Every finding on record at Monument Healthcare American Fork

Based on interview and record review, it was determined the facility did not ensure that residents who use psychotropic drugs received a gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Specifically for 1 out of 19 sampled residents, a resident did not have an attempted GDR for psychotropic medications. Resident identifier: 20.Findings included: 1. Resident 20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, schizoaffective disorder bipolar type and depression.Resident 20's medical record was reviewed on 9/2/25-9/4/25.On 9/2/25 at 9:16 AM, 10:02 AM, and 12:17 PM observations were made of resident 20 sleeping in bed. A physician's order dated 3/14/23, documented clozapine oral tablet (Clozapine) Give 100 mg one time a day for a diagnosis of schizoaffective disorder, bipolar type.A physician's order dated 3/14/23, documented clozapine oral tablet (Clozapine) Give 150 mg one time a day for a diagnosis of schizoaffective disorder, bipolar type.A physician documented clinical contraindication was unable to be located and the medication had not received the appropriate GDR. On 9/4/25 at 8:39 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that psychotropic meetings were held on the third Wednesday of every month and that resident's medications were reviewed at least quarterly. The DON stated that if a resident starts a GDR then they are reviewed in the next month's psychotropic meeting. The DON stated that resident 20 had been on clozapine since March of 2023 and he could not find if a GDR had been done.

Based on observation, interview, and record review, it was determined that for 1 of 19 sampled residents, that the facility did not ensure that a resident was given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including eating. Specifically, a resident did not receive assistance with eating his meals. Resident Identifier: 1 Resident 1 was initially admitted [DATE], readmitted [DATE] with diagnoses including legal blindness, cerebral infarction, tremor, need for assistance with personal care, dysphagia following cerebral infarction, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Resident 1's medical record was reviewed from 9/2/25 through 9/4/25. Resident 1's Care Plan was reviewed. The Care Plan documented that Resident 1 had an activities of daily living deficit related to his hemiplegia, difficulty moving, and his loss of vision. The Care Plan documented that Resident 1 needed setup and cleanup assistance from up to 1 staff member when eating. On 9/4/25 at 7:57 AM, an observation was made of CNA 1 who dropped off resident 1's breakfast tray and left the room. On 9/4/25 at 9:00 AM, an interview was conducted with the Lead [NAME] (LC). The LC stated that Resident 1 is blind, that she is not sure if he feeds himself or not, and that he prefers to have his meat cut up. On 9/4/25 at 9:03 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that Resident 1 uses a divided plate, that he can feed himself, and that the facility sometimes has staff assist him with eating. On 9/3/25 at 1:19 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 1 was blind and had been on a steady decline and could not see what was on his plate when served meals. CNA 1 stated that he had assisted resident 1 with eating for the past couple of weeks. CNA 1 stated that he had noticed that resident 1 was not eating his meals and took it upon himself to assist him with eating. On 9/4/25 at 9:09 AM, an interview was conducted with CNA 2. CNA 2 stated that the facility usually has someone sit with Resident 1 while he eats. CNA 2 stated that sometimes Resident 1 is a total assist for feeding and sometimes he is a supervised assist. CNA 2 stated that the amount of assistance Resident 1 needs depends on how the resident feels that day. On 9/4/25 at 9:14 AM, an interview was conducted with the Registered Nurse (RN). RN stated that Resident 1 is legally blind. RN 1 stated that if Resident 1 is in a good mood, he will allow more staff to assist him more with his activities of daily living.

Based on observation and interview, it was determined that the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, there were numerous observations of staff carrying uncovered dessert and fruit cups down hallways when meal trays were being delivered. On 9/2/25 at 12:20 PM, the hallway lunch service was observed and revealed the following: At 12:20 PM, the meal tray cart was parked outside of room [ROOM NUMBER]. An uncovered dessert on the meal tray was walked down the hallway to room [ROOM NUMBER]. At 12:31 PM, the meal tray cart was moved to be in between rooms [ROOM NUMBERS]. At 12:31 PM, an uncovered dessert on the meal tray was served to room [ROOM NUMBER]. At 12:33 PM, an uncovered dessert was on the meal tray and was served to room [ROOM NUMBER]. On 9/3/25 at 12:26 PM, the Administrator (ADM) was observed opening the meal tray cart doors during the hallway lunch service. The ADM was observed leaving the cart doors open and then walked away without closing the doors. On 9/4/25 at 7:46 AM, the hallway breakfast service was observed and revealed the following: At 7:46 AM, the meal cart was parked in between rooms [ROOM NUMBERS]. At 7:48 AM, cut up oranges were uncovered and served to room [ROOM NUMBER]. At 7:50 AM, cut up oranges were uncovered and served to room [ROOM NUMBER]. At 7:52 AM, cut up oranges were uncovered and served to room [ROOM NUMBER]. At 7:53 AM, a dish of fruit cocktail was uncovered and served to room [ROOM NUMBER]. At 7:57 AM, cut up oranges were uncovered and served to room [ROOM NUMBER]. On 9/4/25 at 9:00 AM, an interview was conducted with the Lead [NAME] (LC). The LC stated that the facility usually leaves dessert cups or fruit cups uncovered on meal trays. On 9/4/25 at 9:03 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that the facility normal leaves dessert plates and fruit cups uncovered on meal trays. The DM stated that staff should take the cart from resident room to resident room and deliver each meal.

Based on interview and record review, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented plans of action to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance for the same deficiencies identified in the last annual recertification survey. Resident identifiers: 22, 25, 27, 30, 31, 36, 44, 47, 51, 53, 58, 64 and 121. Findings included: 1. An annual recertification survey was completed on 2/28/22. During that survey F559, F609, F656, F661, F677, F684, F692, F755, F757, F812, F867, F880, F908, F880, F883, F908. F910, F912 and F915 were cited. 2. A recertification survey was completed on 12/6/23. During that survey F609, F656, F677, F684, F692, F755, F812 and F867 were were identified as repeat deficiencies. 3. Based on observation, interview, and record review it was determined that, for 4 of 47 sampled residents, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive assessment, the comprehensive person-centered care plan, and the residents' choice. Specifically, a resident with an identified mass was not evaluated as requested by the resident representative; a resident was hospitalized after a failure to identify a change of condition in a timely manner; a resident's blood sample was not obtained per protocol which resulted in an emergency room visit; and a resident received medication in error and one medication rectally when oral medication was available. The deficient practice identified for residents 22 and 36 were found to have occurred at a harm level. Resident identifiers: 22, 36, 64 and 121. [Cross refer to F684] 4. Based on observation, interview, and record review it was determined, for 6 of 47 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistive devices to prevent accidents. Specifically, the facility did not provide adequate supervision to prevent a resident with previous falls from falling and sustaining a head laceration and neurological (neuro) checks were not completed as indicated. This deficiency was identified to have occurred at a harm level for resident 27. In addition, a resident who had fallen was moved before an assessment was completed by qualified personnel; the facility had hot water. In addition, facility environment disrepair identified resident accident hazards. Resident identifiers: 25, 27, 44, 47, 51 and 58. [Cross refer to F 689] 5. Based on interview, observation and record review, the facility did not ensure that 5 of 47 sample residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. Specifically, current weights were not being obtained to allow staff to appropriately assess the residents' nutritional status. In addition, interventions were not being implemented in a timely manner, residents were not being provided with the appropriate supplements, and were not assisted with meals . The findings for resident 53 were determined to have occurred at a harm level. Resident identifiers: 30, 31, 51, 53 and 121. [Cross refer to F692] 48709 On 12/06/23 at 4:42 PM, an interview was conducted with Administrator (ADM) 2. ADM 2 stated he is the covering administrator right now. QAA was done every month. ADM 2 stated the Director of Nursing (DON), Medical Director, and other staff attended the QAA meeting. ADM 2 stated nurses and Certified Nurse Assistants (CNA) rotated into the meetings. The ADM stated that the QAA reviewed quality measures, CASPER reports, and documents pulled from CMS based on the Minimum Data Set (MDS). ADM 2 stated he had not seen the QAA process for this building yet and that the facility would be instituting the corporate QAPI program for standardization. ADM 2 stated the standard for QAA was to have it monthly. ADM 2 stated he would look for the logs. ADM 2 stated that he did not know if the facility had found the systematic areas that needed improvement. ADM 2 stated a food committee and a dietitian, who worked with the DON, met to address weight loss immediately. ADM 2 stated, last week, the facility had started weighing everyone in the facility and was working on improving that process. ADM 2 stated he did not know if abuse reporting was done, but it would be done now. ADM 2 stated administration was pulled into a training in October about abuse reporting and follow up.

Based on observation, interview, and record review it was determined that, for 4 of 47 sampled residents, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive assessment, the comprehensive person-centered care plan, and the residents' choice. Specifically, a resident with an identified mass was not evaluated as requested by the resident representative; a resident was hospitalized after a failure to identify a change of condition in a timely manner; a resident's blood sample was not obtained per protocol which resulted in an emergency room visit; and a resident received medication in error and one medication rectally when oral medication was available. The deficient practice identified for residents 22 and 36 were found to have occurred at a harm level. Resident identifiers: 22, 36, 64 and 121. Findings include: HARM 1. Resident 22 was admitted to the facility on [DATE] with diagnoses which included dementia, moderate intellectual disabilities, atherosclerotic heart disease, asthma, and hypertension. Resident 22's medical record was reviewed from 11/27/23 through 12/6/23. A review of the face sheet indicated that a Family Member (FM) was resident 22's responsible party and POA (Power of Attorney). A Nursing Note dated 8/7/23 at 11:20 AM indicated, Noted lump at right breast during shower. Right nipple is inverted as well. NO drainage is noted. Immovable lump approx [approximate] size of 50 cent coin. Contacted sister [name redacted] and informed her. Notified UM [Unit Manager]/DON [Director of Nursing] /Provider as well. No discoloration is noted. Resident without s/sx [signs or symptoms] [sic] pain. WCTM [will continue to monitor]. A Social Services note dated 8/8/23 at 12:18 PM indicated, Spoke with family today. they have decided that [resident 22] needs to stay here because they cannot get 24 hour care at home, and sisters cannot take care of her. They have requested we get a diagnosis and prognosis for the breast issue, and if it is cancer, they are thinking about going on Hospice are in the facility. A [name of facility] document dated 8/17/23 indicated the chief complaint was dementia and breast mass. It also indicated, She further stated that if a lump is found the nurse management and the provider should be notified and, we will get an ultrasound and mammogram. there is a high likelihood this is cancerous. making high complexity. We spoke with the family and they would at least like to have some information. They did not think they will do anything heroic. There was no physician orders regarding breast mass located in resident 22's medical record. A Physician/Practitioner note dated 11/30/23 at 8:35 PM indicated, I was asked to see [resident 22] today because of a breast mass which is described as getting bigger. It is hard to determine how long this has been there. She has a firm mass in her right breast about 4 cm which is caused some puckering just laterally and inferior to the nipple. There is no discoloration or inflammation. This is almost certainly malignant mass. We will talk with the family about desired treatment or evaluation of this. She has no other new complaints. She is up in her wheelchair and is pleasant but a little resistant to being examined. The nurse [name redacted] was present with me during the exam. On 11/28/23 at 10:24 AM, an interview was conducted with resident 22's FM. The FM stated that resident 22 had a large lump on her right breast that had increased in size, and nothing had been done about it. On 12/4/24 at 2:55 PM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated that a skin assessment was focused on the resident's skin and included the entire body. LPN 4 stated a lump was something that could be identified during a skin assessment and should be documented in the medical record. LPN 4 stated that if a lump was found, nurse management and the provider should be notified. LPN 4 stated resident 22's lump was, right here, as she pointed to her own lateral side of the right breast. LPN 4 stated the lump had been there for longer than a month and they were watching it for changes. LPN 4 stated the family of resident 22 was aware of the lump and they did not want her to go through an invasive procedure. LPN 4 stated she had not observed the resident touching the mass or any other indication that the mass was causing resident 22 pain. On 12/6/23 at 10:05 AM, an interview was conducted with the DON. The DON stated that Social Work (SW) had helped make appointments in the past, but the SW was not comfortable doing that, so it became the responsibility of the Unit Managers. The DON stated the Unit Manager was expected to look for needed follow up appointments. The DON stated resident 22's mass was diagnosed but the family decided not to treat it and the nurse manager would be expected to follow up with that if the resident needed a referral. The DON further stated she thought there was documentation of resident 22's family refusing treatment for the breast mass. No documentation of resident representative refusing treatment for the breast mass was provided. 