTED]. The bowel record for Resident 99 included a five day period from 5/3/15 to 5/7/15 which indicated the resident had no bowel movement. The physicians orders did not include any routine stool softener or PRN laxatives. The Progress Note dated 5/13/15 noted the "resident was going home today until (she/he) had some bright red blood come from (her/his) anus, the resident stated (she/he) was constipated and having to bear down very hard to have a bowel movement. The resident stated (she/he) had a bowel movement but it hurt to pass." The resident was very upset about the blood, called 911 (her/himself) and was transported to the hospital emergency room . The hospital record indicated the resident was admitted to the hospital on [DATE] and was treated for [REDACTED]. On 5/27/15 at 3:58 pm Staff 3 (RNCM) acknowledged the physicians orders did not include any laxatives or stool softener. Staff 3 further acknowledged the facility would implement a routine bowel protocol after three days of no bowel movement for residents in the facility. Staff 3 acknowledged the five day period from 5/3/15 to 5/7/15 Resident 99 had no bowel movement and stated he did not know why "it was not flagged in the system". Staff 3 acknowledged Resident 99 left the facility by ambulance after calling 911. Staff 3 was informed Resident 99 was admitted to the hospital with [REDACTED]. On 5/28/15 at 1:24 pm Staff 2 (Interim DNS) was informed Resident 99 had no protocol for the treatment of [REDACTED]. A late entry Nursing Progress Note, written on 5/30/15 after interview with the surveyor, indicated 5/13/15 would have been the third day with no bowel movement and "bowel protocol" would have been started for the resident. 2. Based on interview and record review it was determined the facility failed to follow physicians orders for 2 of 5 (#s 35 &102) sampled residents reviewed for unnecessary medication. Failure to follow physicians orders put the residents at risk for adverse medical issues. Findings include: a. Resident 102 was admitted to the facility in 5/2015 with [DIAGNOSES REDACTED]. The current physicians orders included [MEDICATION NAME] 40 mg injection as a [MEDICATION NAME] (treatment for [REDACTED].) The May 2015 MAR indicated [REDACTED]. The May 2015 MAR indicated [REDACTED]. The May 2015 MAR indicated [REDACTED]. On 6/1/15 at 11:46 am Staff 3 (RNCM) acknowledged Resident 102 was admitted with an order for [REDACTED]. b. Resident 35 was admitted to the facility in 2011 with [DIAGNOSES REDACTED]. Resident 35's current physician orders [REDACTED]. Humalog sliding scale before meal and at bed time 150 - 200 = 2 units 201 - 250 = 4 units 251 - 300 = 6 units 301 - 350 = 8 units 351 - 400 = 10 units above 400 = 12 units and CALL PCP The May 2015 Diabetic Flowsheet revealed two occasions when Resident 35's CBGs were greater than 400 On 5/17/15 at 5:00 pm, CBG = 477 And on 5/19/15 at 9:00 pm, CBG = 451 There was no evidence in Resident 35's medical record the physician was notified of the CBGs greater than 400. 6/2/15 3:38 pm, Staff 5 (RNCM) confirmed Resident 35's medical record contained no evidence the physician was notified of CBGs greater than 400.

Based on observation, interview and record review it was determined the facility failed to follow physician orders, failed to obtain treatment orders for treatments used, complete wound assessment and tracking, address changes of condition timely and comprehensively assess increased complaints of pain for 4 of 4 sampled residents (#s 1, 2, 3 and 4) reviewed for care and services and changes of condition. As a result, Residents 1 & 2 had increased complaints of pain that were not assessed and effectively managed and Resident 1's skin breakdown worsened. Findings include: 1. Resident 1 was admitted to the facility in 3/2012 with [DIAGNOSES REDACTED]. a. Resident 1's 5/16/12 Pain Care Plan noted interventions such as considering a pain clinic, a neurological consult, social services or mental health referral as needed for difficulty with managing pain. A pain assessment was to be reviewed at admit, quarterly and with a change of condition. The physician was to be notified of unacceptable pain or new/acute onset of pain symptoms. The 6/27/12 Quarterly Pain Assessment Form indicated the resident was able to verbalize pain, rated the pain at "8", with an onset of pain in early and mid morning, afternoon, evening and late evening. The resident reported the medication was "somewhat effective", had pain daily that at times was horrible or excruciating. There was no evidence of a comprehensive assessment or changes in the pain treatment plan when the resident expressed on-going pain with partial effectiveness of the pain regimen. The 5/2012 physician orders included [MEDICATION NAME] (a mood stabilizing agent used for pain control) at bedtime, [MEDICATION NAME] (a [MEDICAL CONDITION] medication to treat neuropathic pain) three times a day, [MEDICATION NAME] (an anti-[MEDICAL CONDITION] agent) twice a day, Tylenol every four hours as needed and [MEDICATION NAME] (a narcotic pain medication) twice a day as needed. On 5/29/12 the physician ordered another [MEDICATION NAME] as needed three times a day. The current physician orders included the same pain treatment regimen. According to the 5/2012 MAR, the resident received the PRN [MEDICATION NAME] 15 times, the [MEDICATION NAME] twice and did not receive any Tylenol. According to the 6/2012 MAR, the resident had received the PRN [MEDICATION NAME] 35 times, the [MEDICATION NAME] 30 times and did not receive any Tylenol. According to the 7/2012 MAR, from 7/1 to 7/18/12, the resident had received the PRN [MEDICATION NAME] 18 times, [MEDICATION NAME] 13 times and had received Tylenol once. In interview on 7/19/12 at 11:15 am, Witness 1, Complainant stated he had asked the facility to obtain a therapy screen regarding the resident's pain to see if there were other treatments, other than loading the resident up on narcotics. Witness 1 questioned the on-going pain assessment and how the resident's pain was being managed. Witness 1 stated the resident had reported at a care conference she/he was not getting her/his pain medications timely. In interview on 7/19/12 at 9:17 am, Resident 1 was observed to be up in an electric wheelchair. Resident 1 stated staff were "pretty good" about administering her/his pain medications. Resident 1 stated she/he had to wait for the CMA to talk to the nurse and she/he waited about 10 minutes for the medication. On 7/20/12 at 8:23 am Resident 1 was observed in bed and moved slowly while attempting to move in bed. When asked about her/his pain management, Resident 1 stated her/his pain was not managed and was currently in pain. Resident 1 stated she/he has pain every day, which had become a "pattern" and had worsened since admission. In interview on 7/19/12 at 2:03 pm, Staff 4, RN, stated Resident 1 could express her/his pain and was accurate regarding per pain status and medications. In interviews on 7/19/12 at 4:05 pm and 7/20/12 at 1:30 pm, Staff 3, RNCM, referred to the 6/2012 Quarterly Pain assessment when asked if she had assessed the resident's pain management and the resident's PRN usage to determine the effectiveness of the pain regimen. Staff 3 stated the resident's pain was originally from her/his back and Staff 3 had not heard the resident complain that the regimen was not working. When asked if she had followed up with the resident's statement on the quarterly assessment of the medication being "somewhat effective", Staff 3 stated "I'm not sure, I can't tell you that." Staff 3 stated Staff 11, LPN, completed the quarterly pain assessment. In interview on 7/20/12 at 2:27 pm, Staff 11, LPN, stated Resident 1 had a pain level of "8", frequently had pain, the pain medication was somewhat effective, which took the pain down to a "bearable level." Staff 11 stated when he completed the resident's assessment, he did not ask the resident what level of pain she/he had after the medication was administered, if her/his pain had been managed or had increased, nor did he ask staff regarding the resident's pain status. Staff 11 stated he mainly stayed with the questions on the assessment form. When asked if he had reviewed the resident's PRN usage, Staff 11 stated he did not review previous MARs to compare the resident's PRN usage. In interview on 7/20/12 at 9:25 am, Staff 17, CMA, stated the resident has had an increase in pain over the past month and asked for the PRN [MEDICATION NAME] more often. Staff 17 stated due to having to report the use of PRN medications to nurses, they were aware of how often the resident was taking the medications. In interview on 7/20/12 at 11:02, Staff 27, Activities Director stated the resident "definitely" had changes in her/his pain level. Staff 27 stated the resident sighed, slumped down and it impacted her/his ability to do activities. Staff 27 stated when the resident was first admitted , she/he was walking a lot more, had a lot more energy, was more talkative, outgoing and was helping a lot in activities. Staff 27 stated in the past month or so, the resident had lost interest in coming to activities and would state "I've got to get my pain medicine." Staff 27 stated the resident never used to complain to her about pain until about a month ago. In interview on 7/21/12 at 9:10 am, Staff 24, CNA, stated regarding Resident 1's pain, the resident had slowed doing things for herself/himself and it took longer for the resident to get out of bed and required assistance with toileting, which was different for the resident. In interview on 7/21/12 at 9:48 am, Staff 15, CMA, stated the resident's pain had been changing as she/he had asked for pain medication more often. Staff 15 stated she had informed the LN, who assessed the resident. In interview on 7/21/12 at 10:32 am, Staff 10, LPN stated Resident 1 had more pain related to having a UTI (urinary tract infection), which was chronic for the resident. Staff 10 stated when Resident 1 had UTIs, her/his pain level was really high and could be excruciating for the resident. Staff 10 stated the focus was more on treating the UTI, pushing fluids and they have looked at her/his pain medications and discussed it with other nurses in report. In interview on 7/23/12 at 12:59 pm, Staff 21, CNA, stated the resident was more slow in her/his movements. Staff 21 stated Resident 1 had not asked her for pain medication, but might asked a CMA or LN while being up in the wheelchair. b. Resident 1's 5/2012 Wound Assessment Flow Sheets disclosed the resident had an open lesion on the right inner thigh, with an onset date of 5/11/12. A 5/15/12 Physician Order directed staff to cleanse the area with saline, treat with triple antibiotic ointment and cover with gauze daily. The 5/2012 TAR lacked documented evidence the lesion was treated on 5/18, 5/19 and 5/20/12. A 5/19/12 Fax to the physician indicated the resident appeared to have a breakout of genital [MEDICAL CONDITION] and requested an order for [REDACTED]. There was no documented on-going assessment or tracking of the genital [MEDICAL CONDITION] breakout. The 5/2012 TAR indicated the resident received the Acylovir ointment as ordered on 5/20 and 5/21/12. The resident was documented as receiving the ointment only once on 5/22/12. It was noted the treatment was not available. The treatment was documented as discontinued on 5/23/12. There was no documented physician order in the clinical record to discontinue the treatment. According to the Wound Assessment Flow Sheets, the right thigh lesion increased in size on 5/29 and 6/5/12. A 6/8/12 Nursing Order directed staff to monitor the lesion to the right inner leg for signs/symptoms of infection until a treatment order was received from the physician. A new treatment order was not obtained until 6/13/12 (five days later), when the physician ordered an antibiotic ointment to treat open areas on the right and left inner thighs twice a day. The 6/2012 TAR documented the antibiotic ointment was applied to the right and left inner thighs from 6/14/12 to 6/18/12. There was no documented on-going assessment or tracking of the wound on the left inner thigh. The Wound Assessment Flow Sheets revealed on 6/14/12 the wound on the right inner thigh had increased in size. It was noted to request a change of treatment to [MEDICATION NAME]. A 6/18/12 (four days later) Fax was sent to the physician, informing the physician the open areas on the inner thighs were not improving, "look like they are spreading". The physician ordered [MEDICATION NAME] orally 400 mg, [MEDICATION NAME] to the right and left inner thighs and [MEDICATION NAME] ointment to open areas. Again, there was no documented assessment of the genital [MEDICAL CONDITION] breakout or any open area on the left thigh. The 6/2012 TAR indicated the resident did not receive the [MEDICATION NAME] ointment on 6/19, 6/20 and 6/21/12. On 6/21/12, it was noted the treatment was not available. The Resident's Wound Assessment Flow Sheet dated 7/10/12 for the weekly skin assessment was blank. The wound assessment information was not completed for that date. In interview on on 7/19/12 at 11:52 am Witness 1 stated there had been changes in the resident's skin status, there should have been more prompt interventions and the resident had a delay in healing the skin breakdown. Witness 1 stated approximately a month ago the facility did not have treatment in place to treat the resident's genital [MEDICAL CONDITION] as they were waiting for treatment orders from the physician and nursing staff could not describe the resident's wound status. During observations on 7/19/12 at 9:17 am, Resident 1 was observed sitting in an electric wheelchair. In interview on 7/20/12 at 8:23 am, Resident 1 was observed in lying in bed and stated the facility had missed a few wound treatments. In interviews on 7/19/12 at 3:48 pm, 7/20/12 at 1:30 pm and 7/24/12, Staff 3, RNCM, stated she could not locate a physician order to discontinue the [MEDICATION NAME] ointment on 5/23/12. Regarding the delay in obtaining treatments from the physician, obtaining treatments from the pharmacy and following physician orders, Staff 3 stated staff should have followed up right away when the physician did not respond timely and the physician orders had not been followed. Staff 3 stated the resident had skin breakdown areas on the right and left sides of her/his thighs and there were closed [MEDICAL CONDITION]. Staff 3 stated a skin sheet should have been initiated for all areas so staff would know if the breakdown was better or worse. Staff 3 stated she had not found additional documentation of the wound assessment and tracking. Staff 3 stated she had completed a skin audit on Resident 1 on 7/24/12. At that time, the skin breakdown on the right thigh was getting smaller, had no drainage and the [MEDICAL CONDITIONS] had mostly cleared. In interview on 7/19/12 at 4:27 pm, Staff 8, RN, stated the resident had multiple [MEDICAL CONDITION] from genital [MEDICAL CONDITION] and had it for awhile. Staff 8 acknowledged there was only a documented assessment and tracking of one wound, not the multiple areas present. In interview 7/19/12 at 8:14 pm, Staff 10, LPN, stated Resident 1 had a wound on the left side that was "pretty big", but also had several smaller areas that were "pimply". The area on the right opened later and was the only current open area. In interview on 7/20/12 at 4:28 pm, Staff 2, DNS stated staff should have followed up "right away" when they did not receive an answer from the physician or medications were not available. Staff 2 stated the treatments were not given as ordered in a timely manner. c. On 7/6/12 a Fax was sent to Resident 1's physician, informing the physician the resident had signs/symptoms of vaginal yeast and requested an order for [REDACTED]. A 7/7/12 Progress Note revealed the resident had complained of burning and itching in the vaginal area and had evidence of a yeast infection. The physician had been faxed with an order for [REDACTED]. On 7/10/12 the physician ordered the [MEDICATION NAME]. There was no documented evidence the facility had followed up with the physician when there had not been a timely response. According to the 7/2012 MAR, the resident started the [MEDICATION NAME] on 7/11/12, five days after the physician had been initially notified regarding the symptoms. In interview on 7/19/12 at 11:52 am, Witness 1, Complainant, stated when Resident 1 experienced changes of condition, Witness 1 was concerned regarding the responsiveness of the physician and felt there should have been more prompt interventions. In interview on 7/20/12 at 1:30 pm, Staff 3, RNCM, stated she expected nursing staff to call the physician at the end of the day (7/6/12) if there had been no response. Staff 3 stated the resident's change of condition was not addressed timely. d. The current physician orders included Dexilant (a medication to treat reflux). The 7/2012 MAR indicated [REDACTED]. A 7/16/12 Fax indicated the physician was requested to complete paperwork required by the pharmacy. On 7/18/12 the physician ordered [MEDICATION NAME] to be given pending the prior authorization for the Dexilant. In addition, a 7/8/12 Emergency Department Report revealed the resident had a UTI (urinary