46232 2. Resident 36 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included rheumatoid arthritis, type 2 diabetes mellitus, muscle weakness, cognitive communication deficit, pressure ulcer of unspecified site, repeated falls, and major depressive disorder. Resident 36's medical record was reviewed on 12/5/23. Resident 36's progress notes documented the following: On 9/26/23 at 6:21 AM, a nurses note revealed, Pt [patient] increase lethargic, he struggled taking his meds which I put in pudding. he was not able to take water through a straw and he has some chest congestion. I tested patient for COVID twice and both were negative. notified MD [medical doctor]. On 9/26/23 at 10:41 AM, a nurse note revealed, pt is lethargic but arousable. wet cough noted. pts VS [vital signs] stable and WNL [within normal limits] at T [temperature] 36.4 C [Celsius], BP [blood pressure] 124/80, HRR [heart rate] 69, RR [respiratory rate] 16, O2 sat [oxygen saturation] 98% on 3L [liters] via. chest Xray requested from MD. orders pending. On 9/27/23 at 5:21 AM, a nurse note revealed, Day shift nurse got orders for CBC [complete blood count], CMP [complete metabolic panel], Xray and UA [urinalysis]. I put orders in. [Note: No orders were located for the CBC or CMP to indicated if the provider wanted the labs orderd as routine or stat.] On 9/28/23 at 12:55 AM, nurse note revealed, Pts lethargic sx [symptoms] continue. The patient is alert and oriented but has difficulty speaking. Had difficulty swallowing after being given crushed meds that were in applesauce. Was unable to sip water out of a straw. Did not look interested in eating his dinner. Is now sleeping well. On 9/28/23 at 10:04 PM, a nurse note revealed, Aide went into the pt room to change pt brief, Pt was unresponsive, shallow breathing, and pt was sating at 58% on 2L of oxygen, increased oxygen to 5L and pt started sating in the 90's but still unresponsive. Called [local hospital] ambulance pt was transferred to the hospital . Also tiger texted [MD name removed],[Director of nursing], on call manager. On 10/12/23 at 7:36 PM, a Physician - Admission history and physical note documented resident 36 had been hospitalized on [DATE] due to acute respiratory failure with hypoxia and hypercapnia. It stated, he was recently hospitalized for sepsis likely secondary to UTI [urinary tract infection] as well as respiratory failure. On 9/27/23, a chest x-ray was obtained and read. The results became available to be reviewed on 9/27/23 at 4:32 PM. It was noted that the doctor reviewed the results on 10/2/23. A statement on the x-ray results read as followed, patient discharged on [DATE]. Please forward to ordering provider or pcp [primary care provider]. [Note: There was a 6 day delay in the provider reviewing the x-ray results.] A laboratory report with a collection date of 9/27/23 at 6:25 AM, documented the results had been printed on 9/28/23 at 4:29 PM. The CBC and CMP resulted with abnormal low and high lab values. A statement written on the laboratory report documented, At hospital with a date of 10/2/23. It should be noted that a UA was not collected or ordered by the physician as indicated by the progress note made on 9/27/23. Resident 36 presented with a change of condition on 9/26/23 and was sent to the hospital 3 days later on 9/28/23 due to becoming unresponsive. Imaging and lab work were collected on 9/27/23 but it was unclear whether the m want all this done urgently or routinely. Ultimately, there was a delay in the physician provider reviewing the results and getting the resident the care, they required based upon their initial presentation on 9/26/23. On 12/6/23 at 5:05 PM, an interview was conducted with the Licensed Practical Nurse (LPN) 2. LPN 2 stated they recalled resident 36 had to go to the hospital a couple of months ago because he was septic. LPN 2 stated they were concerned about resident 36's condition on 9/26/23, so the physicians was contacted. LPN 2 stated they remembered resident 36 had not been doing well the day before and the night of and that was why she contacted the doctor that day. LPN 2 stated they were able to obtain orders from the doctor. LPN 2 stated if the doctor ordered anything stat, then results were supposed to be reported to the provider as soon as they were available. LPN 2 stated if blood work was ordered stat then it needed to be collected within 4 hours of being ordered and results were made available within a few hours. LPN 2 was unable to locate an order for the CBC and CMP that was collected on 9/27/23 and was unable to determine if the labs were to be ordered stat or routinely. On 12/6/23 at 5:25 PM, an interview was conducted with the DON. The DON stated if a resident had a change of condition, a change of condition form needed to be filled out and the physician needed to be informed. The DON stated based on the progress notes made on 9/27/23 by the night shift staff, it indicated the day shift nurse had received orders from the doctor to obtain a CBC, CMP and UA. The DON stated they were able to locate the x-ray order. The DON was unable to locate any order's for a CBC, CMP and UA on 9/26/23 or 9/27/23 in resident 36's medical record. The DON stated if the nurse received a verbal order, it was supposed to be entered in the medical record. The DON stated the purpose in entering a physician's order in the computer was to have the physician review what they had ordered and then acknowledge it by signing it. The DON stated resident 36's lab results had been printed on a Thursday and the doctor had already been in that day. The DON stated the next day the doctor came into the facility would have been on 10/2/23 and that was why it had been signed that day. The DON was unsure if the provider had been notified of resident 36's results before 10/2/23 since there was no documentation to indicate otherwise. The DON stated there were some out of range lab values present on the CBC and CMP but there was no blaring sign to indicate an infection. The DON stated the doctor was responsible for reviewing all lab work and decided what needed to be done next based on the results. 30563 POTENTIAL FOR HARM 3. Resident 121 was admitted to the facility 7/1/23 and discharged on [DATE] with diagnoses which included congestive heart failure, chronic kidney disease, monoclonal gammopathy, transient cerebral ischemic attack, pulmonary fibrosis, and respiratory disorder. A form titled exhibit 358 was submitted to the State Survey Agency (SSA) on 9/1/23 at 12:03 AM. The form revealed there was an allegation of Deprivation of Goods and Services by Staff. The form revealed what was reported On the morning of August 31sr [sic], 2023, aroujd [sic] 10:30am, I [ADM 1] rece]ived [sic] a call from [name removed]/APS [Adult Protective Services]; She informed me of an allegation her office had received regarding [resident 121], and concerns with her 8-day respite stay from July 1st to 8th. [Name removed] provided the list of concerns regarding her care at [name of facility] during this period. Facility Administrator, following-up on requests for recorde [sic], etc. [Name removed] reported that the patient has improved, walking on own. Nurse, [initials removed]. placed on Admin. [Administrative] Leace [sic] pending further investigation details and findings. There was no exhibit 359 submitted to the SSA with the investigation results. Resident 121's medical record was reviewed 12/4/23 through 12/6/23. A Physician's Order dated 6/30/23 at 1:30 PM revealed to admit resident 22 to facility on 7/1/23 and discharge date [DATE]. The form revealed to Administer the following medications as directed: There were no medications listed. A form titled Patient Medication Record printed 6/21/23 and signed by a hospice nurse dated 5/19/23 revealed the following physician medication orders: a. Bumetanide Oral 2 MG (Milligram) by mouth once daily for diuretics. b. Potassium Chloride Extended Release (ER) 20 MEQ (Milliequivalent) by mouth once daily for diuretic. c. Acetaminophen 325 MG 2 tablets as needed for pain. d. Morphine Sulfate Oral Solution 20 MG/5ML (milliliters) every 2 hours if needed for anxiety. e. Lorazepam Intensol Oral Concentrate 2 MG/ML every 2 hours if needed for anxiety. f. Ondansetron 4 MG every 4 hours if needed for nausea/vomiting. An order summary report for resident 121's medication dated 7/3/23 revealed the following orders: a. Acetaminophen Suppository 650 MG insert 1 suppository rectally every 4 hours as needed for pain. b. Biscodly Rectal Suppository insert 1 suppository rectally every 24 hours as needed for constipation c. Bumetanide (Diuretic Medication) Oral 1 MG give 1 tablet by mouth every 24 hours as needed for edema. d. Escitalopram (anti-depressant) 20 MG by mouth in the morning for depression. e. Haloperidol (antipsychotic) Lactase give 0.5 ml by mouth every 4 hours as needed for nausea agitation. f. Hyscyamine Sulfate give 0.125 mg by mouth every 4 hours as needed for excessive secretions. g. Lorazepam 2 MG/ML 0.5 ml by mouth every 2 hours as needed for anxiety. h. Morphine Sulfate solution 20 MG/ML. Give 0.25 ml by mouth every 1 hour as needed for shortness of breath (SOB)/pain. i. Morphine Sulfate Solution 20 MG/ML. Give 0.5 ml by mouth every 1 hours as needed for pain SOB. j. Morphine Sulfate Solution 20 MG/ML. Give 0.75 ml by mouth every 1 hours as needed for pain SOB. k. Morphine Sulfate Solution 20 MG/ML. Give 1 ml by mouth every 1 hours as needed for pain/SOB. l. Ondansetron tablet disintegrating. Give 4 mg by mouth every 4 hours as needed for nausea. m. Potassium Chloride ER table 10 MEQ. Give 10 MEQ by mouth every 12 hours as needed for supplement. n. Senna Plus oral tablet 8.6-50 MG. Give 1 tablet by mouth every 24 hours as needed for constipation. o. Senna Plus oral tablet 8.6-50 MG. Give 2 tablets by mouth every 24 hours as needed for constipation. p. Senna Plus oral 8.6-50 MG. Give 3 tablets by mouth every 24 hours as needed for constipation. q. Senna Plus oral 8.6- 50 MG. Give 4 tablets by mouth every 24 hours as needed for constipation. A physician's visit dated 7/4/23 revealed This is an [AGE] year-old here on hospice respite. The patient most recently was at [name of local hospital] in the fall. Patient does have significant dementia, congestive heart failure, pulmonary fibrosis, and now has transitioned to hospice care. The patient did not have any particular complaints today. She denies any problems with pain that is not controlled she is not having trouble breathing there are no issues with her chest as far as pain. The following medications were listed: a. Escitalopram (anti-depressant) 10 mg every day b. Escitalopram (anti-depressant) 20 mg every day b. Furosemide (diuretic) 20 mg once daily. Can increase to 2 tablets daily if needed. Use as needed for swelling. c. Metolazone (diuretic) 5 mg. One tablet by mouth every other day. d. Omeprazole 20 mg. Table 1 capsule once daily. e. Potassium Chloride ER 10 MEQ. One capsule orally three times a day by oral route once daily with food. f. Synthroid 88mcg every day. Take 1 tablet by oral route once daily. The physician documented under Assessment/Plan: .1. Unspecified diastolic (congestive heart failure) .Comments: we will have her continue her current medications. A form titled Client Medication Report dated 7/6/23 revealed the following medication orders: a. Acetaminophen 325 MG. Take two tablets by mouth every 6 hours as needed for pain. b. Acetaminophen 650 MG rectal suppository. Place 1 suppository rectally every 4 hours as needed for pain and fever. c. Bisacodyl 10 MG rectal suppository. Administer one suppository rectally daily as needed for constipation. d. Bumetanide 2 MG. Take one tablet by mouth daily for diuretic. e. Depakote 500 MG. Take 1 tablet by mouth twice daily for agitation. f. Escitalopram 20 MG. Take one tablet by mouth daily for depression. g. Hyoscyamine 0.125 MG sublingually tablet take 1 tablet by mouth every 6 hours as needed for secretions. h. Lorazepam 2 MG/ML oral concentrate. Give 0.5 ML by mouth or sublingually every 2 hours as needed for anxiety or agitation. i. Morphine Concentrate 100 MG/5ML oral solution. Take 0.25 ML by mouth or sublingually every hour as needed for pain and dyspnea. j. Ondansetron 4 MG Disintegrating tablet . One tablet on tongue or in mouth every 4 hours as needed for nausea or vomiting. k. Potassium Chloride ER 20 MEQ. Take one tablet by mouth daily for supplement. l. Senna 8.6 mG-50 MG tablet. 1-4 tablets by mouth daily as needed for constipation. Resident 121's July 2023 Medication Administration Record (MAR) revealed resident 121 was Administered the following medications: a. Escitalopram Oxalate Oral tablet 20 MG daily for depression. Administered daily from 7/1/23 through 7/8/23. b. Acetaminophen Suppository 650 MG. Administered 7/6/23 with a pain score of 3. Resident 121 had as needed (prn) orders according to the July 2023 MAR for the following medications: a. Bumetanide Oral tablet 1 MG. Give 1 tablet by mouth every 24 hours as needed for edema. b. Potassium Chloride ER tablet 10 MEQ. Give 10 MEQ by mouth every 12 hours as needed for supplement. c. Lorazepam oral concentrate 2MG/ML. Give 1 ml by mouth every 2 hours as needed for anxiety. It should be noted the above medications were not administered 7/1/23 through 7/8/23. A Nursing Admission/Readmission Medication Regimen Review dated 7/1/23 revealed No, medication inconsistencies have not been identified. Nursing progress notes were reviewed and there was no information why resident 121 was administered Acetaminophen Suppository 650 MG on 7/6/23 with a pain score of 3. There were other pain medications available orally for resident 121. On 12/6/23 at 11:36 AM, an interview was conducted with LPN 3. LPN 3 stated medication scripts were faxed to pharmacy when a resident was admitted . LPN 3 stated medications were doubled checked by nursing staff. LPN 3 stated that the double check process included a nurse entering the medication into the medical record. LPN 3 stated then the medications were checked by a nurse manager. LPN 3 stated that when a resident with hospice services was admitted , medication orders came from the hospice company. LPN 3 stated the double check process was the same for a hospice respite resident as other admissions. On 12/6/23 at 11:40 AM, an interview was conducted with LPN 2. LPN 2 stated that the admission process for orders was recently changed. LPN 2 stated that the Assistant Director of Nursing (ADON), Unit Manager (UM), or Director of Nursing (DON) entered the medications into the electronic medical record, the floor nurse checked the medications that were entered into the medical record, then the nurse managers rechecked the medication orders. LPN 2 stated the admission orders were scanned into the medical record after they were inputted into the medical record. On 12/6/23 at 11:43 AM, an interview was conducted with the DON. The DON stated there was a nursing evaluation to double check admission orders. The DON stated usually the UM put the physician's orders in the medical record from the hospital orders. The DON stated the nurse reviewed the order to determine if the orders were accurate, then the medications were activated in the medical record. The DON stated that the orders were then faxed to the pharmacy. The DON stated that the pharmacy completed a review when the orders were sent to the pharmacy. The DON stated if there were concerns with the medication orders, the pharmacy called the facility staff. The DON stated admission paper work was sent to the central admission office to review and upload into the the electronic medical record. The DON stated if a resident was admitted from home, medication orders were brought with the resident when admitted . The DON stated the physician orders the nurse used for resident 121 upon admission were from the form titled Patient Medication Record that was printed 6/21/23 and signed by a hospice nurse on 5/19/23. The DON stated the medications from that form and the ones in the MAR were different. The DON stated there was no Depakote ordered, the potassium was as needed, and the Furosemide was as needed. The DON stated no Depakote could cause increase in behaviors because it was an anti-depressant. The DON stated not receiving the Furosemide would cause increase in weight gain and concerns with the heart. The DON stated that the potassium was administered with the Furosemide so there was not as much of a concern that it was not administered during admission. The DON stated that administration of medications orally was the preferred route. The DON stated there should have been documentation as to why resident 121 was administered Acetaminophen rectally verses orally. On 12/6/23 at 2:27 PM, an interview was conducted with Regional Nurse Consultant (RNC) 1. RNC 1 stated that upon admission resident 121's medications were entered as needed and not scheduled. RNC 1 stated that medications should have been administered daily. RNC 1 stated resident should be administered medications orally, unless there was a reason they were unable to swallow. RNC 1 stated resident 121 should have been administered Acetaminophen orally verses rectally. 45490 4. Resident 64 was admitted to the facility on [DATE] with diagnoses which included diabetes type 2, anxiety, and depression. On 11/27/23 at 2:56 PM, an interview was conducted with resident 64. Resident 64 stated that she was admitted because she had a recent toe amputation and had to be on IV (intravenous line) antibiotics and would need frequent blood draws. Resident 64 stated that she had a nurse provide a lab draw and knew that with her PICC (peripherally inserted central catheter) lab draws the nurses needed to first flush her picc line then remove blood and throw that blood away, then take another sample of blood after and use that fresh draw to be used for the lab levels. Resident 64 stated that a nurse was doing a lab draw and noticed the nurse did not flush her PICC line and just took a blood sample for an upcoming lab. Resident 64 stated that when the lab results came to the facility, she was told her levels were critical and was immediately taken to the hospital. Resident 64 stated that she was very upset and scared. Resident 64 stated she requested to have her PICC line removed so that mistake could not happen again, but that without the PICC for easy access to lab draws it was difficult to have her labs drawn. Resident 64's medical record was reviewed 11/27/23 through 12/6/23. Resident 64 had an order for labs to be drawn weekly. One time a day every Tuesday pull labs from picc line and call courier for pick up. Resident 64 had an order that documented, PICC/Central- Flush accessed lumen(s) with 10ml [milliliter] NS [normal saline] before blood draw, discard 5ml of blood, draw labs then flush with 20ml NS after blood draw. Change needleless connector after complete. As needed for Blood draws. On 11/1/23 a nursing note documented, Received a critical lab result for pt. Potassium of 10. MD [medical director] notified, received order to send pt out to ED [emergency department]. Pt notified and pt sister said she would take her to the ED. Pt left the facility around 1845 [6:45 PM]. This nurse called the hospital around 2045 [8:45 PM] for an update and ED nurse stated they rechecked her levels and it was at a 4. He also stated the pt had left the ED and was on their way back to the facility. Pt arrived back to the facility around 1900 [7:00 PM]. On 12/6/23 at 10:40 AM, an interview was conducted with LPN 2. LPN 2 stated that only nurses could draw labs from a PICC line and that there were specific protocol to follow with PICC line draws. On 12/6/23 at 10:44 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that PICC line lab draw were done by nurses. RN 1 stated the process to draw from a picc line included wiping the area with an alcohol wipe, flush the line with normal saline, draw 7-10 mL of blood and waste, then draw the lab, then flush the line with 10 mL's of normal saline. RN 1 stated that if the process was done incorrectly it could result in an incorrect lab value. RN 1 stated that was the protocol for PICC line draws and if a nurse was unfamiliar with how to do that they could either ask another nurse or there was instructions in the residents medical record.