tract infection) and was discharged with physician orders for Bactrim (an antibiotic). The 7/2012 TAR documented Resident 1 did not receive the Bactrim until 7/9/12. According to the facility's E-Kit (emergency medication kit) list, Bactrim was included in the E-Kit. In interview on 7/19/12 at 11:52 am, Witness 1, stated the resident's physician orders had not been followed as the medications had not been available. Witness 1 stated the last time the medications were not available, the resident missed six days of the medication. Witness 1 stated the facility did not have a system to communicate from the CMA to the RNCM and DNS regarding unavailable medications. In interviews on 7/19/12 at 9:17 am and 7/20/12 at 8:23 am, Resident 1 stated medications had not been available. Resident 1 stated not receiving the Dexilant "greatly" affected her/him. Resident 1 stated the medication worked "wonderful" and the [MEDICATION NAME] did not help, describing her/his stomach as "on fire" without the Dexilant. In interview on 7/19/12 at 11:28 am, Staff 26, Staffing/Ward Clerk, stated the resident did not get the medication from 7/6 to 7/11/12 and then the facility ordered a seven day supply that the facility had paid for. While pending a prior authorization, on 7/18/12 the physician ordered [MEDICATION NAME] to be administered until the Dexilant was available. Staff 26 stated the resident had reported the [MEDICATION NAME] was not effective for her/him, which was why the Dexilant had been originally ordered. In interview on 7/19/12 at 2:03 pm Staff 4, RN stated when a medication was not available, the CMA informed the LN (licensed nurse), who called the pharmacy. If there was no timely response from the pharmacy, Staff 1, DNS and Staff 2, RNCM were informed. Staff 4 stated Bactrim was available in the Ekit and she would have used the Ekit if the medication had not been available. In interviews on 7/19/12 at 4:27 pm and 7/23/12 at 1:16 pm Staff 8, RN stated if a medication was not available, she would call the pharmacy to see if it had been ordered. If there was a missed dose, she would inform the physician. Staff 8 stated she did not recall any details about the Dexilant. Staff 8 stated when Resident 1 readmitted with orders for Bactrim, she could not recall if she had checked the Ekit for the medication. In interview on 7/19/12 at 8:14 pm, Staff 10, LPN, stated the Bactrim should have been obtained from the Ekit and administered after the resident readmitted from the emergency room . In interview on 7/20/12 at 8:43 am, Staff 13, LPN, stated she was not aware of any time Bactrim was not available in the Ekit. Staff 13 stated if it had not been in the Ekit, the pharmacy would have been contacted for replacement. In interview on 7/20/12 at 1:30 pm, Staff 3, RNCM, stated the medication aide was to re-order medication seven days before it ran out. If there was a prior authorization required, the pharmacy informed the facility and the facility was to follow up in two days if the medication had still not arrived. Staff 3 stated she did not recall the Dexilant not being available. Staff 3 stated the Bactrim should have been administered within eight hours of the order being written and if it was not available in the Ekit, staff should have had the pharmacy satellite the medication to the facility. In interview with Staff 1, Administrator and Staff 2, DNS, on 7/20/12 at 4:28 pm, Staff 2 stated she was aware [MEDICATION NAME] was not effective for the resident. Staff 1 stated the CMA was to let the LN know about the medication not being available and the LN was to order the medication, but there was no follow-up. Staff 1 stated if the Bactrim was not available in the Ekit, the LN should have either called the physician or the pharmacy to have the medication satellited to the facility. In interview on 7/21/12 at 9:48 am, Staff 15, CMA stated regarding the Dexilant, she worked one day and the resident did not have the medication. Staff 15 stated she re-ordered it from the pharmacy and informed the LN, but could not recall who she had reported it to. In interview on 7/21/12 at 10:00 am, Staff 6, LPN, stated he had faxed the physician regarding a prior authorization for Dexilant. Staff 6 stated he could not recall when he followed up with the insurance company. In interview on 7/21/12 at 11:51 am, Staff 18, CMA stated when she found out the Dexilant was not available, she reported it to Staff 2, DNS and called the pharmacy. In interview on 7/21/12 at 12:04 pm, Staff 16, CMA, stated when the resident missed the first dose, she wrote an order to the pharmacy. The next day when she worked and the medication was still not available, she called the pharmacy again. The pharmacy had stated the medication was sent to the facility, but Staff 16 could not recall when that occurred. Staff 16 stated the physician ordered [MEDICATION NAME] while waiting for the Dexilant, however, the resident was refusing it due to not helping. 2. Resident 2 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Resident 2's 5/17/12 Pain Care Plan noted interventions such as considering a pain clinic, a neurological consult, social services or mental health referral as needed for difficulty with managing pain. A pain assessment was to be reviewed at admit, quarterly and with a change of condition. The physician was to be notified of unacceptable pain or new/acute onset of pain symptoms. The 7/19/12 Quarterly Pain Assessment Form noted the resident was currently expressing pain verbally, reporting a pain level of "9." The resident reported having an onset of pain at all times of day and night, the medication was "somewhat effective" and she/he had pain daily that at times was horrible or excruciating. There was no evidence of a comprehensive assessment or changes in the pain treatment plan when the resident expressed on-going pain with partial effectiveness of the pain regimen. The 4/27/12 physician orders included the following pain medications: [MEDICATION NAME] (a medication to treat muscle spasms) four times a day, [MEDICATION NAME] (a [MEDICAL CONDITION] medication to treat neuropathic pain) three times a day, [MEDICATION NAME] (a narcotic pain medication) every six hours as needed for pain and Tylenol as needed for pain. According to the 5/2012 MAR, the resident received the PRN [MEDICATION NAME] 88 times and Tylenol 12 times. During that month, due to not being available, the resident did not receive the routine [MEDICATION NAME] from 5/13 to 5/22/12 and a portion or all of the prescribed doses of [MEDICATION NAME] on 5/7, 5/9, 5/11 and 5/14/12. The physician ordered for the dosage of the [MEDICATION NAME] to be increased on 6/11/12. There were no other changes with the pain medications. According to the 6/2012 MAR, the resident received the PRN [MEDICATION NAME] 67 times and Tylenol 4 times. According to the 7/2012 MAR, from 7/1 to 7/19/12, the resident received the PRN [MEDICATION NAME] 46 times and Tylenol three times. In interviews on 7/20/12 at 8:49 am and 12:55 pm and on 7/23/12 at 11:40 am, Resident 2 was observed in a specialized wheelchair, with a hand contracture and splint in place and had a specialized call light pad under her/his chin. Resident 2 stated over the past month or two, her/his pain level had increased related to her condition and the worsening of her/his paralysis. Resident 2 stated the pain was in her back and neck and she/he needed to talk with the physician about the pain. The resident stated she/he had informed the facility the pain had worsened. Resident 2 stated when she/he did not receive the routine pain medications in 5/2012, she/he was "Not very good" and was in pain from not receiving those medications. Resident 2 stated the increase of the pain had not affected her/his abilities due to being paralyzed, but made her/him more uncomfortable. In interview on 7/20/12 at 9:25 am, Staff 17, CMA, stated the resident had increased in her/his requests for [MEDICATION NAME] over the past month or so and goes through the PRN medications more quickly. Staff 17 stated due to having to report the use of PRN medications to nurses, they were aware of how often the resident was taking the medications. In interview on 7/20/12 at 10:10 am, Staff 26, Staffing/Ward Clerk, stated the resident had an increase in pain complaints and had been complaining of neck pain while smoking and they were trying to find a way to assist the resident while smoking. In interview on 7/20/12 at 2:05 pm, Staff 3, RNCM, stated she was aware the facility was having trouble obtaining the resident's [MEDICATION NAME]. Staff 3 stated she was not aware the resident was in pain in May