Based on observation, interview, and record review it was determined, for 6 of 47 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistive devices to prevent accidents. Specifically, the facility did not provide adequate supervision to prevent a resident with previous falls from falling and sustaining a head laceration and neurological (neuro) checks were not completed as indicated. This deficiency was identified to have occurred at a harm level for resident 27. In addition, a resident who had fallen was moved before an assessment was completed by qualified personnel; the facility had hot water. In addition, facility environment disrepair identified resident accident hazards. Resident identifiers: 25, 27, 44, 47, 51 and 58. Findings Include: HARM 1. Resident 27 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis, type 2 diabetes, anxiety disorder, major depressive disorder, obstructive sleep apnea, and vascular dementia. Resident 27's medical record was reviewed from 11/29/23 to 12/6/23. On 9/24/23, a quarterly Minimum Data Set (MDS) documented resident 27 had a Brief Interview for Mental Status (BIMS) score of 8 which indicated resident 27 had moderate cognitive impairment. Resident 27's functional status documented resident 27 was an extensive one person assist with toilet use and was one person supervision assist with ambulation. Resident 27's progress notes, facility incident reports and neuro checks were reviewed and documented the following falls: a. On 8/9/23 at 6:19 PM, a nurse note stated, Pt [patient] was transferring [sic] herself from her wheelchair to her bed unassisted when she lost her balance. pt stated that she hit her head when she fell . she also hit her right shoulder. bruising noted to right shoulder skin tear note to upper right arm. skin tear cleansed with wound cleanser and and tegaderm applied. md [medical doctor] notified. 2 view xray right shoulder ordered. results pending. family notified of fall. Vs [vital signs] stable and neurochecks intact PERRLA [pupils are equal, round, and reactive to light and accommodation]. wctm [will continue to monitor]. The neuro checks were not completed as indicated. The Incident report documented the fall happened due to resident 27 being weak and not calling for assistance. Interventions included a room change, a physical therapy and speech language evaluation and staff was to assist resident 27 to the restroom at 11:00 AM and 5:00 PM before meals and she was to be assisted to get up for dinner. b. On 8/26/23 at 10:05 AM, a nurse note stated, This RN [registered nurse] was standing at med [medication] cart just outside resident's room when there was a loud crash. This RN went into room and observed resident laying on the floor with her head next to her roommates bed. Resident's lunch tray/dishes was on the floor behind her. A large hematoma observed to R [right] forehead with a drop of blood laterally to her R eye on cheek. Unable to tell this RN what she was doing at the time, but did deny hitting head on room mates bed. The roommate stated that she didn't see what happened. ROM [range of motion] assessed with no deficits. Skin assessed with no new bruising or wounds to report. Ice applied to hematoma for < [less than] 20 min [minutes] for comfort and swelling. PRN [As needed] Tylenol administered for headache post fall. Site cleansed to lateral right cheek and left OTA [open to air]. Daughter [name removed] notified. MD [medical doctor] notified. Neuro checks initiated. VSS [vital signs stable] post fall. No increased confusion to report at this time. The neuro checks were not completed as indicated. The facility incident report documented resident 27's fall was due to a diagnosis of leukemia and increased risk and weakness. No new interventions were identified. c. On 9/11/23 at 8:56 AM, a nurse note stated, Pt found on floor. Pt is unable to tell me what happened. She appears to have hit her head as she has a raised/bruised area to her right forehead. Pt VS at time of fall was BP [blood pressure] 131/84, P [pulse] 102, T [temperature] 97.2, RR [respiration rate] 24, O2 [oxygen] Sat [saturation] 97%RA [room air]. Pt eyes are reactive to light however she is unable to track. Her grip is equal bilaterally. Pt able to move all extremities. Pt does c/o [complain of] Pain stating 'yes' when I asked if she was in pain. She again stated yes when I asked if her pain was in her head. PRN pain meds given. MD notified of fall. Family, [name removed], notified of fall. No neuro check were located to indicated resident had any neuro's checks done on the day she fell . The facility incident report determined resident 27 had fallen because she was unable to transfer herself. Identified interventions included resident 27 was to be assisted to bed after dinner and staff were to help resident 27 become more comfortable. It documented resident 27 was not to try to get up by herself. d. On 9/15/23 at 10:38 AM, an orders administration note stated, .Fall Charting: No adverse effects noted or reported. Continues to have an elevated bump on upper right forehead. Her face is now pale yellow . e. On 9/26/23 at 10:00 PM, a nurse note stated, Resident slid out of bed at 22:00 (10:00 PM), no head injury reported by resident, the patient was smiling and was assisted back to the bed, Vitals BP174/89, HR 92, O2 96%, R18. Resident refused vitals check every 15 minutes, wanted to go back to sleep. Call lightwithin [sic] reach. No neuro checks were located. The facility Incident report documented resident 27 had fallen due to getting up unattended. Identified interventions included attaching a light cord to the call light, an update in the toileting schedule to include 10:00 PM and educating the resident on how to call light. f. On 10/8/23 at 6:14 PM, an alert note stated, Was informed by Noc [night shift] staff that pt fell at 0500 this morning. VSS and have been monitored all day. No injuries noted. pt stated she feels fine. husband notified. The neuro checks were not fully completed as indicated. No incident report was located about this fall. No new interventions were identified to prevent resident 27 from further falls. g. On 10/11/23 at 4:33 PM, a nurse note stated, The resident fell from her bed and was found in a sitting position on the floor. The nurse assessed the resident and the resident has no new bruise and she is WNL condition for her baseline assessment. No neuro checks were located to indicate resident 27 was monitored after her fall. The facility incident report documented that wheelchair safety was reviewed with resident 27 and another Physical Therapy (PT) evaluation was made. h. On 10/23/23 6:28 AM, a nurse note stated, the resident was found sitting on the floor in massive diarrhea. The nurse got done with counting carts with the night nurse and the resident's husband came to the nurse and he asked for help to put her back on bed. The resident is not aware to let the nurse know if she fell or was she just sitting on the floor. No neuro checks were located to indicate resident 27 neurological status had been monitored after being found on the floor. No incident report was located. i. On 10/24/23 at 2:38 PM, a nurse note stated, the resident was found sitting on the bathroom floor today at 1220 pm [12:20 PM]. the nurse assessed the patient there is no bruise and no complaints of pain. the nurse addressed the issue to the doctor and DON [Director of Nursing] and suggested that they change her room so at least wecan [sic] keep an eye on her. No neuro checks were located to indicate resident 27 neurological status was monitored after her fall. An identified intervention was a room change further away from the nurse's station. j. On 10/24/23 at 11:46 PM, an Event note stated, Nurse assessed pt because day shift nurse reported that pt was found on the floor several times today before noc nurse came on duty. Pts hand grips are equal, leg and hand strength equal and strong, pts pupils are 3mm [millimeters], PERRLA, alert and oriented, no visible s/s [signs/symptoms] injury r/t [related to] incidents apparent. Aides reported that pt will not ask for help and will get up alone to toilet so they are rounding frequently. Pts call light and personal items are within reach, adequate lighting in room, pt wearing non-slip socks, bed in lowest position, walker is nearby, pt given education and reminders to call for help. No neuro checks were located to indicate resident 27 neurological status was monitored after her fall. No incident report was located. k. On 10/26/23 at 5:32 AM, an alert note stated, Resident had a fall this shift where she received a laceration to her head and a skin tear to her right forearm. sent to hospital where she received stitched to her forehead . There were no neuro checks located to indicate resident 27's neurological status had been monitored post fall. No incident report was located. l. On 10/29/23 at 4:51 PM, a nurse note stated, Found resident sitting on the floor in front of her wheelchair. Assisted back to her wheelchair per two assist and taken to the bathroom. Neuros started. No apparent new injuries noted. No neuro checks were located. The interventions identified on the incident report included an update in resident 27's toileting schedule and making sure resident 27 had no skid foot wear on. m. On 10/30/23 at 2:14 PM, a physician note stated, Nursing requested visit after another recent fall. Patient was found in room, seated up in bed, alert and cooperative, NAD. Patient's husband is also present. Bruising left side of forehead improving after fall approximately 1 week ago. She denies any new pain or injury after fall yesterday. She denies headache, dizziness, near syncope. Patient's husband attributes falls to patient's impulsive behavior and stroke related cognitive and physical disabilities. We discussed plan to continue fall precautions with frequent toileting, fall mat at bedside, call light within reach, and frequent checks. n. On 11/2/23 at 4:57 AM, a nurse note stated, Pt keeps falling, doing frequent checks. and education on how to use call light, she can't really show how to use, just repeats yes. Neuro checks started notified MD and oncall manager. An Incident report documented resident 27 had a witnessed fall on 11/1/23. The neuro checks were not fully completed. o. On 11/24/23 at 3:41 AM, a nurse note stated, Pt had a fall at approximately 0300 [3:00 AM]. On call doctors were called and the person who picked up the phone stated, 'I don't think I am the one on call tonight but use your best judgement.' Due to the size of the goose egg on the pt's head and delayed speech from baseline, I believe it is in the patient's best interest to be evaluated by a doctor in the emergency dept at [name of local hospital]. Pt c/o headache and tenderness to palpation. Goose egg is soft and pt's blood pressure was elevated at 152/94, RR 22, pupils reactive and responsive to light, but are slightly delayed. EMS [emergency medical service] was contacted and arrived. Initial assessment of the pt was performed by EMS. Fall was unwitnessed. Pt was transferred from the w/c [wheelchair] to the stretcher via stand and pivot with nursing and EMS assistance. Pt was secured to the stretcher via straps times three and side rails times two. Pt was transported outside with paramedics and taken to [name of local hospital]. Pt's daughter was notified. The neuro checks were not fully completed. The facility incident report documented it was unknown why resident 27 had fallen. Documented interventions included an update to resident 27 toileting schedule, educating resident 27 in using the call light, a medication review and labs were requested. p. On 11/24/23 at 5:42 AM, a nurse note stated, [name of local hospital] called and stated the pt had a head CT [computed tomography scan] that was negative for any brain injury or brain bleed. Pt is being discharged and is going to be transported back to this facility. Pt has a right frontal scalp hematoma. q. On 11/27/23 at 1:17 PM, a physician/practitioner note stated, [Resident 27] is seen and examined for an acute visit today regarding recent multiple falls .Nursing reported that patient has had more than one recent fall due to getting up to the bathroom by herself. Pt has decreased mobility and is unable to ambulate to the bathroom without assistance. r. On 11/28/23 at 4:16 PM, a nurse note stated, regarding recent multiple falls. contusion/ bruising to the right side of forehead continues to heal routinely. bruising turning from purple to yellowish in color. md orders to collect ua [urinalysis] with c&s [culture and sensitivity] as indicated . On 12/5/23 at 11:46 AM, an interview was conducted with Certified Nursing Assistant (CNA) 5. CNA 5 stated resident 27 was considered a high fall risk and could not be left unattended. CNA 5 stated resident 27 had memory issues and was unable to safely stand by herself. CNA 5 stated resident 27 fell all the time. CNA 5 stated intervention they had in place included having the bed in the lowest position and a bed mat. CNA 5 stated they check on resident 27 about every hour when her husband was not here. On 12/6/23 at 10:36 AM, an interview was conducted with Licensed Practical Nurse (LPN) 5. LPN 5 stated resident 27 was a one person transfer and believed staff assisted her to the restroom. LPN 5 stated resident 27 had an abnormal gait and was a fall risk. LPN 5 stated resident 27 believed she was capable of doing things on her own and but was not safe to do so because she was only oriented to herself. LPN 5 stated interventions they had in place included doing frequent rounding. LPN 5 stated other intervention they were able to implement for resident safety included restraints to prevent them from falling. LPN 5 stated resident 27 toileting schedule was the CNA rounding. LPN 5 stated resident 27 knew how to use her call light. On 12/6/23 at 2:20 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated resident 27 had an over inflated idea of what she can do versus what she can actually do. LPN 3 stated resident 27 was reminded to not walk on her own but stated she still did anyways. LPN 3 stated resident 27 was a fall risk and she recently had a fall that sent her to the emergency room . LPN 3 stated it was another nurse that had found her on the floor that night. LPN 3 stated that other nurse was also an emergency medical technician and stated the nurse was concerned with how resident 27 presented after the fall that they sent her to the hospital. LPN 3 stated they have signs posted in her room to reminded her to call if she needed to get up. LPN 3 stated resident 27 was located a little further away then what they liked from the nurses station. LPN 3 stated the neuro checks were a group effort between the aids and nurses. LPN 3 stated neuro checks were put in place to monitor for acute changes post fall such as a subderal hematoma. LPN 3 stated a subderal hematoma took hours to manifest and it was considered the silent killer post falls. On 12/6/23 at 2:23 PM, an interview was conducted with Certified Nursing Assistant (CNA) 7. CNA 7 stated the aids checked on resident 27 often to make sure she was not getting up on her own. CNA 7 stated every time they walked by her room, they checked on her to avoid any percarious situation. CNA 7 stated they had a note posted on her call that reminded her to call to avoid falls. CNA 7 stated there was no official toileting schedule but they had a routine in place. CNA 7 stated resident 27's call light was the first one to be answered because of her history. CNA 7 stated resident 27 was considered a high fall risk and stated one of the interventions they had in place was lowering her bed to the lowest position she allowed. CNA 7 stated resident 27 communication had been hampered from a previous stroke so her communication was not the most precise. On 12/6/23 at 3:07 PM, an interview was conducted with the Director of Nursing (DON). The DON stated a registered nurse needed to do the initially assessment when a resident fell . The DON stated the registered nurse could then be the one to determine if the LPN performed the indicated neuro checks. The DON stated if the registered nurse determined something abnormal during the neuro checks then they notified to the doctor. The DON stated the purpose of the neuro checks was to monitor resident's for a certain amount of time for any abnormal outcomes after a fall. The DON stated they expected neuro checks to be completed as ordered and any resident refusals to be documented. The DON stated head injuries were less likely to happen and less risky for a resident the longer out they were from the fall. The DON stated an incident report needed to be done after every fall. The DON stated they expected to be notified of every fall. The DON stated incident reports were a way of tracking falls and it helped with the investigation and adding interventions for the residents to prevent future falls. The DON stated they tried to determine the cause of the fall. The DON stated that for one resident 27's intervention, they ordered pain medication to address her pain post fall. The DON stated they had added toilet times on the CNA task to reminded them when resident 27 needed to be toileted. The DON stated the toilet times included 3:00 AM, 9:00 AM, 11:00 AM, 4:00 PM, 7:00 PM, and 11:00 PM. The DON was unable to located where the CNA's were consistently documenting resident 27's toileting times. 30563 POTENTIAL FOR HARM 2. Resident 51 was admitted to the facility on [DATE] with diagnoses which included prediabetes, hypertension, major depressive disorder, anxiety disorder, lack of coordination, and alcohol abuse with alcohol-induced psychotic disorder with delusions. On 12/6/23 at 9:05 AM, the DON was observed to enter the secured unit. An observation was made of resident 51 in the dining room sitting in a chair with LPN 6 wiping blood off the left side of his face. There was blood observed on the floor. Resident 51's left hand was observed to have shake when LPN 6 wiped his face with a wash cloth. There was a laceration to the right eye and bruising observed to resident 51's right cheek. Resident 51 was observed with non-slip socks. The DON was observed to obtain resident 51's vital signs. Resident 51's medical record was reviewed 12/6/23. A care plan dated 8/31/22 and updated on 9/15/22 revealed a focus of resident 51 .is at risk for falls: Confusion. The goal was [Resident 51 will be free of falls through the review date. An intervention included to Anticipate and meet the resident's needs. On 12/6/23 at 9:20 AM, an interview was conducted with LPN 6. LPN 6 stated she worked the 400 hallway on Tuesday and Wednesdays. LPN 6 stated that resident 51 had behaviors of walking with his eyes closed. LPN 6 stated that Certified Nursing Assistant (CNA) 4 was in assisting resident 51 off the floor when she entered the dining room. LPN 6 stated that resident 51 had a head wound. LPN 6 stated that LPN's were unable to assess residents after a fall and needed a an RN to assess the resident. LPN 6 stated that the DON assessed resident 51 after the fall. LPN 6 stated after a resident fell with a head wound, the RN assessed the resident, neurological assessments were done, and the nurse was instructed what to do from the RN. LPN 6 stated that the physician was notified and documentation was completed. LPN 6 stated staff kept an eye on him for the next few days. LPN 6 stated resident 51 was bleeding everywhere and she asked him to squeeze her hands. LPN 6 stated that resident 51 was observed to be in pain and needed pain medication. LPN 6 stated that resident 51 should have been left on the ground until the RN was there to assess the resident prior to moving him. On 12/6/23 at 9:21 AM, an interview was conducted with the DON. The DON stated after a fall, the nurse identified what the resident was doing, was trying to do, what help that was provided prior, figure out what they were trying to do previous to the fall. The DON stated the family and physician were notified. The DON stated an incident report was completed by the nurse after every fall. The DON stated the resident was then monitored for a few days, assessed for increased pain, injuries or any adverse side effects. The DON stated the CNA was to notify the nurse and help the resident if the resident was in immediate harm. The DON stated for example the CNA needed to get the resident a blanket or pillow. The DON stated she would like vital signs to be done right away before moving the resident. The DON stated CNA's should wait to move the resident until after the nurse had assessed for injuries, pain, and neurological. The DON stated after the resident was assessed with no injuries then the resident was to be moved. The DON stated resident 51 should have been left until the RN was able to assess. The DON stated if a resident was moved prior to the nurse assessing, it could cause more damage if there was a head injury or a fracture. On 12/6/23 at 9:25 AM, an interview was conducted with CNA 4. CNA 4 stated resident 51 stood up a lot and wandered. CNA 4 stated that resident 51 stood up and fell sideways on his right side. CNA 4 stated that CNA 1 and her helped resident 51 off the floor when they noticed blood. CNA 4 stated resident 51 was placed into a chair in the dining room. CNA 4 stated she usually left the resident on the floor until nurse assessed but since resident 51 was bleeding, the CNA's thought it was better to get him up into a chair. CNA 4 stated usually have nurse assess before moving resident. On 12/6/23 at 5:22 PM, an interview was conducted with Regional Nurse Consultant (RNC) 1. RNC 1 stated resident's should not be moved until the resident was assessed by an RN. 3. On 12/4/23, hot water temperatures were observed through out the facility. The following temperatures were observed: [Note: All temperatures were in degrees Fahrenheit.] a. At 10:36 AM, an observation was made of the 100 hallway bathroom at the nurses station. The water temperature was 125.2. b. At 10:39 AM, room [ROOM NUMBER]'s bathroom water temperature was 124.8. Resident 47 resided in room [ROOM NUMBER]. Resident 47 was interviewed and stated the water was hot but he knew how to add cold water. c. At 10:44 AM, room [ROOM NUMBER]'s bathroom water temperature was 126.3. Resident 58 resided in room [ROOM NUMBER]. Resident 58 was interviewed and stated the water was hot but he knew to use cold water when it was too hot. d. At 10:47 AM, room [ROOM NUMBER]'s bathroom water temperature was 131.9. e. At 10:56 AM, the Secured Unit/400 hallway dining room sink had a water temperature of 122.9. f. At 11:01 AM, room [ROOM NUMBER]'s sink temperature was 119.6. Resident 25 resided in room [ROOM NUMBER]. Resident 25 was observed to be ambulatory through the Secured Unit. g. At 11:07 AM, room [ROOM NUMBER]'s sink water temperature was 123.5. h. At 11:09 AM, room [ROOM NUMBER]'s sink water temperature was 119.4. i. At 11:19 AM, the sink in the shower room of the Secured Unit water temperature was 120.1. j. At 11:32 AM, room [ROOM NUMBER]'s sink water temperature was 121.2. k. At 11:35 AM, room [ROOM NUMBER]'s sink water temperature was 124.0. Resident 44 resided in the room and was interviewed. Resident 44 stated she liked how hot her sink water was because she was able to make a cup of coffee. Resident 44 stated that she touched the spout to see how hot the water was because if she put her finger under the water it would get burned. On 12/4/23 at 11:17 AM, an interview was conducted with CNA 4. CNA 4 stated resident 25 was able to use the restroom independently and able to wash his hands independently. CNA 4 stated the water had been hot and had to be adjusted with showering residents. CNA 4 stated she worked on all the units at the facility and residents had stated Too hot when being showered. CNA 4 stated they could not remember who the residents were and the water was easily adjusted. CNA 4 stated there were no residents that had sustained burns from the water. On 12/4/23 at 11:40 AM, an interview was conducted with CNA 5. CNA 5 stated the water was warm but no residents had complained it was too hot. On 12/4/23 at 11:53 AM, an observation and interview was conducted with Regional Plant Operations 1. The hot water heaters were observed to be set at 158 degrees Fahrenheit. Regional Plant Operations 1 stated that the hot water heaters were set to 158. There was no observed mixing valve. Regional Plant Operations 1 stated he was unable to find the mixing valve. Regional Plant Operations 1 stated the mixing valve was usually set to 110 and not above 115 which made the resident rooms around 110. Regional Plant Operations 1 stated that the Maintenance Director was to check water temperatures daily Monday through Friday. On 12/4/23 at 2:32 PM, an interview was conducted with Regional Plant Operations 2. Regional Plant Operations 2 stated he checked water temperatures and the temperatures were 120.3, 119.0, and 122.0 in the 100 hallway. Regional Plant Operations 2 stated he turned the hot water heater temperature down to 152 from 158. Regional Plant Operations 2 stated that 152 would then make the water temperatures 113 in the hallways. Regional Plant Operations 2 stated that he could not find a mixing valve and was unable to locate water temperatures documented by the previous Maintenance Director. 4. On 11/30/23 at 1:44 PM, a facility tour was conducted. The following was observed: a. A handrail was loose near the maintenance door and the double doors. There was a broken metal beam along the bottom of the door that projected out towards the hallway. b. A counter was broken off and had sharp edges were exposed in the dining area near the microwave. c. Near the exit doors and room [ROOM NUMBER], a metal piece was bent and protruding out, along the bottom of the door. d. The bathroom in room [ROOM NUMBER] had two sets of toilet paper holders. The sets were missing parts which created a projection from the wall. e. In room [ROOM NUMBER], there was a floor vent that had missing metal pieces which created sharp edges at the foot of bed. f. A wire shelf located at the head of the bed in room [ROOM NUMBER]B was loose. On 12/5/23 at 11:09 AM, an interview was conducted with Regional Plant Operations 1. Regional Plan Operations 1 stated that he had probably not seen anything that needed repair because the facilities maintenance staff was no longer employed at the facility as of 11/30/23. On 12/5/23 at 11:09 AM, a facility walk through was completed with Regional Plant Operations 1. Regional Plant Operations 1 observed the items listed above and had no additional information. No documentation was provided that indicated the facility had previously made an attempt to address the identified concerns.