when she did not receive her pain medications nor that the resident's pain was worsening. In interview on 7/20/12 at 2:27 pm, Staff 11, LPN, stated he was not aware of the resident's complaints of increased pain. Staff 11 stated when completing the resident's pain assessment he did not ask the resident what level of pain she/he had after the medication was administered, if her/his pain had been managed or had increased, nor did he ask staff regarding the resident's pain status. Staff 11 stated he mainly stayed with the questions on the assessment form. When asked if he had reviewed the resident's PRN usage, Staff 11 stated he did not review previous MARs to compare the resident's PRN usage. In interview on 7/21/12 at 9:10 am, Staff 9, LPN, stated Resident 2 had been having more pain, requesting [MEDICATION NAME]. Staff 9 stated the resident complained of pain in her/his neck. In interview on 7/21/12 at 10:00 am, Staff 6, LPN, stated the resident had been complaining of pain in her/his neck, but had no increase in pain complaints. Staff 6 stated the resident could be asked about pain as she/he was reliable regarding her/his pain. In interview on 7/21/12 at 10:59 am, Staff 5, LPN, stated Resident 1 had been complaining more often about her/his pain. In interview on 7/21/12 at 12:14 pm, Staff 20, CNA, stated the resident did not used to complain of pain, but she/he "does now." In interview on 7/21/12 at 12:20 pm, Staff 28, CNA, stated the resident's complaints of pain had been stable over the month and the resident had been complaining of pain in her/his back and neck. Staff 28 stated it was hard for the resident to be in the wheelchair or bed and hard for the resident to get comfortable. In interview on 7/21/12 at 1:45 pm, Staff 12, LPN, stated the resident had been in a lot of pain lately. The resident had neck pain, staff tried to reposition the resident and she/he "has asked for a lot more PRN medications in the past couple of months." In interview on 7/23/12 at 12:56 pm, Staff 21, CNA, stated the resident had complained of pain at a level "10." Staff 21 stated that was higher than the resident's normal pain level and she had never heard the resident complain of that level of pain before. b. A 7/15/12 Progress Note revealed Resident 2 complained of pain, nausea and shortness of breath and had an oxygen saturation level of 93-94%. A 7/15/12 Fax was sent to the physician, informing the physician the resident complained of chest congestion, was worried about pneumonia and had a history of [REDACTED]. A 7/16/12 Progress Note revealed staff were awaiting results from the chest x-ray that was completed that evening. On 7/18/12 chest x-ray results suggested pneumonia with follow-up recommended. There was no documentation of the resident's condition related to possible pneumonia on 7/17/12. On 7/18/12 the physician ordered for IV Levofloxcin (an antibiotic medication) to be administered after labs and a culture were obtained. According to the 7/2012 MAR, the IV antibiotic was administered on 7/19/12, four days after the resident complained of symptoms of pneumonia. In interview on 7/20/12 at 2:05 pm, Staff 3, RNCM, stated when staff had not received the results on 7/16/12, they should have followed up. c. Resident 2's 4/27/12 re-admission physician orders included: [MEDICATION NAME] (an antibiotic) three times a day, [MEDICATION NAME] (a medication to treat [MEDICAL CONDITION] bladder) four times a day, [MEDICATION NAME] (a medication to treat thrush) four times a day, [MEDICATION NAME] three times a day and [MEDICATION NAME] four times a day. According to the 5/2012 MAR, the following medications were not administered as ordered due to not being available: [MEDICATION NAME], two doses on 5/9/12 [MEDICATION NAME], one dose on 5/7, all doses on 5/9, 5/11, two doses on 5/12 and all doses on 5/14/12 [MEDICATION NAME], all doses from 5/13 to 5/22/12 Mycostantin, one dose on 5/12, all doses on 5/14 and two doses on 5/16/12 [MEDICATION NAME], two doses on 5/7, two doses on 5/8 and all doses from 5/9 to 5/14/12. In interview on 7/20/12 at 12:55 pm Resident 2 stated the facility had run out of her/his medications, including pain medications. When asked how the lack of medications, including the pain medications impacted her/him, Resident 2 stated "Not very good" and she/he was in pain. In interview on 7/20/12 at 2:05 pm, Staff 3, RNCM, stated she was aware the facility was having trouble obtaining the [MEDICATION NAME], but was not aware the resident was in pain when the regular pain medications not being available. In interview on 7/21/12 at 9:10 am, Staff 4, RN and Staff 9, LPN described the facility's process of CMAs informing the LN if a medication was not available and contacting the physician and the pharmacy. Both staff stated they could not recall the resident not receiving medication in May 2012. In interviews on 7/21/12 at 9:48 am with Staff 15, CMA, 10:32 am with Staff 10, LPN, 10:41 am with Staff 15, CMA, 10:59 am with Staff 5, LPN and 7/23/12 at 1:16 pm with Staff 8, RN, those staff did not recall the resident not receiving medication in May 2012. In interview on 7/21/12 at 1:45 pm, Staff 12, LPN, stated there had been times with administering evening medications when she had struggled finding medications, including for Resident 2. Staff 2 stated she searched around, utilized the Ekit and if the medication was not available, then would documented it and contact the pharmacy. Staff 12 stated she could not recall how she followed up on Resident 2's unavailable medications. In interview on 7/21/12 at 8:15 pm, Staff 7, LPN, stated she did not recall the resident not having medications. However, it the medication had not been filled for several days, staff needed to inform Staff 3, RNCM, the physician and the pharmacy. 3. Resident 3 re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 6/2012 Injectables Flow Sheet revealed the resident had received a dose of the medication at the hospital at 2:30 pm. The resident was due another dose at 10:30 pm on 6/29/12. According to the record, the resident did not receive the 6/29/12 dose and the 6/30/12 dose was not administered until 8:30 am that morning. In interview on 7/23/12 at 2:00 pm, Staff 3, RNCM, stated she was aware of the medication not being available and was not sure why the delay from the pharmacy. Staff 3 stated she did not know if staff contacted the physician for direction while waiting for the medication to arrive. In interview on 7/24/12 at 10:24 am, Staff 13, LPN, stated she was on shift when the resident was readmitted to the facility around 7:00 pm. Staff 13 stated she had received report regarding the medication from the hospital LN and the next dose was due around 10:00 pm. Staff 13 stated the medication should have been started or she should have called the pharmacy to get the medication satellite or obtain it from the Ekit if it was available. In interview on 7/24/12 at 2:40 pm, Staff 7, LPN, stated Resident 3 was readmitted on the prior shift and the medication was not available. Staff 7 stated she called the pharmacy and the medication was delivered in the night. When asked about the delay in administering the medication on 6/30/12, Staff 7 stated she needed to check the orders, check other residents and started the medication as soon as it was possible. 4. Resident 4 admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 4's Wound Assessment Flow Sheet disclosed on 6/29/12 the resident was found to have an open lesion on the left thigh. It was noted on the flow sheet to clean the area and cover with gauze. There was no documented assessment and tracking of the wound until 7/12/12 (approximately two weeks later), when it was noted to have decreased in size. At that time, the treatment documented on the wound flow sheet indicated saline, application of an antibiotic and gauze were used as a treatment. On 7/16/12, the wound status was documented with the treatment noted as "monitor." There was no further documentation on the status of the open lesion. There were no physician orders found for the treatment of [REDACTED]. In interview on 7/24/12, Staff 4, RN, stated "on last Saturday" (7/21/12), the resident did not have an open area on the left thigh. In interview on 7/24/12 at 2:48 pm, Staff 25, LPN, stated she only observed the open area once or twice, which was almost healed. Staff 25 stated she did not recall when she last observed the area being opened and it was now healed. This information was shared with Staff 3, RNCM on 7/23/12 at 2:00 pm and Staff 1, Administrator and Staff 2, DNS on 7/23/12 at 4:00 pm. No additional information was provided.