Based on interview, observation and record review, the facility did not ensure that 5 of 47 sample residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. Specifically, current weights were not being obtained to allow staff to appropriately assess the residents' nutritional status. In addition, interventions were not being implemented in a timely manner, residents were not being provided with the appropriate supplements, and were not assisted with meals . The findings for resident 53 were determined to have occurred at a harm level. Resident identifiers: 30, 31, 51, 53 and 121. Findings include: HARM 1. Resident 53 was admitted to the facility on [DATE] with diagnoses that included crushing injury of right shoulder and upper arm, hemolytic anemia, congestive heart failure, vitamin B12 anemia, osteoporosis, epilepsy, atrial fibrillation, and prediabetes. Resident 53's medical record was reviewed from 11/27/23 through 12/6/23. On 8/8/23, resident 53 had a diet order for double portions. On 8/9/23, resident 53 weighed 218 pounds (lbs). On 8/11/23, resident 53 weighed 220 lbs. On 8/31/23, facility staff completed a Skin and Nutrition Review (SNR) for resident 53. The most recent weight used for the SNR was from 8/11/23. The facility did not have a current weight in order to help assess resident 53's nutritional status. On 9/7/23, facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 8/11/23. The facility did not use the current weight taken on 9/7/23 listed in the Electronic Health Record (EHR) of 181.8 lbs. On 9/8/23, a physicians order was written for resident 53 to receive a mighty shake supplement twice daily. On 9/13/23 facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 9/7/13. The facility did not have a current weight in order to help assess resident 53's nutritional status. The SNR indicated Significant wt change of -17.4% in a month from weight 9/7. BMI (Body Mass Index): 23.6. Need udpated weight for this week. no wounds or edema noted at this time. Meal intake [about] 75%. Recommend adding double portions. Will continue to monitor and review in a week. (Note: Resident 53 had already receiving double portions since admission, so this was not a new intervention.] On 9/21/23 facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 9/7/13. The facility did not have a current weight in order to help assess resident 53's nutritional status. On 9/22/23, resident 53 weighed 179.8 lbs. On 9/28/23, facility staff completed a SNR for resident 53. The SNR indicated Significant wt change of -17.7% in a month from wt taken 9/28. BMI: 23.3. No wounds or edema noted at this time. Meal intake >75%. Continue with mirtazapine and double portions given at meal time and mightyshakes BID (twice daily). Will continue to monitor and review in a week. On 9/29/23, a physicians order indicated resident 53 was to be administered Mirtzapine 15 milligrams at bedtime for an appetite stimulant. On 10/5/23 facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 9/28/23. The facility did not have a current weight in order to help assess resident 53's nutritional status. The SNR indicated Significant wt change of -17.7% in a month from wt taken 9/28. BMI: 23.3. No wounds or edema noted at this time. Meal intake >75%. Continue with mirtazapine and double portions given at meal time and mightyshakes BID. Will continue to monitor and review in a week. On 10/12/23 facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 9/28/23. The facility did not have a current weight in order to help assess resident 53's nutritional status. The SNR indicated Need updated weight for this week. BMI: 23.3. No wounds or edema noted at this time. Meal intake ~75%. Continue with mirtazapine and double portions given at meal time and mightyshakes BID. Will continue to monitor and review in a week. On 10/19/23 facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 9/28/23. The facility did not have a current weight in order to help assess resident 53's nutritional status. The SNR indicated Need updated weight for this week. BMI: 23.3. No wounds or edema noted at this time. Meal intake >75%. Continue with mirtazapine and double portions given at meal time and mightyshakes BID. Will continue to monitor and review in a week. On 10/26/23 facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 9/28/23. The facility did not have a current weight in order to help assess resident 53's nutritional status. The SNR indicated Need updated weight for this week. BMI: 23.3. No wounds or edema noted at this time. Meal intake ~75%. Continue with mirtazapine and double portions given at meal time and mightyshakes BID. Will continue to monitor and review in a week. On 11/2/23 facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 9/28/23. The facility did not have a current weight in order to help assess resident 53's nutritional status. The SNR indicated Need updated weight for this week. BMI: 23.3. No wounds or edema noted at this time. Meal intake ~75%. Continue with mirtazapine and double portions given at meal time and mightyshakes BID. Will continue to monitor and review in a week. On 11/2/23, a nursing progress note indicated that resident 53 had been seen by his cardiologist, and had given orders to . 3. Discuss having the pt (patient) have a protein drink to increase his weight. 4. Set a goal for the pt to gain 10-15 lbs over the next few months . 5. Pt should eat 3000 calories a day, encouraged pt to follow up with a nutritionist. On 12/3/23, resident 53 weighed 184.4 lbs. It should be noted that despite weight loss over several months, and multiple interventions, resident 53 did not have a care plan developed to address his nutritional needs. On 12/6/23 at 4:30 PM, an interview was conducted with the facility Dietary Manager (DM). The DM was asked how the facility was ensuring that resident 53 received 3000 calories a day. The DM stated that he provided extra milk to provide double protein. The DM provided surveyors with a calorie breakdown of the menu. Per review of the menu, an extra milk would add 8 grams of protein. On 11/29/23 at 3:30 PM, an interview was conducted with the facility RD. When asked why current weights were not being used for the SNR meetings, the RD stated we've been struggling to keep up to date on the weights. There's not enough staff to have CNAs (Certified Nursing Assistants) get weights. I've talked to them multiple times about it. POTENTIAL FOR HARM 2. Resident 30 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, dysphagia, impulse disorder, mental disorders due to known physiological condition, major depressive disorder, mild protein calorie malnutrition, hemiplegia, alcohol dependence, avoidant personaility disorder, acute kidney failure, and history of a traumatic brain injury. Resident 30's medical record was reviewed from 11/27/23 through 12/6/23. On 7/10/23, resident 30 weighed 148.6 lbs. On 9/22/23, resident 30 weighed 138.8 lbs. This was a 6.6 percent weight loss in 2.5 months. Resident 30 had not been weighed since 7/10/23, nor had any refusals to be weighed been documented. On 9/24/23, a physicians order was written for resident 30 to receive a Boost supplement twice daily. On 9/28/23 facility staff completed a SNR for resident 30. The SNR indicated that facility staff would serve an egg salad sandwich with resident 30's meals. Review of resident 30's orders revealed that this was not implemented until 10/16/23. On 10/19/23 facility staff completed a SNR for resident 30. The most recent weight used for the SNR was from 10/10/23. The facility did not have a current weight in order to help assess resident 30's nutritional status. On 10/26/23 facility staff completed a SNR for resident 30. The most recent weight used for the SNR was from 10/10/23. The facility did not have a current weight in order to help assess resident 30's nutritional status. On 11/2/23 facility staff completed a SNR for resident 30. The most recent weight used for the SNR was from 10/10/23. The facility did not have a current weight in order to help assess resident 30's nutritional status. On 11/6/23 resident 30 weighed 141.2 lbs. On 11/16/23 resident 30 weighed 137.4 lbs. 48709 3. Resident 51 was admitted to the facility on [DATE] with diagnoses which included dementia, hypertension, depression, anxiety, alcohol abuse, and cognitive communication deficit. On 11/27/23 at 11:04 AM, an observation was made of resident 51. Resident 51 was observed laying in bed with a food tray next to him on the bedside table. On 11/27/23 at 1:33 PM, an observation was made of resident 51. Resident 51 was observed alone in his room, laying in bed with a food tray on the bedside table next to the bed. The main dish was covered with a lid and the drink cups were full and covered. On 11/28/23 at 10:10 AM, an observation was made of resident 51. Resident 51 was observed alone in his room sitting in his bed with the head of the bed about 75% raised, he had his breakfast in front of him on the bedside table. Resident 51 had a bowl of cereal with milk in his hand and rested on his chest. Soggy cereal was observed on his clothes. Resident 51 slowly spooned milk towards his mouth, he spilled the milk on his chest, and failed to get any cereal or milk in his mouth. His food tray was observed to have approximately 90% of scrambled eggs; 80% of cereal and half of a cup of milk in his cereal bowl, with 10% of cereal on his chest; one whole sausage patty; two glasses of milk, one cup was empty; 50% of one vanilla mighty shake; and 100% of one glass of orange juice with saran wrap on top was on the food tray. Resident was staring straight and did not react when spoken to. On 11/29/23 at 8:31 AM, an observation of resident 51 was made. Resident 51 was laying in his bed with his eyes closed, there was no food tray in his room. On 11/29/23 at 8:35 AM, an observation of resident 51 was made. A food tray was delivered to resident 51 in his bed. Staff raised the head of the bed to about 75% degrees. Staff opened the resident's mighty shake and removed the covers of the plate of food, orange juice, and milk. Resident 51's eyes were closed, and he was not eating. On 11/29/23 at 8:45 AM, an observation of resident 51 was made. Resident 51 was alone in his room with the breakfast tray sitting in front of him, untouched. Resident 51 was staring straight with his eyes half open. He did not respond when spoken to. On 11/29/23 at 8:58 AM, an observation of resident 51 was made. Resident was sitting up and awake, his food remained untouched. Certified Nurse Assistant (CNA) 1 was observed at bedside taking resident's blood pressure. The Director of Nursing (DON) entered the room and assisted CNA 1 with obtaining vital signs. On 11/29/23 at 9:06 AM, an observation was made of resident 51. Resident 51 was alone in his room and his food remained untouched. On 11/29/23 at 9:09 AM, an observation was made of CNA 1. CNA 1 was observed to go into resident 51's room and ask him if he was done eating. No response from the resident was heard and CNA 1 left the resident's room. On 11/29/23 at 9:14 AM, an observation of CNA 9 was made. CNA 9 was observed in resident 51's room assisting resident eat breakfast. CNA 9 told CNA 1 that resident 51 was not reacting or taking any food. CNA 1 asked CNA 9 if resident 51 was spitting his food out. CNA 1 told CNA 9, he'll be up and moving around later. After I am done with breakfast, I will get him up and get him ready and he will wake up more. CNA 1 was assisting other residents in the dining room. On 11/29/23 at 9:51 AM, an observation was made of resident 51's room. It was observed that the resident was not in his room and there was an open mighty shake on the tv stand that was approximately 50% full. On 11/29/23 at 12:07 PM, an observation was made of resident 51. Resident 51 was observed to be in his bed, his eyes were open, and he had no response when he was spoken to. A mighty shake was on the tv stand that was approximately 50% full. On 11/29/23 at 12:32 PM, an observation was made of resident 51. Resident 51 was observed to walk out of the dining room and stood next to the door, stared, and drank a tan liquid from a cup that was approximately half full. A concurrent interview with CNA 1 was conducted. CNA 1 stated that resident 51 was drinking a med pass because he had not eaten breakfast. On 11/29/23 at 12:45 PM, an observation was made of resident 51. Resident 51 was in his bed laying on his stomach. He was propping his head up and holding the med pass cup that was approximately 35% full. CNA 1 walked resident 51 back to the dining room and had him sit at the table while she encouraged him to eat. On 11/29/23 at 1:03 PM, an observation was made of resident 51. Resident 51 walked out of the dining room. Resident 51's tray was then observed in the dining room to have a vanilla mighty shake that was approximately 25% full, 35% of a taco, 35% of a serving of zucchini, one full glass of tan liquid, 70% of a glass of milk, and 70% of a glass of orange juice was left on the resident's tray. On 11/30/23 at 8:59 AM, an observation was made of resident 51. Resident 51 was in his room alone. He is sitting up in bed holding a cereal bowl, he was not moving or eating. On 11/30/23 at 9:12 AM, an observation was made of the Activities Director (AD). The AD entered resident 51's and encouraged him to eat. Resident 51 was observed to be feeding himself cereal with a plastic fork. The AD then left the resident's room. The AD returned to his room at 9:16 AM and left again. Resident was alone in his room and slowly ate his cereal with a spoon, cereal was observed to be spilled on his tray. No mighty shake was observed on his meal tray. The AD returned to the room at 9:22 AM and encouraged the resident to eat. On 11/30/23 at 9:27 AM, an observation was made of resident 51 in his room, alone eating cereal. The AD returned to the resident's room and encouraged him to eat. At 9:50 AM, the AD removed resident 51's breakfast tray from his room. The meal tray was observed which had two empty milk cups, a combined total of approximately 1 cup of milk was in cereal bowls; 25% of orange juice; eggs had been eaten; 100% of breakfast potatoes and toast on plate; two bowls of cereal had 25% of cereal in each bowl; and no magic shake container was on the tray. A concurrent review of resident 51's meal card that was on his tray indicated that resident 51 was on a fortified, regular diet, and regular food texture with thin liquids. It further indicated that eight ounces of milk, a mighty shake, an assorted juice, choice of hot or cold cereal, cheese and egg casserole, o'brien potatoes, toast, margarine or jelly, milk or beverage with notes that indicated to serve two raisin bran cold cereals and to send milk with all meals. On 11/30/23 at 9:53 AM, an interview was conducted with CNA 3. CNA 3 stated resident 51 did not eat unless he was prompted. CNA 3 stated he did not know how much resident 51 had eaten for breakfast and that the RD took his tray and he would ask her. CNA 3 stated he did not know if resident 51 had a mighty shake on his tray and that that was taken care of by the kitchen. He stated that the staff who delivered the tray should have checked that resident 51 received his mighty shake and that he was unsure why resident 51 needed a mighty shake. Resident 51's medical record was reviewed from 11/27/23 through 12/6/23. The Annual MDS Section G- Functional Status Activities of Daily Living (ADL) Assistance dated 8/26/23 indicated, Eating- how resident eats and drinks, regardless of skill. Do not include eating/drinking during medication pass. 1. Supervision. 