Based on interview and record review it was determined the facility failed to ensure 1 of 3 sampled residents (# 1) was free from a significant medication error related to the administration of [MEDICATION NAME]. Resident 1 received 41 injections of [MEDICATION NAME] in error and was hospitalized with a left thigh hematoma which required surgical intervention. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].) The resident was admitted with physician orders [REDACTED]." According to the 2011 Nursing Drug Handbook, for the treatment of [REDACTED]." In addition, "bleeding complications" may be an adverse side effect of [MEDICATION NAME]. When [MEDICATION NAME] is used with other blood thinning medications the risk of bleeding may increase and the medications should be used together "cautiously." On the resident's 11/2011 Injectables Flowsheet the [MEDICATION NAME] was originally transcribed to read "[MEDICATION NAME] 120 mg (subcutaneously every 12 hours for 5 days), 11/05/2011 - 11/09/2011." According to the flow sheet the [MEDICATION NAME] was administered to the resident per physician orders [REDACTED]. On the 11/7/11 evening shift the [MEDICATION NAME] was re-written on the flow sheet as "[MEDICATION NAME] 120mg (twice a day), 11/7/11." According to the Flow sheet between the 11/7/11 evening shift and the 11/30/11 day shift, the resident received [MEDICATION NAME] injections twice daily. According to nurse's notes on the 12/1/11 evening shift the resident was "not responding to baseline." The resident was noted to be "very pale and skin cold to touch." Staff could not able to obtain a blood pressure reading. The resident was transported to the hospital for evaluation. According to a hospital laboratory report the resident had a critically low Hematocrit and Hemoglobin values. The resident was given a transfusion of packed red blood cells. On 12/2/11 a CT scan showed the resident had a "large hematoma" (a collection of blood outside the blood vessels) on the left thigh. On 12/6/11 the resident had surgery on the left thigh to remove "400 to 500 ml of coagulated blood." According to a 12/6/11 hospital physician's note the resident's acute blood loss was "likely from left thigh hematoma and possibly relating to (the resident's) medications." On 12/8/11 the resident was readmitted to the facility without physician orders [REDACTED]. According to a medication error investigation completed by Staff 1, DNS, on 11/7/11 Staff 2, RN, accidentally highlighted the original [MEDICATION NAME] order to discontinue the medication. Staff 2 re-wrote the order but did not include the stop date for the medication. On 12/7/11 Staff 2's employment with the facility was terminated. In a written statement dated 12/8/11 Staff 2 indicated she highlighted the [MEDICATION NAME] order in error. Staff 2 re-wrote the order but was distracted by a CNA who asked for a PRN medication for another resident. Staff 2 was also distracted by the alarm on the door when a resident entered the facility. Staff 2 closed the MAR indicated [REDACTED]. Staff 2 forgot to go back to the page in the MAR indicated [REDACTED]. In an interview on 1/4/12 at 10:30 am Staff 2 stated the [MEDICATION NAME] error occurred per her written statement and she didn't know why she didn't remember the stop date for the [MEDICATION NAME].

Based on interview and record review it was determined Staff 2, RN, failed to ensure 1 of 3 sampled residents (# 1) was free from a significant medication error related to the administration of [MEDICATION NAME]. Resident 1 received 41 injections of [MEDICATION NAME] in error and was hospitalized with a left thigh hematoma which required surgical intervention. Findings include: Review of the Oregon State Board of Nursing, Nurse Practice Act, Scope of Practice Standards for All Licensed Nurses [PHONE NUMBER] revealed: "(6) Standards related to the licensed nurse's responsibility to accept and implement orders for client care and treatment. The licensed nurse: (e) ...determine that the order or recommendation is consistent with the overall plan for the client's care; and (f) Has the authority and responsibility to question any order or recommendation which is not clear, perceived as unsafe, contraindicated for the client or inconsistent with the plan of care." Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted with physician orders [REDACTED]." According to the 2011 Nursing Drug Handbook, for the treatment of [REDACTED]." In addition, "bleeding complications" may be an adverse side effect of [MEDICATION NAME]. When [MEDICATION NAME] is used with other blood thinning medications the risk of bleeding may increase and the medications should be used together "cautiously." According to a 11/2011 Injectables Flowsheet Flow sheet between the 11/7/11 evening shift and the 11/30/11 day shift, the resident received 41 [MEDICATION NAME] injections in error. On 12/1/11 the resident was transported to the hospital. On 12/6/11 the resident had surgery on the left thigh to remove "400 to 500 ml of coagulated blood." According to a 12/6/11 hospital physician's note the resident's acute blood loss was "likely from left thigh hematoma and possibly relating to (the resident's) medications." According to a medication error investigation completed by Staff 1, DNS, on 11/7/11 Staff 2, RN, accidentally highlighted the original [MEDICATION NAME] order to discontinue the medication. Staff 2 re-wrote the order but did not include the stop date for the medication. In an interview on 1/4/12 at 10:30 am Staff 2 stated the [MEDICATION NAME] error occurred per her written statement and she didn't know why she didn't remember the stop date for the [MEDICATION NAME]. Refer to F-333 for additional information.

Based on observations, interviews and record reviews, it was determined the facility failed to provide care and services to prevent an injury and follow up on a physician's orders [REDACTED]. Resident 3 experienced a right humerus fracture. Findings include: 1. Resident 3, a long time resident of the facility was admitted with [DIAGNOSES REDACTED]. Review of the 6/17/10 RAPs revealed the resident was assessed to be alert and oriented. The resident was extremely difficult to understand due to [MEDICAL CONDITION]. Non-sampled Resident 1 (family member) translated for the resident. The resident had a communication computer and used her/his knees to operate the mouse. Review of the 3/17/11 MDS revealed the resident was assessed to require extensive assistance with dressing. According to the Contracture assessment dated [DATE], the resident had slightly limited range of motion (ROM) to the right and left shoulders; full ROM to the right and left elbow; slightly limited ROM to the left wrist and moderate ROM to the right wrist and slightly limited ROM to the left fingers and moderate ROM to the right fingers. In an interview on 4/25/11 at 10:50 am Staff 2 (RNCM) stated the resident had not been in the Restorative program for over a year. No Contracture Assessments could be located between September 2010 and March 2011. According to the Contracture assessment dated [DATE] the resident had full ROM to the left shoulder and slightly limited ROM to the right shoulder; full ROM to the left elbow and slightly limited ROM to the right elbow; slightly limited ROM to the right and left wrist and full ROM to the left fingers and slightly ROM to the right fingers. Observation of the resident on 4/25/11 at 11:10 am revealed the resident sitting in an electric wheelchair leaning to the right with her/ his head forward and to the right. The resident's right and left fingers were contracted. The resident was able to use the control for the electric wheelchair using the left arm bent at the elbow and contracted fingers. The resident's right arm was completely bent at the elbow and held close to the body. Review of the NN dated 4/3/11 at 1:01 pm revealed Non-sampled Resident 1 (family member) reported the resident was in pain. Non-sampled Resident 1 reported a CNA had assisted the resident to remove her/his coat and heard something "pop." The resident was sent to the hospital. According to the hospital Physician Notes, the resident sustained [REDACTED]. Review of the investigation revealed Witness 2 (former CNA) was going to lunch when the resident asked for help removing her/his coat. Witness 2 pulled the resident's right arm straight out and removed the coat from the right arm first. Non-sampled Resident 1 reported Witness 2 "accidentally used too much force or strength." According to the investigation, the resident had poor sitting posture and was able to use the left arm/hand "enough to control handle for power chair. Currently there was no special instruction on care plan for how to take off clothing or/and how far right arm can go up ..." Review of the PT evaluation dated 4/9/11 revealed the resident's right upper extremity was "contracted and relatively non-functional." The PT evaluation indicated when the arm was healed the resident was to receive gently ROM and PT. In an interview on 4/25/11 at 9:32 am Staff 7 (RA) stated the resident had "very limited" ROM to the right arm, hand and fingers. Staff 7 indicated the resident's left arm was the functional side and had "pretty good" ROM. Staff 7 stated the resident did not have full ROM to the left arm. In an interview on 4/25/11 at 1:10 pm Staff 8 (CNA) stated she normally did not work with the resident. Staff 8 stated she talked to Staff 9 (CNA) about how much and what kind of assistance the resident required with dressing. Staff 8 indicated there was nothing in writing about assistance with dressing. In an interview on 4/25/11 at 1:20 pm Staff 9 (CNA) stated when a new CNA worked with the resident, Non-sampled Resident 1 directed the CNA about assistance with dressing. Staff 9 indicated the resident's arms could be raised to approximately waist level bent at the elbows. Staff 9 stated the resident had limited ROM to both arms, hands and fingers. In an interview on 4/25/11 at 1:55 pm the resident and Non-sampled Resident 1 (family member) stated the resident did not tell Witness 2 (former CNA) how to remove the coat. The resident and Non-sampled Resident 1 indicated they instruct new CNAs how to dress the resident. The resident and Non-sampled Resident 1 indicated the shirt or coat should be taken over the head from the back first then removed from both arms. The resident stated Witness 2 pulled the right arm up and straight out when removing the coat. The resident heard a "pop." Non-sampled Resident 1 stated the resident could not move her/his right arm that high. In an interview on 4/25/11 at 2:15 pm Staff 3 (CNA) stated she was in the break room when the fracture occurred. Staff 3 stated Witness 3 pulled the sleeve off of the right arm by straightening the right arm and lifting it slightly above the waist. Staff 3 indicated she had worked with the resident "a few times" and Non-sampled Resident 1 directed her regarding assistance with dressing, or she asked other CNAs that had worked with the resident. On 4/21/11 at 4:00 pm the resident's right humerus fracture and limited ROM was discussed with Staff 1 (DNS) and Staff 2 (RNCM). No additional information was provided. 2. Resident 1 was admitted to the facility in the last four months with [DIAGNOSES REDACTED]. According to the Care Area Assessment (CAA) dated 2/1/11, the resident was assessed to be alert and oriented and able to answer "yes" or "no" questions or answer with one word. Review of a fax sent to the resident's physician dated 2/19/11 revealed the resident had refused the anti-[MEDICAL CONDITION] medication [MEDICATION NAME] 300 mg HS for "more than 2 weeks" with no [MEDICAL CONDITION]. On 2/24/11 the resident's physician discontinued the [MEDICATION NAME]. On 3/9/11 the resident was sent to the hospital with [DIAGNOSES REDACTED] (low blood sugar) and a witnessed [MEDICAL CONDITION]. Review of the re-admission orders [REDACTED]. On 3/25/11 a fax was sent to the resident's physician that indicated the resident had refused "multiple medications over the last week." On 3/28/11 a fax was sent to the physician that indicated the resident refused medications including the [MEDICATION NAME] since 3/25/11. On 3/31/11 a fax was sent to the physician that indicated the resident had refused the [MEDICATION NAME] since 3/28/11. Review of the April 2011 MAR indicated [REDACTED]. According to an Incident Report dated 4/10/11, at 7:30 pm the resident attempted to strike Resident 2, hitting Resident 2 twice on her/his arms and one time to Resident 2's head. Resident 2 swung back, striking the resident. When the staff went to the room, the resident was sitting on the bed and began having a [MEDICAL CONDITION]. According to the investigation, the resident had no memory of the altercation, the [MEDICAL CONDITION] or going to the hospital. Review of the April 2011 MAR indicated [REDACTED]. On 4/12/11 a waiver form that explained the risks associated with refusing anti-[MEDICAL CONDITION] medication was signed by the resident and Staff 2 (RNCM). On 4/12/11 a physician's orders [REDACTED]. Review of the NN dated 4/12/11 at 10:39 pm the staff tried mixing it with applesauce and re-approached twice but the resident refused to take the applesauce. According to the April 2011 MAR, the resident refused the [MEDICATION NAME] from 4/13/11 through 4/20/11. In an interview on 4/20/11 at 2:20 pm the resident answered "yes" when asked if she/he had refused the anti-[MEDICAL CONDITION] medication. The resident answered "yes" when asked if the facility staff had explained the possible risks of not taking the anti-[MEDICAL CONDITION] medication. In an interview on 4/20/11 at 2:00 pm Staff 4 (CMA) stated she put the anti-[MEDICAL CONDITION] medication in applesauce in a plastic medication cup and gave it to the resident. Staff 4 stated the resident refused to take it. Staff 4 indicated she had not tried mixing the medication with any other food since the resident refused the applesauce. Staff 4 stated she had asked charge nurses about the 4/12/11 physician's orders [REDACTED]. In an interview on 4/20/11 at 4:00 pm Staff 1 (DNS) and Staff 2 (RNCM) stated the resident had the right to refuse the medication. Staff 1 and Staff 2 indicated the resident's rights would be violated by putting the anti-[MEDICAL CONDITION] medication in food without the resident's knowledge. There was no evidence the physician had been contacted regarding the 4/12/11 physician's orders [REDACTED].