2. One person physical assist. The Functional Abilities, Self-Care quarterly dated 11/26/23 indicated, Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident .Substantial/maximal assistance. The physician orders indicated: 1. Mirtazapine Tablet 15 mg (milligrams) Give 0.5 tablet by mouth at bedtime for appetite related to MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, start date 11/10/23 at 7:00 PM 2. Mirtazapine Tablet 15mg Give 1 tablet by mouth at bedtime for appetite related to MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, start date 9/26/23 at 7:00 PM and discontinued 11/10/23 at 1:52 PM 3. Mighty Shakes three times a day for nutrition support and to, Offer with meals. Start date 9/21/23 at 3:00 PM 4. Snack of Choice two times a day for nutrition support, start date 8/17/23 at 3:00 PM 5. Regular Diet diet, Regular texture, Thin consistency Add fortified foods started 8/12/23 at 6:57 AM 6. Weight monthly 10th in the afternoon starting on the 10th and ending on the 11th every month for weight, started 11/10/22 at 3:00 PM, discontinued 11/30/23 at 2:12 PM. 7. Folic Acid Oral Tablet 1 mg by mouth in the morning for SUPPLEMENT, start date 9/1/22 at 7:00 AM Weights were reviewed and documented: 7/31/23 184; 8/28/23 175; 9/28/23 166.5; 10/27/23 170; 11/27/23 155.5. A Nursing Skin and Nutrition Review dated 8/24/23 at 7:04 AM indicated that resident 51's level assistance needed was supervision and was to have had encouragement of intake at mealtimes in the dining room. It further indicated, Significant wt (weight) change of -14.6% in 6 months. BMI: 26.5. Encourage intake at meal time. No wounds or edema noted at this time. Added snack of choice BID (two times a day) for nutrition support. Will continue to monitor and review in a week. A Nursing Skin and Nutrition Review dated 9/28/23 at 8:42 AM indicated, Significant wt change of -7.2% in a month, -9.5% in 3 months and -18.4% in 6 months. BMI: 24.7. Encourage intake at meal time. No wounds or edema noted at this time. Receiving snack of choice BID and Mightyshake TID for nutrition support and fortified foods. Will continue to monitor and review in a week. A Nursing Skin and Nutrition Review dated 11/14/23 at 9:48 AM indicated the resident's level of assistance needed was, Supervision. It indicated the resident was to be encouraged to eat at mealtimes. The document further indicated, Significant wt (weight) change of 6.1% in a month, -9.8% in 3 months and -14.6% in 6 months. A Nutritional Screen dated 11/24/23 indicated, No wt change in the last week but significant wt change of -6.5% in a month, -9.1% in 3 months, and -16.1% in 6 months and, [Resident 51] has had significant wt change in the last 6 months, several interventions have been implemented and he is currently on Mirtazapine (a medication) to increase appetite. Continue to offer foods [Resident 51] prefers. RD (Registered Dietitian) will continue to monitor PO (by mouth) intake and weight and make diet recommendations PRN (as needed). The care plan indicated, [Resident 51] has an ADL (activities of daily living) performance deficit related to dementia s/s (signs and/or symptoms), forgetfulness with a goal of, [Resident 51] will improve current level of function through the review dated was initiated on 9/1/22, revised on 11/17/22, with a target date of 9/18/23; Interventions were listed as, Eating: [Resident 51] is set up with eating. Needs reminders and cuing to start meal at times/mimics others initiated 9/1/22 and revised on 9/15/22. An interview on 11/29/23 at 12:55 PM, was conducted with CNA 1. CNA 1 stated resident 51 needed to be supervised when he ate, but the level of supervision changed throughout the day. CNA 1 stated resident 51 needed set-up and supervision, but sometimes he needed total assistance to eat. The CNA stated supervision meant staff needed to stay with the resident when they ate. An interview on 12/6/23 at 10:28 AM, was conducted with the Director of Nursing (DON). The DON stated the facility had been working with resident 51 for awhile with the dietitian; we had tried different supplements and diet plans. The DON stated staff had been trying to spoon feed him, but he would not open his mouth. The DON stated placing a feeding tube was discussed but the resident's family did not want to do that. The DON stated resident 51 needed to be monitored while he ate and that when he wanted to eat, he could. The DON stated that mighty shakes were ordered and the CNA's knew which resident's received shakes and that it is also on the meal ticket. The DON stated that the CNA's should have made sure that a mighty shake was on his tray. 45490 4. Resident 31 was admitted to the facility on [DATE] with diagnoses which included dementia, bipolar disorder, history of gastric bypass, hyperglycemia, and chronic respiratory failure. Resident 31's medical record was reviewed 11/27/23 through 12/6/23. Resident 31's care plan dated 2/18/23 with a revision on 8//28/23 included a focus area of nutritional problems related to increased energy needs due to bipolar disorder and current mania, being very active and constantly moving. Goals for resident 31 included, the resident will maintain adequate nutritional status as evidenced by maintaining weight, no s/sx [signs and symptoms] of malnutrition through review date. The interventions list included: Provide and serve diet as ordered. RD[registered dietitian] to evaluate and make diet change recommendations PRN [as needed]. Weight per facility policy. Resident 31's diet order dated 2/17/23 documented a regular diet, fortified with large protein. [Note: Residents in the facility were not receiving the proper fortified diets.] Resident 31's weights revealed the following: a. On 2/18/23 resident 31's admission weight was 191.0 Lbs (pounds). b. On 3/23/23 resident 31's weight was 158.6 Lbs. [Note: A possible weight loss of 32 lbs was documented with out a reweigh.] c. On 6/16/23 resident 31's weight was 159.0 Lbs. [Note: The next documented weight after the potential weight loss was taken more than 3 months later.] Resident 31's skin and nutrition notes revealed the following: a. On 4/6/23, a skin and nutrition review documented, most recent wt [weight] 158.6 # [lbs] (3/23). Wt loss 32.4 # . Questioning accuracy- current wt was wheelchair, and previous wt was standing . Recommend to review again in one week to determine accuracy of wts. b. On 4/26/23, a skin and nutrition review documented, the most recent weight as 156.8 lbs taken on 3/23/23. The previous weight documented 191 lbs, dated 2/18/23. The comments documented, Most most recent wt [weight] 158.6 # [lbs] (3/23). Wt loss 32.4 # . Questioning accuracy- current wt was wheelchair, and previous wt was standing . Recommend to obtain new wt and review again in one week to determine accuracy of wts . c. On 5/2/23, a skin and nutrition review documented, the most recent weight as 156.8 lbs taken on 3/23/23. The comments documented, Most most recent wt [weight] 158.6 # [lbs] (3/23). Wt loss 32.4 # . Questioning accuracy- current wt was wheelchair, and previous wt was standing . [Note: No recommendation were made.] d. On 5/12/23 a skin and nutrition review documented, the most recent weight as 156.8 lbs taken on 3/23/23. The comments documented, Most most recent wt [weight] 158.6 # [lbs] (3/23). Wt loss 32.4 # . reported in the month prior to most recent wt (191 #, 2/18). Questioning accuracy- current wt was wheelchair, and previous wt was standing . Recommend to obtain new wt when possible/ once off isolation to determine additional interventions needed. e. On 5/19/23, a nutritional screen documented, the most recent weight as 156.8 lbs dated 3/23/23. A screening question included, Has the resident had unintended weight loss over the past 7 days? The answer marked documented, Does not know. f. On 5/26/23, a skin and nutrition review documented, the most recent weight as 156.8 lbs taken on 3/23/23. [Note: There were no comments or recommendations documented.] g. On 6/2/23, a skin and nutrition review documented, the most recent weight as 156.8 lbs taken on 3/23/23. [Note: There were no comments or recommendations documented.] h. On 6/15/23, a skin and nutrition review documented, the most recent weight as 156.8 lbs taken on 3/23/23. [Note: There were no comments or recommendations documented.] I. On 6/22/23, a skin an nutrition review documented, the most recent weight as 159.0 lbs taken on 6/18/23. [ Note: This is the first re-weigh done since 3/23/23.] The comments documented, significant wt loss triggered . Doctor notified. 30563 5. Resident 121 was admitted to the facility 7/1/23 and discharged on [DATE] with diagnoses which included congestive heart failure, chronic kidney disease, monoclonal gammopathy, transient cerebral ischemic attack, pulmonary fibrosis, and respiratory disorder. Resident 121's medical record was reviewed 12/4/23 through 12/6/23. A physician's order dated 6/30/23 and discontinued 7/9/23 revealed Encourage fluids to ensure adequate hydration and minimize uti [Urinary Tract Infection] risk. Offer 120 mls [milliliters] at least qid [four times a day] for hydrational support four times a day for offers fluids for hydrational support. A physician's order dated 6/30/23 and discontinued 7/9/23 revealed Mightyshakes every 24 hours as needed for [sic] offer mighty shakes for nutritional support. Resident 121's July Medication Administration Record (MAR) revealed that resident was administered fluids four times a day of 120 mls. The MAR further revealed mighty shakes were not administered from 7/1/23 through 7/9/23. An assessment titled Nutrition Screen dated 7/4/23 revealed no estimated fluid needs were calculated. Additional notes revealed [Resident 121] appears to be meeting nutritional needs at this time with intake of [greater than] 75% at meals and mighty shakes given daily. Fluids offered meets estimated needs. A nursing progress note dated 7/4/23 at 1:01 AM, the nutrition section was blank. A nursing progress note dated 7/7/23 revealed Called [name and phone number removed] with urine sample for [name of lab removed] to process. Hospice Company. It should be noted there was no follow-up information or laboratory values located in resident 121's medical record. On 12/6/23 at 2:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated she was not sure how fluid needs were calculated and stated she did not know if that was enough fluid to maintain resident 121's hydration status.

Based on interview and record review, the facility did not ensure that the menus were followed. Specifically, residents who were prescribed a fortified diet, were not provided with the appropriate foods. Findings include: On 11/29/23 at 2:20 PM, the facility Dietary Manager (DM) provided a list of residents receiving a fortified diet to surveyors. The DM also provided a spreadsheet of the menu for residents receiving a fortified diet. The DM was asked how he fortified the milk that was provided to residents. The DM stated that he was using whole milk as the fortified milk. The DM stated that he used to add fortified milk powder to 2% milk but that the most recent manager before him told him to just use whole milk instead. When asked about alternate meals, the DM stated that there were not alternate menu items prepared in advance, and that if we have extra chicken, we just say let's make an extra chicken dish. On 12/4/23 at 1:47 PM, an interview was conducted with Cook 1. Cook 1 stated she was prepping food for dinner. Cook 1 stated she did not know what a fortified diet was and needed to ask the DM. On 11/29/23 at 3:30 PM, an interview was conducted with the facility Registered Dietitian (RD). When asked about the fortified diet menu, the RD stated that there was not a specific menu for the dietary staff to follow to fortify the diets, and that the dietary staff would add extra butter and cheese to things where they can. The RD stated that if a resident was prescribed a fortified diet, they would receive whole milk. When the RD was asked about the menu system and if she could locate the fortified recipes provided by the company who wrote the menus, the RD stated she was unaware that there were specific recipes for residents receiving fortified diets. On 11/30/23 at 12:45 PM, the RD and DM were interviewed. The RD and DM stated that they had looked into their menu system, and were able to locate the specific recipes for items residents should be receiving if they were prescribed a fortified diet. The RD verified that if a resident was receiving a fortified diet, they should have been given whole milk with non fat dry milk added to it, for example. The RD and DM confirmed that they were previously unaware that specific recipes were used to fortify residents' diets, and therefore had not been adding the appropriate menu items. On 12/4/23 at 1:55 PM, an interview was conducted with the DM. The DM stated there was nothing that could be fortified for lunch that day. The DM stated they were using whole milk for fortified but did not have another item fortified. The DM stated there were recipes to fortify items like the hot cereal. The DM stated there were menus posted throughout the facility and residents can submit a change menu item, if the resident disliked the item to be served. The DM stated the alternative menus were not set and the cook figured out what to serve that day. The DM stated there was a substitution log for the alternative menu and the Registered Dietitian (RD) signed the log when she was at the facility. The DM stated the cooks did not contact the RD for approval prior to serving the items. 30563

Based on observation, interview and record review it was determined, for 6 of 47 sampled residents, that the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhanced of his or her quality of life, recognizing each resident's individuality. Specifically, a staff member escalated with a resident regarding financial concerns, residents were observed eating when another resident was bleeding in the dining room, staff were not knocking before entering resident rooms, residents voiced concerns regarding staff attitudes, and staff were observed yelling at each other in the hallways. Resident identifiers: 17, 22, 24, 39, 43 and 51. Findings include: 1. Resident 43 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cellulitis of left lower limb, collapsed vertebra, major depressive disorder, dementia and Methicillin-resistant Staphylococcus aureus. On 12/6/23 at 12:04 PM, an observation was made of resident 43 and the Activities Director (AD). Resident 43 was yelling that his bank card had been taken and was being used. Resident 43 stated that his bank account had charges that were not from him and he was being ripped off. Resident 43 stated he got hammered for 500 to 600 dollars this month. Resident 43 stated to the AD that he was charged for too many cartons of cigarettes that month. The AD was observed to raise her voice and tell resident 43 that she bought him several cartons but was unsure if it had been 8 cartons she had purchased. The AD stated in a raised voice to resident 43 that he smoked that much and that he had used the vending machine that much. The AD stated resident 43 was charged extra fees on the vending machine because of using a credit card. Resident 43 was observed to walk off and say he was a cop and someone was going to jail. An observation was made of Licensed Practical Nurse (LPN) 3, LPN 2 and LPN 5 at the nurses station across from where resident 43 and the AD were having a loud conversation. LPN 2, LPN 3, and LPN 5 were not observed to intervene when the AD was observed to raise her voice when talking with resident 43. On 12/6/23 at 12:20 PM, an interview was conducted with resident 43. Resident 43 was observed to be walking away from the AD. Resident 43 stated that he received a bank statement with about $1000 of purchases that were not his. Resident 43 stated that there were purchases from the vending machine that were not his. Resident 43 stated that he did not get 8 cartons of cigarettes last month because he usually smoked 2 to 3 cartons per month. Resident 43 stated that someone took his bank card and did some things with it and they were going to jail because he was a retired cop and he knew people. On 12/6/23 at 12:29 PM, an interview was conducted with the AD. The AD stated that resident 43 had dementia and was forgetful. The AD stated that resident 43 was very disrespectful to her. The AD stated that resident 43 smoked more than a carton a week. The AD stated that every Tuesday resident 43 was out of cigarettes. The AD stated that weekly she went to the smoke shop to get residents cigarettes. The AD stated she used his bank card to purchase him cartons of cigarettes weekly. The AD stated she remembered buying him 2 cartons at a time. The AD stated if resident 43 ran out of cigarettes, he screamed and yelled that he was calling the police. The AD stated prior to going shopping for residents she obtained a list of items needed, then went to the store, bought the items and returned the items with the resident receipt to the resident. The AD stated since resident 43 did not have dementia and no personal funds account with the facility she did not keep a copy of resident 43's receipts. The AD stated she was unable to show how resident 43's money was spent because it was resident 43's responsibility to keep his receipts. On 12/6/23 at 5:02 PM, an interview was conducted with Administrator (ADM) 2 and Regional Nurse Consultant (RNC) 1. RNC 1 stated they were working with the physician to get laboratory values on resident 43 because he was confused. RNC 1 stated that resident 43 was more emotional today. ADM 2 stated resident 43 had a bunch of transactions on his card from the vending machine and wanted to talk to the vending machine company. ADM 2 stated they had not canceled the card because then resident 43 could not use the card. ADM 2 stated resident 43 told him that he was not accusing anyone at the facility of anything. ADM 2 stated he filed a grievance for resident 43 to talk to the vending machine staff member. ADM 2 stated the AD bought residents cigarettes weekly. ADM 2 stated he asked resident 43 if he would like to put his money in a trust so staff could keep track of spending. ADM 2 stated the AD should have a process in place to keep the receipts to protect herself. ADM 2 and RNC 1 stated the AD should not have escalated with resident 43 in the manner she did. 2. On 12/6/23 at 9:05 AM, an observation was made of resident 51 in the Secured Unit dining room. Resident 51 was observed to be sitting in the dining room with blood running down the left side of his face. LPN 6 was observed to be wiping blood from resident 51's face. There was blood observed on the floor. Resident 24 was observed to be seated across the table from resident 51 eating breakfast. Resident 22 was observed sitting next to resident 51 eating breakfast. 45490 3. On 11/28/23 at 9:29 AM, an interview was conducted with resident 17. Resident 17 stated that the staff have a poor attitude and that when he asked for help he was ignored. Resident 17 stated that the Certified Nursing Assistants (CNAs) spend most of their time on their phones and treat him with indifference. 22992 4. Resident 39 was admitted to the facility on [DATE] with diagnoses that included intervertebral disc disorders, osteoarthritis, morbid obesity, iron deficiency, history of malignant neoplasm of breast, and chronic viral hepatitis C. On 11/28/23 at approximately 10:00 AM, an interview was conducted with resident 39. Resident 39 stated that staff entered her room without knocking, typically housekeeping staff. Resident 39 stated she had asked for staff to knock before they enter her room, but they continue to come in unannounced, even with her door closed. Resident 39 stated that this bothered her, because she felt like everyone in the hall could see her. On 11/28/23 at 10:09 AM, a facility housekeeping staff member was observed to enter resident 39's room without knocking. 5. On 11/27/23 at approximately 2:00 PM, CNA 10 was observed arguing with another staff member in the hallway near the kitchen. CNA 10 was yelling at the staff member loud enough that it could be heard in the conference room several feet away from the kitchen area. CNA 10 was observed to be telling the staff member that he was expected to complete his tasks alone, and was upset that other CNAs were leaving their assigned halls to help CNAs in other areas. Several residents were observed to be in the area. 6. On 11/28/23 at approximately 2:00 PM, CNA 10 was observed in the hallway near the conference room telling another staff member, That damn guy doesn't know what the hell he's doing in reference to another CNA. Several residents were observed to be in the area. On 11/28/23 at 2:42 PM, an interview was conducted with CNA 10. When asked about the argument the day before, and the comment about the other CNA earlier on the 11/28/23 , CNA 10 stated oh you heard that?