Based on interviews and record reviews, it was determined the facility failed to update care plans for 4 of 6 sampled residents (#s 3, 4, 5 and 6). Resident 3 experienced a right humerus fracture. Findings include: 1. Resident 3, a long time resident of the facility was admitted with [DIAGNOSES REDACTED]. Review of the 3/17/11 MDS revealed the resident was assessed to require extensive assistance with dressing. Review of the NN dated 4/3/11 at 1:01 pm revealed Non-sampled Resident 1 (family member) reported the resident was in pain. Non-sampled Resident 1 reported a CNA had assisted the resident to remove her/his coat and heard something "pop." The resident was sent to the hospital. According to the hospital Physician Notes, the resident sustained [REDACTED]. On 4/21/11 at 4:00 pm Staff 1 (DNS) and Staff 2 (RNCM) stated the comprehensive care plans with the problems, goals and approaches were located in the computer. Staff 1 stated portions of the comprehensive care plan was on ADL General Flowsheets located in notebooks at the nurse's station for the CNAs to review. Staff 2 indicated the in-room care plans were updated for the CNAs to review. Review of the April 2011 ADL General Flowsheets and in-room care plans revealed no information regarding the resident's ROM, contractures or what assistance was required for dressing. Review of the Comprehensive Care Plan on 4/26/11 revealed a problem of "Self Care Deficit." One of the approaches, dated 9/6/05 indicated " dressing with 1 assist." There was no indication the care plan had been updated since 9/6/05. Updating the care plan was discussed with Staff 1 (DNS) and Staff 2 (RNCM) on 4/21/11 at 4:00 pm. No additional information was provided. Refer to F-309, example 1. 2. Resident 4, a long time resident of the facility was admitted with [DIAGNOSES REDACTED]. Review of the comprehensive care plan on 4/25/11 revealed the care plan was located in the computer. There was no copy located in the resident charts or the nurse's station for the licensed nurses to update. The care plan had not been updated since 10/26/10. Updating the care plan was discussed with Staff 1 (DNS) and Staff 2 (RNCM) on 4/21/11 at 4:00 pm. No other information was provided. 3. Resident 5, a long time resident of the facility was admitted with [DIAGNOSES REDACTED]. Review of the comprehensive care plan on 4/25/11 revealed the care plan was located in the computer. There was no copy located in the resident charts or the nurse's station for the licensed nurses to update. The care plan had not been updated since 4/19/10. Updating the care plan was discussed with Staff 1 (DNS) and Staff 2 (RNCM) on 4/21/11 at 4:00 pm. No other information was provided. 4. Resident 6, a long time resident of the facility was admitted with [DIAGNOSES REDACTED]. Review of the comprehensive care plan on 4/25/11 revealed the care plan was located in the computer. There was no copy located in the resident charts or the nurse's station for the licensed nurses to update. The care plan had not been updated since 4/30/10. Updating the care plan was discussed with Staff 1 (DNS) and Staff 2 (RNCM) on 4/21/11 at 4:00 pm. No other information was provided.

Based on interviews and record review, it was determined the facility failed to perform safe medication administration practices for 1 of 3 sampled residents (#1). Resident 1 needed to be transported to the local hospital emergency room for an evaluation. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. State Standards and Scope of Practice for the Licensed Practical and Registered Nurse-Scope of Practice Standards for All Licensed Nurses [PHONE NUMBER](3) (e) Accepts only nursing assignments for which one is educationally prepared and has the current knowledge, skills and ability to safely perform; Scope of Practice Standards for Registered Nurses (2)(d) (A) Implementing treatments and therapy, appropriate to the context of care, including emergency measures, interpretation of medical orders, medication administration, independent nursing activities, nursing, medical and interdisciplinary orders, health teaching and health counseling. On 1/20/11 Staff 1 (DNS) faxed a facility self-report to the local protective services agency to indicate on 1/19/11 Resident 1 received the wrong dose of [MEDICATION NAME] and was sent to the local hospital emergency room . An interview on 2/23/11 at 4:30 pm with Staff 1(DNS) revealed the physician's orders [REDACTED]. Staff 1 indicated Staff 3 (RN) used 5 ml of normal saline instead of 150 ml. The local hospital's 1/19/11 physician transfer orders indicated the resident was to receive [MEDICATION NAME] (antibiotic) 1.25 gm/150 ml through a PICC line (Peripherally Inserted Central Catheter-a special catheter placed in a vein through which medications, blood products and fluids can be administered) every twelve hours. The 1/19/11 NN written by Staff 2 (RN) at 11:54 pm indicated Staff 3 (RN) stated she needed help in Resident 1's room. Staff 3 stated she gave the resident the 1.25 gm of IV [MEDICATION NAME] in only 5 ml instead of the ordered amount of 150 ml. The resident stated her/his arm was tingling and was not feeling well. Staff 2 indicated she called the resident's physician and IV specialist from pharmacy and indicated the resident needed to be transported to the emergency room related to possibility of shock and organ damage. According to Wikipedia the administration of too-dilute or too-concentrated solution can disrupt the resident's balance of sodium, potassium, magnesium and other electrolytes. The 1/20/11 NN written at 7:16 am indicated the resident returned to the facility from the local hospital emergency room with no new orders. The physician discontinued the order for [MEDICATION NAME] on 1/21/11. The facility's Medication Error Reporting Form indicated on 1/19/11 at 10:15 pm the physician ordered 1.25 gm ([MEDICATION NAME])/150 ml (normal saline) every twelve hours and the resident was given 1.25 gm in 5 ml of normal saline. The error described that Staff 3 (RN) gave the wrong form of medication, miscalculated the dose and the physician's orders [REDACTED]. The 1/20/11 Witness Statement written by Staff 3 (RN) indicated she checked the physician's orders [REDACTED]. Staff 3 indicated she brought the medications to the resident's room and told the resident that she was going to give the medication by the PICC line. Resident 1 moved her/his left arm toward Staff 3 and she flushed the PICC line with normal saline prior to administering [MEDICATION NAME]. Staff 3 stated she was almost finished administering the medication when the resident asked what kind of medication Staff 3 was administering. Staff 3 stated it was the [MEDICATION NAME] and the resident asked Staff 3 to stop giving the medication. The nurse stopped and stated she did not know how she mixed the wrong dose of normal saline. The 1/20/11 written statement by Staff 4 (RNCM) indicated Resident 1 stated that she/he "barely survived last night." The resident stated she/he told Staff 3 (RN) not to give the [MEDICATION NAME] the way Staff 3 was giving it. Resident 1 stated Staff 3 was informed that it was not the way the [MEDICATION NAME] was to be given. The resident stated Staff 3 was told to contact the physician and find out the correct method of administration and Staff 3 stated "let me give you this, then I will go get the physician." An interview on 3/7/11 at 12:15 pm with Staff 4 revealed it was the expectation of the nursing staff to follow nursing standards of practice and to look at the order and check the dose and administration three times before administration. The nurse was expected to ask for a clarification of an order if the nurse was not certain how to administer the medication. On 1/20/11, Staff 3 was given a written warning and was suspended from work for three days during the investigation. Staff 3 commented on the form "I don't know how it happen. I was so busy to have emergency other resident. At that time I had call the Dr (physician) for other resident and worked all of the paper