Based on observation, interview, and record review it was determined, for 5 of 47 sampled residents, that the facility did not provide the necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish unless circumstances of the individual's clinical condition demonstrated that such diminution was unavoidable. Specifically, two residents did not receive showers as requested or as scheduled. In addition, residents were not provided assistance with nail care or dining. Resident identifiers: 15, 27, 30, 36, and 51. Findings Included: 1. Resident 27 was admitted on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis, type 2 diabetes, anxiety disorder, major depressive disorder, obstructive sleep apnea, and vascular dementia. On 11/27/23 at 11:22 AM, an interview was conducted with resident 27's family member. Resident 27's family member stated resident 27 was showered only when staff were able to. Resident 27's family member stated resident 27 was showered once a month and stated the last time resident 27 had a shower was a couple weeks ago. Resident 27's medical records were reviewed from 11/29/23 to 12/6/23. The facility shower binder was reviewed and documented resident 27 had showers scheduled for Tuesdays and Fridays and documented she required one person assistance. Resident 27's ADL (activity of daily living) bathing task documented, Tuesday, Friday AM [morning] ensure resident is seated while placing pants on and then stand when safe to do so fall prevention. On 11/29/23, the ADL task for the last 30 days were reviewed and no documentation was located to indicate resident 27 had a shower/bath in the last 30 days. On 12/5/23 at 11:46 AM, an interview was conducted was conducted with Certified Nursing Assistant (CNA) 5. CNA 5 stated they had a shower binder that indicated when residents were supposed to be showered. CNA 5 stated when they showered or bathed a resident, they were supposed to document how much assistance they need and what kind of bath they had received. CNA 5 stated CNAs had shower sheets they were supposed to fill out which indicated to the nurse if residents had new skin issues. CNA 5 stated resident 27 had received a shower today but they were not able to look back in the resident's chart to see the last time they had received a shower before today. On 12/6/23 at 12:08 PM, an interview was conducted with the Director of Nursing (DON). The DON stated staff were supposed to document when a resident had a bath or shower. The DON stated they would look for resident 27 shower sheets to demonstrate she had a bath in the last several weeks. [Note: No shower sheet were provided by the facility.] 2. Resident 15 was admitted on [DATE] with diagnoses which included paranoid schizophrenia, personality disorder, persistent mood affective disorder, cognitive communication deficit, seizures, repeated falls, muscle weakness, and need for assistance with personal care. On 11/27/23 at 2:50 PM, an observation was made of resident 15 having long fingernails. An interview was immediately conducted with resident 15. Resident 15 stated they did not like having their fingernails the length they were. Resident 15 stated they have asked staff to cut their nails but staff tells them they will do it later. Resident 15's medical record was reviewed. On 9/7/23, an Annual Minimum Data Set (MDS) gave no indication of how much assistance resident 15 required with personal hygiene. A care plan focus area initiated on 11/6/18 documented resident 15 had an activities of daily living self-care performance deficit. Interventions were listed and included the following: 1. Assist resident to keep fingernails trimmed and avoid scratching. 2. The resident requires extensive assist of staff for personal hygiene and oral care. 3. Resident 36 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included rheumatoid arthritis, type 2 diabetes mellitus, muscle weakness, cognitive communication deficit, pressure ulcer of unspecified site, repeated falls, and major depressive disorder. On 11/27/23 at 10:22 AM, an observation was made of resident 36's long yellow finger nails with brown substance underneath . Resident 36 was immediately interviewed and stated they wanted their fingernails trimmed but staff did not trim their fingernails. Resident 36 stated they have asked staff to cut them but they were told by staff they were not able to cut his fingernails due to them being a diabetic. Resident 36's medical record was reviewed 11/27/23 through 12/6/23. On 10/14/23, a Quarterly MDS documented resident 15 was a substantial/maximum assist with personal hygiene. On 12/5/23 at 11:46 AM, an interview was conducted with Certified Nursing Assistant (CNA) 5. CNA 5 stated they were able to cut resident's fingernails as long as the resident was not a diabetic. On 12/6/23 at 11:51 AM, an interview was conducted with Licensed Practical Nurse (LPN) 5. LPN 5 stated they had cut resident 36's fingernails the past Saturday when they noticed they were long and thick. LPN 5 stated they had enough time to cut resident fingernails if they noticed they were long. LPN 5 stated it only took about 10 minutes to cut fingernails. LPN 5 stated they were not aware of resident 15 having long fingernails. 48709 4. Resident 51 was admitted to the facility on [DATE] with diagnoses which included dementia, hypertension, depression, anxiety, alcohol abuse, and cognitive communication deficit. On 11/27/23 at 11:04 AM, an observation was made of resident 51. Resident 51 was observed laying in bed with a food tray next to him on the bedside table. On 11/27/23 at 1:33 PM, an observation was made of resident 51. Resident 51 was observed alone in his room, laying in bed with a food tray on the bedside table next to the bed. The main dish was covered with a lid and the drink cups were full and covered. On 11/28/23 at 10:10 AM, an observation was made of resident 51. Resident 51 was observed alone in his room sitting in his bed with the head of the bed about 75% raised, he had his breakfast in front of him on the bedside table. Resident 51 had a bowl of cereal with milk in his hand and rested on his chest. Soggy cereal was observed on his clothes. Resident 51 slowly spooned milk towards his mouth, he spilled the milk on his chest, and failed to get any cereal or milk in his mouth. His food tray was observed to have approximately 90% of scrambled eggs; 80% of cereal and half of a cup of milk in his cereal bowl, with 10% of cereal on his chest; one whole sausage patty; two glasses of milk, one cup was empty; 50% of one vanilla mighty shake; and 100% of one glass of orange juice with saran wrap on top was on the food tray. Resident was staring straight and did not react when spoken to. On 11/29/23 at 8:35 AM, an observation of resident 51 was made. A food tray was delivered to resident 51 in his bed. Staff raised the head of the bed to about 75% degrees. Staff opened the resident's mighty shake and removed the covers of the plate of food, orange juice, and milk. Resident 51's eyes were closed, and he was not eating. On 11/29/23 at 8:45 AM, an observation of resident 51 was made. Resident 51 was alone in his room with the breakfast tray sitting in front of him, untouched. Resident 51 was staring straight with his eyes half open. He did not respond when spoken to. On 11/29/23 at 8:58 AM, an observation of resident 51 was made. Resident was sitting up and awake, his food remained untouched. Certified Nurse Assistant (CNA) 1 was observed at bedside taking resident's blood pressure. The Director of Nursing (DON) entered the room and assisted CNA 1 with obtaining vital signs. On 11/29/23 at 9:06 AM, an observation was made of resident 51. Resident 51 was alone in his room and his food remained untouched. On 11/29/23 at 9:09 AM, an observation was made of CNA 1. CNA 1 was observed to go into resident 51's room and ask him if he was done eating. No response from the resident was heard and CNA 1 left the resident's room. On 11/29/23 at 9:14 AM, an observation of CNA 9 was made. CNA 9 was observed in resident 51's room assisting resident eat breakfast. CNA 9 told CNA 1 that resident 51 was not reacting or taking any food. CNA 1 asked CNA 9 if resident 51 was spitting his food out. CNA 1 told CNA 9, he'll be up and moving around later. After I am done with breakfast, I will get him up and get him ready and he will wake up more. CNA 1 was assisting other residents in the dining room. On 11/30/23 at 8:59 AM, an observation was made of resident 51. Resident 51 was in his room alone. He is sitting up in bed holding a cereal bowl, he was not moving or eating. On 11/30/23 at 9:12 AM, an observation was made of the Activities Director (AD). The AD entered resident 51's and encouraged him to eat. Resident 51 was observed to be feeding himself cereal with a plastic fork. The AD then left the resident's room. The AD returned to his room at 9:16 AM and left again. Resident was alone in his room and slowly ate his cereal with a spoon, cereal was observed to be spilled on his tray. No mighty shake was observed on his meal tray. The AD returned to the room at 9:22 AM and encouraged the resident to eat. On 11/30/23 at 9:27 AM, an observation was made of resident 51 in his room, alone eating cereal. The AD returned to the resident's room and encouraged him to eat. Resident 51's medical record was reviewed from 11/27/23 through 12/6/23. The Annual MDS Section G- Functional Status Activities of Daily Living (ADL) Assistance dated 8/26/23 indicated, Eating- how resident eats and drinks, regardless of skill. Do not include eating/drinking during medication pass. 1. Supervision. 2. One person physical assist. The Functional Abilities, Self-Care quarterly dated 11/26/23 indicated, Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident .Substantial/maximal assistance. A Nursing Skin and Nutrition Review dated 11/14/23 indicated the resident's level of assistance needed was, Supervision. It indicated the resident was to be encouraged to eat at mealtimes. The document further indicated, Significant wt (weight) change of 6.1% in a month, -9.8% in 3 months and -14.6% in 6 months. The care plan indicated, [Resident 51] has an ADL (activities of daily living) performance deficit related to dementia s/s (signs and/or symptoms), forgetfulness with a goal of, [Resident 51] will improve current level of function through the review dated was initiated on 9/1/22, revised on 11/17/22, with a target date of 9/18/23; Interventions were listed as, Eating: [Resident 51] is set up with eating. Needs reminders and cuing to start meal at times/mimics others initiated 9/1/22 and revised on 9/15/22. An interview on 11/29/23 at 12:55 PM, was conducted with CNA 1. CNA 1 stated resident 51 needed to be supervised when he ate, but the level of supervision changed throughout the day. CNA 1 stated resident 51 needed set-up and supervision, but sometimes he needed total assistance to eat. The CNA stated supervision meant staff needed to stay with the resident when they ate. On 11/30/23 at 9:53 AM, an interview was conducted with CNA 3. CNA 3 stated resident 51 did not eat unless he was prompted. An interview on 12/6/23 at 10:28 AM, was conducted with the Director of Nursing (DON). The DON stated staff had been trying to spoon feed resident 51, but he would not open his mouth. The DON stated resident 51 needed to be monitored while he ate and that when he wanted to eat, he could. The DON stated that mighty shakes were ordered and the CNA's knew which resident's received shakes and that it was also on the meal ticket. The DON stated that the CNA's should have made sure that a mighty shake was on his tray. 22992 5. Resident 30 was admitted to the facility 6/14/18 with diagnoses that included cerebral infarction, acute kidney failure, hypertension, and personal history of traumatic brain injury. On 11/27/23 resident 30 was observed throughout the day to be wearing a gray sweatshirt that was greasy and had several soiled areas. Resident 30's hair was observed to be uncombed and greasy. Resident 30 had fingernails that extended approximately one-quarter inch past his fingertips. Resident 30 also had an intense smell of body odor. Resident 30's medical record was reviewed from 11/27/23 through 12/6/23. A quarterly MDS assessment dated [DATE] indicated that resident 30 required partial/moderate assistance with showering/bathing. Resident 30's ADL care plan dated 6/14/18 indicated that resident 30 required limited assistance with showers/bathing. Resident 30's bathing records were reviewed. Per the record, resident 30 received supervision assistance with a shower on 11/11/23, 11/29/23, and 12/6/23. This was a total of 3 showers in 30 days.

Based on interview and record review, it was determined for 5 of 47 sampled residents that the facility did not ensure the comprehensive care plan included the services needed to achieve the highest practicable physical, mental and psychosocial well-being. Specifically, a resident was on a medication that required monitoring, which was not addressed in the comprehensive care plan; nutrition care plans were not developed, and vision care plans were not developed. Resident identifiers: 22, 51, 53, 170 and 268. Findings included: 1. Resident 170 was admitted to the facility on [DATE] with diagnosis which included subarachnoid hemorrhage, acute respiratory failure, encephalopathy and seizures. Resident 170's medical record was reviewed 11/27/23 through 12/6/23. An admissions Minimum Data Set (MDS) dated [DATE] documented a brief interview for mental status (BIMS). Resident 170 scored a BIMS of 3 which suggested severe cognitive impairment. A physician order dated 11/6/23, Quetiapine Fumarate oral tablet 25 MG[miligrams], give 1 tablet at bedtime for sleep. It should be noted quetiapine was an antipsychotic, the ordered use for sleep was not an approved off label use for the medication. It should also be noted resident 170 did not have a diagnosis indicated sleep problems. A care plan dated 11/17/23, documented a focus area, resident uses psychotropic medications. The goal documented The resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotention, gait disturbance, constipation/ impaction or cognitive/ behavioral impairment through review date. The care plan did not have any interventions listed, the section was left blank. 48709 2. Resident 22 was admitted to the facility on [DATE] with diagnoses which included dementia, moderate intellectual disabilities, atherosclerotic heart disease, asthma, and hypertension. Resident 22's medical record was reviewed from 11/27/23 through 12/6/23. An annual MDS dated [DATE] indicated resident 22's ability to see in adequate light with glasses or other visual appliances was impaired. It further indicated that the resident required corrective lenses. No care plan regarding vision impairment was discovered. 3. Resident 51 was admitted to the facility on [DATE] with diagnoses which included dementia, hypertension, depression, anxiety, alcohol abuse, and cognitive communication deficit. Resident 51's medical record was reviewed from 11/27/23 through 12/6/23. A Quarterly Nutrition Screen dated 8/28/23 indicated resident 51 had a 4 to 5 pound unintended weight loss over the past seven days. It further indicated a significant weight change of -7.7% over the last three months and -16.5% over the last six months. The nutrition screen also documented that resident 51's nutrition screen score was 9, which indicated that he was, at risk of malnutrition. A Quarterly Nutrition Screen dated 11/24/23 indicated resident 51 had no weight loss over the past seven days. It further indicated there was no weight change in the last week but a significant weight loss of 6.5% in a month, 9.1% over the last three months, and 16.1% over the last six months. The nutrition screen also documented that, [Resident 51] has had a significant wt [weight] change in the last 6 months, several interventions have been implemented and he is currently on Mirtazapine to increase appetite. Continue to offer foods [resident 51] prefers. RD [Registered Dietitian] will continue to monitor PO [by mouth] intake and weight and make diet recommendations PRN [as needed]. The care plan indicated that, Impaired nutrition altered nutritional status was initiated on 9/21/23. The care plan's sections of Goal and Interventions were left blank. 4. Resident 268 was admitted to the facility on [DATE] with diagnoses which included frontotemporal neurocognitive disorder, encephalopathy, dementia, memory deficit following cerebrovascular disease, anxiety, depression, hyperlipidemia, and degenerative disease of nervous system. Resident 268's medical record was reviewed from 11/27/23 through 12/6/23. An annual MDS Section V dated 11/12/23 indicated that resident 268 was administered an antipsychotic and an antidepressant medication in the last seven days. The physician orders were reviewed on 11/28/23 and revealed the following: a. Depakote Sprinkles Capsule Sprinkle 125 MG (milligrams) (Divalproex Sodium) Give 8 capsule by mouth in the morning for mood related to anxiety disorder dur to known physiological condition. b. Seroquel Oral Tablet (Quetiapine Fumarate) Give 200 mg by mouth one time a day related to dementia in other diseases classified elsewhere, severe, with other behavioral disturbance. c. Aricept Tablet 10 MG (Donepezil HCl) Give 1 tablet by mouth one time a day for dementia. d. Trazodone HCl Tablet 150 MG Give 1 tablet by mouth one time a day for antidepressants. e. Quetiapine Fumarate Tablet 200 MG Give 1 tablet by mouth at bedtime for antipsychotics. f. Paroxetine HCl Oral Tablet 20 MG (Paroxetine HCl) Give 3 tablet by mouth one time a day for depression. No care plan for dementia, depression or anxiety was located. 