work. I feel sorry to (Resident 1) about what happen last night ...." An interview on 3/2/11 at 2:45 pm with Staff 2 (RN) revealed on 1/19/11 she instructed Staff 3 (RN) of Resident 1's physician's orders [REDACTED]. Staff 2 stated she reviewed the procedure of mixing the correct amount of [MEDICATION NAME] with the correct amount of normal saline from the E-kit at the facility. Staff 2 stated she also informed Staff 3 to contact the on-call pharmacist if there were any questions regarding the dosage and mixing instructions. Staff 2 stated Staff 3 told her that something was wrong with Resident 1 after she administered the [MEDICATION NAME]. Staff 2 asked that Staff 5 (RN) assist Staff 3 in evaluating Resident 1. Staff 2 stated she asked Staff 3 what happened and Staff 3 stated she gave the resident the [MEDICATION NAME] in 5 ml instead of 150 ml. Staff 2 was concerned and monitored the resident's vital signs. The vital signs were within normal limits though the resident's blood pressure was elevated and the resident complained of her/his arm tingling. Staff 2 stated she called the resident's physician and the IV pharmacy consultant and it was recommended the resident be sent to the local emergency room to evaluate the resident for the possibility of shock and organ damage. An interview on 3/2/11 at 3:30 pm with Staff 5 (RN) revealed he assisted Staff 3 (RN) to assess Resident 1's condition. Staff 5 stated the resident stated she/he had a tingling in her/his "veins." Staff 5 interviewed Staff 3 and learned that Staff 3 conducted an "IV push" of the [MEDICATION NAME] (an IV push or [MEDICATION NAME] means that a syringe is connected to the IV access device and the medication is injected directly. Once a medicine has been injected into the fluid stream of the IV tubing there must be some means of ensuring that it gets from the tubing to the resident. Usually this is accomplished by allowing the fluid stream to flow normally and thereby carry the medicine into the bloodstream; however, a second fluid injection is sometimes used, a "flush," following the injection to push the medicine into the bloodstream more quickly). Staff 5 indicated he told Staff 3 that the [MEDICATION NAME] was to be diluted in 150 ml in the intravenous bag and administered every twelve hours. Staff 5 indicated he talked with Staff 3 and stated that she was not to do an IV push and the [MEDICATION NAME] needed to be diluted. Staff 5 stated the resident was confused with another resident who also received [MEDICATION NAME]. An interview on 3/7/11 at 11:59 am with Witness 1 (consulting pharmacist) revealed the expectation that if a nurse had any questions pertaining to the mixing and administration of a medication from the E-kit or from the pharmacy the nurse was to contact the pharmacy for directions. Witness 1 indicated [MEDICATION NAME] was to be administered through a PICC line over a period of time and not as an "IV push." Witness 1 indicated if the medication was provided too quickly it could cause the resident to go into shock and cause organ damage. An interview on 3/16/11 at 2:45 pm with Staff 3 (RN) revealed Staff 3 did not follow the physician's orders [REDACTED].

Based on interviews and record review, it was determined the facility failed to administer IV (intravenous) antibiotics as prescribed by the physician and document the PICC line (Peripherally Inserted Central Catheter-a special catheter placed in a vein through which medications, blood products and fluids can be administered) was flushed according to physician's orders [REDACTED]. Resident 1 needed to be transported to the local hospital emergency room for an evaluation. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. On 1/20/11 Staff 1 (DNS) faxed a facility self-report to the local protective services agency to indicate Resident 1 received the wrong dose of [MEDICATION NAME] and was sent to the local hospital emergency room . The local hospital's 1/19/11 physician transfer orders indicated the resident was to receive [MEDICATION NAME] (antibiotic) 1.25 gm/150 ml through a PICC line every twelve hours. The 1/19/11 NN written by Staff 2 (RN) at 11:54 pm indicated Staff 3 (RN) stated she needed help in Resident 1's room. Staff 3 stated she gave the resident the 1.25 gm of IV [MEDICATION NAME] in 5 ml instead of the ordered amount of 150 ml. The resident stated her/his arm was tingling and was not feeling well. Staff 2 indicated she called the resident's physician and IV specialist from pharmacy and indicated the resident needed to be transported to the emergency room related to possibility of shock and organ damage. According to Wikipedia the administration of too-dilute or too-concentrated solution can disrupt the resident's balance of sodium, potassium, magnesium and other electrolytes. The 1/20/11 NN written at 7:16 am indicated the resident returned to the facility from the local hospital emergency room with no new orders. The Medication Error Reporting Form indicated on 1/19/11 at 10:15 pm the physician ordered 1.25 gm of [MEDICATION NAME] in 150 ml of normal saline every twelve hours. The error was the resident was given 1.25 gm in 5 ml of normal saline. The error described that Staff 3 (RN) gave the wrong form of medication, miscalculated the dose and the physician's orders [REDACTED]. The 1/20/11 written statement by Staff 3 (RN) indicated she checked the physician's orders [REDACTED]. Staff 3 stated she did not know how she mixed the wrong dose of normal saline. On 1/20/11, Staff 3 was given a written warning and was suspended from work for three days during the investigation. Staff 3 commented on the form " I don't know how it happen. I was so busy to have emergency other resident. At that time I had call the Dr (physician) for other resident and worked all of the paper work. I feel sorry to (Resident 1) about what happen last night ...." An interview on 3/7/11 at 12:15 pm with Staff 4 revealed Staff 3 was to review the order and check the dose and administration three times before administration. The nurse was expected to ask for an clarification of an order if the nurse was not certain how to administer the medication. An interview on 3/2/11 at 2:45 pm with Staff 2 (RN) revealed she instructed Staff 3 (RN) of Resident 1's physician's orders [REDACTED]. Staff 2 stated she reviewed the procedure of mixing the correct amount of [MEDICATION NAME] with the correct amount of normal saline from the E-kit at the facility. Staff 2 stated she also informed Staff 3 to contact the on-call pharmacist if there were any questions regarding the dosage and mixing instructions. An interview on 3/2/11 at 3:30 pm with Staff 5 (RN) revealed Staff 3 did not follow physician's orders [REDACTED]. An interview on 3/16/11 at 2:45 pm with Staff 3 (RN) revealed Staff 3 did not follow the physician's orders [REDACTED]. b. There was a 1/19/11 physician's orders [REDACTED]. Resident 1's January 2011 IV Flowsheet had an area where flushing of the resident's PICC line was to be flushed. There was no documentation the resident's PICC line was flushed during Shift 1 (day shift) on 1/21/11, 1/24/11, 1/25/11, 1/26/11 and 1/27/11. There was a 1/21/11 physician's orders [REDACTED]. An interview on 3/2/11 at 3:30 pm with Staff 5 (RN) revealed the flushing of the PICC needed to documented on the IV Flowsheet. An interview on 3/7/11 at 10:30 am with Staff 1 (DNS) revealed the flushing of the PICC needed to be documented on the IV Flowsheet and Staff 1 confirmed there was no consistent documentation of the IV flush. 2. Resident 3 was admitted to the facility in early 2011 with [DIAGNOSES REDACTED]. The 2/21/11 physician's orders [REDACTED]. The resident's February 2011 IV Flowsheet contained no documentation the PICC line was flushed during Shift 1 (day shift) on 2/22/11, 2/24/11 and Shift 2 (evening shift) on 2/23/11, 2/24/11 and 2/25/11. An interview on 3/7/11 at 10:30 am with Staff 1 (DNS) revealed the flushing of the PICC needed to be documented on the IV Flowsheet and Staff 1 confirmed there was no consistent documentation of the IV flush.