22992 5. Resident 53 was admitted to the facility on [DATE] with diagnoses that included crushing injury of right shoulder and upper arm, hemolytic anemia, congestive heart failure, vitamin B12 anemia, osteoporosis, epilepsy, atrial fibrillation, and prediabetes. Resident 53's medical record was reviewed from 11/27/23 through 12/6/23. On 8/8/23, resident 53 had a diet order for double portions. On 8/9/23, resident 53 weighed 218 pounds (lbs). On 8/11/23, resident 53 weighed 220 lbs. On 9/8/23, a physicians order was written for resident 53 to receive a mighty shake supplement twice daily. On 9/22/23, resident 53 weighed 179.8 lbs. On 9/28/23, facility staff completed a SNR for resident 53. The SNR indicated Significant wt change of -17.7% in a month from wt taken 9/28. BMI: 23.3. No wounds or edema noted at this time. Meal intake >75%. Continue with mirtazapine and double portions given at meal time and mightyshakes BID (twice daily). Will continue to monitor and review in a week. On 9/29/23, a physicians order indicated resident 53 was to be administered Mirtzapine 15 milligrams at bedtime for an appetite stimulant. On 10/5/23 facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 9/28/23. The facility did not have a current weight in order to help assess resident 53's nutritional status. The SNR indicated Significant wt change of -17.7% in a month from wt taken 9/28. BMI: 23.3. No wounds or edema noted at this time. Meal intake >75%. Continue with mirtazapine and double portions given at meal time and mightyshakes BID. Will continue to monitor and review in a week. On 11/2/23, a nursing progress note indicated that resident 53 had been seen by his cardiologist, and had given orders to . 3. Discuss having the pt (patient) have a protein drink to increase his weight. 4. Set a goal for the pt to gain 10-15 lbs over the next few months . 5. Pt should eat 3000 calories a day, encouraged pt to follow up with a nutritionist. On 12/3/23, resident 53 weighed 184.4 lbs. It should be noted that despite weight loss over several months, and multiple interventions, resident 53 did not have a care plan developed to address his nutritional needs. On 12/4/23 at 2:55 PM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated she did the initial care plan for newly admitted residents. LPN 4 stated the initial care plan was very basic and included activities of daily living and eating. LPN 4 stated the nurse managers did the care plans and revisions. LPN 4 stated that she did not attend care plan meetings. On 12/6/23 at 2:23 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that nursing staff complete baseline care plans for all residents through the nursing assessment. LPN 3 stated that the Unit Manager and Director of Nursing (DON) updated care plans. LPN 3 stated when an assessment was completed care plans were triggered in the electronic medical record to be created or updated. On 12/6/23 at 2:40 PM, an interview was conducted with the DON. The DON stated that baseline care plans were completed by nursing staff. The DON stated that each department completed their own comprehensive care plans. The DON stated the admitting nurse did the initial care plans. The DON stated that the MDS coordinator and nurse managers completed the compressive care plans for residents. [Cross refer to F758 and F692]

Based on interview and record review it was determined, for 3 of 47 sampled residents, that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to have evidence that all alleged violations were thoroughly investigated. Specifically, the facility did not thoroughly investigate an allegation of neglect, a resident who sustained a significant injury, and an elopement. Resident Identifiers: 9, 32 and 121. Findings included: 1. Resident 121 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses which included congestive heart failure, chronic kidney disease, monoclonal gammopathy, transient cerebral ischemic attack, pulmonary fibrosis, and respiratory disorder. A form titled exhibit 358 was submitted to the State Survey Agency (SSA) on 9/1/23 at 12:03 AM. The form revealed there was an allegation of Deprivation of Goods and Services by Staff. The form revealed what was reported On the morning of August 31sr [sic], 2023, aroujd [sic] 10:30am, I [ADM 1] rece]ived [sic] a call from [name removed]/APS [Adult Protective Services]; She informed me of an allegation her office had received regarding [resident 121],.and concerns with her 8-day respite stay from July 1st to 8th. [Name removed] provided the list of concerns regarding her care at [name of facility] during this period. Facility Administrator, following-up on requests for recorde [sic], etc. [Name removed] reported that the patient has improved, walking on own. Nurse, [initials removed]. placed on Admin. Leace [sic] pending further investigation details and findings. There was no exhibit 359 submitted to the SSA. The abuse log was reviewed. Resident 121's name was not listed on the log. On 12/5/23 at 12:21 PM, an interview was conducted with Regional Nurse Consultant (RNC) 1. RNC 1 stated that there were two facility reported abuse investigations since Administrator (ADM) 1 had started. RNC 1 stated the company was bought in March 2023 and there were no previous abuse investigations provided. RNC 1 stated there was a portal with facility reported allegations of abuse so she were trying to get access for it because it was under ADM 1's name and password. RNC 1 stated that ADM 1 was no long employed with the company. On 12/6/23 at 10:34 AM, a follow-up interview was conducted with RNC 1. RNC 1 stated there was no investigation information located. On 12/6/23 at 2:07 PM, an interview was conducted with ADM 2. ADM 2 stated when there was an allegation of abuse, staff were to make sure resident was safe, the accused staff member was suspended, reported to the SSA within 2 hours and a 5 days to report was completed. ADM 2 stated staff interviews were conducted, resident interviews were conducted, family interviews interviews were conducted for the investigation. On 12/6/23 at 2:24 PM, a follow-up interview was conducted with ADM 2. ADM 2 stated that there was no information besides a couple papers found in the previous ADM's (ADM 1) desk. ADM 2 stated there should have been an exhibit 359 completed within 5 working days. The paperwork provided by ADM 2 was reviewed. The paperwork was dated 8/31/23 and revealed a typed form of detailed complaints. The form revealed Currently, working the [sic] [ADM 2] and [RNC 1] to review further and additional plans. Now that we are aware of the incident, plan to submit the allegation as a reportable, but will confirm and ensure further reviews before proceeding. Contacting [name of hospice] for additional information and review and move forward with creating a soft file and documents for further reviews and insection [sic] by other entities or agencies. Interviewing staff, resident, and other. ***[Licensed Practical Nurse (LPN) 3] - Entered some of the orders (LPN). The form further revealed [Director of Nursing]: Review Both Orders (Hospice/Ours), Documents - [Name of hospice] medication report ., Hospice H&P [history and physical], Orders TAB: REPORTS: Administration Record. Interview all nurses. There was no investigation information provided. There was no exhibit 359 provided. On 12/6/23 at 4:50 PM, a follow-up interview was conducted with ADM 2. ADM 2 stated that resident 121's allegation of neglect should have been reported to the SSA within 2 hours of the allegation, investigated and a 5 day report completed and submitted to the SSA. 45490 2. Resident 9 was admitted to the facility on [DATE] with diagnoses which included dementia, lack of coordination, difficulty in walking. On 9/9/23 at 2:35 PM, the facility reported to the SAA with exhibit 358 initial entity report that on 9/8/23 at 12:33 PM, during the facility's outdoor lunch BBQ, [resident 9], fell and suffered a broken hip. As the residents and staff were finishing the lunch, another resident sitting next to [resident 9] softly said to her that she wanted to go inside. [resident 9], stood-up and motioned towards the other resident to provide assistance and fell to the ground on the grass outside. Staff immediately responded to the incident and provided further care and assistance. Resident 9 was sent to a local hospital and had a broken left hip. Resident 9's medical record was reviewed 11/27/23 through 12/6/23. A nursing progress note dated 9/8/23 revealed, resident 9 was out on lawn having BBQ and she got up from wheel chair and pushed it to the table and came to help another resident get on the sidewalk to come back into the building when she turned around to help this resident she fell on the grass. a nurse was asked to come out to the activity and check on patient. she was left on the ground and assessed for problems. her left hip hurt only and she was transferred by EMS [emergency medical services] to [a local] hospital. A nursing progress note dated 9/8/23 revealed that the Dr. was notified of the fall while he was rounding in the building. He ordered her to be sent to the hospital. Family also notified. A request to review exhibit 359: follow-up investigation report. The 359 follow-up was reported to the SSA on 11/29/23 at 10:38 AM. The follow-up report did not include the full investigation conducted by they facility, the report only included the summary of the investigation. On 12/6/23 at 4:33 PM, an interview was conducted with ADM 2. ADM 2 stated the allegation should have never been reported and investigated because the facility staff observed the fall. ADM 2 stated there was no need to investigate the incident as an allegation of abuse or neglect. 46232 3. Resident 32 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included vascular dementia, type 2 diabetes mellitus, hypertensive heart disease with heart failure, anxiety disorder, major depressive disorder, border line personality, disorder, mild cognitive impairment, suicide ideations, and history of falling. Resident 32's medical record was reviewed on 11/28/23. On 10/13/23, a quarterly Minimum Data Set (MDS) documented resident 32's Brief interview for Mental Status (BIMS) score of 13 which indicated resident 32 was cognitively intact. On 7/18/23, a wander risk assessment documented resident 32 was at risk for wandering/elopement with a score of 12. It documented resident 32 had a history of wandering. An elopement care plan initiated on 10/10/19 documented the following focus care area: [Resident 32] might be an elopement risk/wanderer, [resident 32] has high enough bims and phq9 [patient health questionnaire] that she may leave voluntarily and this will not be considered an elopement. She is able to leave at will. Resident 32's progress notes were reviewed, and no documentation was located about the elopement. On 9/1/23, a facility incident report nursing description documented that a CNA [certified nursing assistant] called the facility reporting they had passed a resident walking on the street about a mile away from the facility. The CNA stopped and talked to the resident. The resident description documented that resident 32 had reported they were just going on a walk to clear their head and get some fresh air. It also documented resident 32 had reported their frustration with their roommate's visitor visiting when they were in the room. The incident report documented the immediate action taken was that resident 32 was brought back to the facility after being found by staff. Resident 32 was offered a room change after they had discussed their concerns they had with their roommate and the roommates visitor. An intervention implemented on 9/1/23 documented as followed, The nurse educated receptionist that residents leaving the front door need to sign the LOA [leave of absence] book and notify the nurse. If red card, they need a responsible party to accompany them. An Interdisciplinary team was held on 9/4/23 and determined the root cause of the elopement was ineffective coping mechanisms related to frustration or inconveniences. The incident report documented staff offered resident 32 counseling, a room change and encouraged them to communicate their feelings routinely. A form title exhibit 358 dated 9/2/23 documented resident 32 had requested a room change and the facility had delayed in following through which caused resident 32 to become upset. Resident 32 indicated she left the facility and walked several blocks. A CNA saw the resident while driving and returned them back to the facility. The form documented staff had been provided further education and facility systems were assessed and were found to be working properly. [Note: No staff or resident interviews were located to indicate a thorough investigation had been conducted. No documentation was located to indicate who and what kind of education was provided and what facility systems had been assessed.] A form titled exhibit 359 dated 11/28/23 documented the facility had followed up with resident 32 and noted they had no further issues. It revealed front staff had been interviewed which determined resident 32 wanted to walk across the parking lot on 9/1/23 and staff were unaware of resident 32's potential elopement risk. The form revealed training had been done and front staff were educated on which resident were allowed to independently leave on LOA. [Note: No front staff interviews and trainings were located.] On 11/29/23 at 12:12 PM, an interview was conducted with ADM 1. ADM 1 stated for any type of allegation, they ensure the resident's safety first and foremost. Admin 1 stated a mini investigation was then conducted and the SSA would be notified within 2 hours if there was any suspicion of abuse or neglect. ADM 1 stated after a mini-investigation was done, a full investigation was conducted which included staff and resident interviews. ADM 1 stated they kept all supporting documentation with the final investigation. ADM 1 stated resident 32 had made the comment that they wanted to walk across the parking lot and staff had been concerned about them returning back to the facility on their own. ADM 1 stated resident 32 was found and safely returned to the facility which triggered an investigation to be conducted. [Note: ADM 1 was unable to provide any staff/resident interviews.]

Based on record review and interview it was determined, for 3 of 47 sampled residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency (SSA). In addition, report the results of all investigations to the SSA within 5 working days of the incident. Specifically, the facility did not report allegations of abuse within 2 hours of the incident. Resident identifiers: 9, 32 and 121. Findings included: 1. Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included vascular dementia, type 2 diabetes mellitus, hypertensive heart disease with heart failure, anxiety disorder, major depressive disorder, border line personality disorder, mild cognitive impairment, suicide ideations, and history of falling. Resident 32's medical record was reviewed on 11/28/23. On 10/13/23, a quarterly Minimum Data Set (MDS) documented resident 32's Brief interview for Mental Status (BIMS) score of 13 which indicated resident 32 was cognitively intact. On 9/2/23 at an unknown time, exhibit 38 was submitted to the SSA. It documented the elopement had occurred on 9/1/23 at 4:00 PM to which staff became aware at 5:15 PM. The exhibit 358 documented resident 32 had requested a room change and the facility had agreed to. It stated the room change was delayed and resident 32 became upset. Resident 32 indicated she left the facility and walked several blocks. A certified nursing assistant (CAN) saw the resident while driving and they returned the resident back to the facility. It documented staff were provided further education and facility systems were assessed and were found to be working properly. On 11/28/23 at 3:15 PM, exhibit 359 was submitted to the SSA. Exhibit 359 was submitted after the 5-business day deadline. [Note: The administrator (ADM) 1 submitted exhibit 359 when asked about the follow up investigation on 11/28/23.) Resident 32's progress notes were reviewed and no documentation was located about the elopement. On 11/29/23 at 12:12 PM, an interview was conducted with ADM 1. ADM 1 stated he thought he had originally submitted exhibit 359 but realized yesterday he had not. ADM 1 stated he submitted the exhibit form 359 submitted it late. 45490 2. Resident 9 was admitted to the facility on [DATE] with diagnoses which included dementia, lack of coordination, difficulty in walking. Resident 9's medical record was reviewed 11/27/23 through 12/6/23. A nursing progress note dated 9/8/23 revealed, resident 9 was out on lawn having BBQ and she got up from wheel chair and pushed it to the table and came to help another resident get on the sidewalk to come back into the building when she turned around to help this resident she fell on the grass. a nurse was asked to come out to the activity and check on patient. she was left on the ground and assessed for problems. her left hip hurt only and she was transferred by EMS [emergency medical services] to [a local] hospital. A nursing progress note dated 9/8/23 revealed that the Dr. was notified of the fall while he was rounding in the building. He ordered her to be sent to the hospital. Family also notified. On 9/9/23 at 2:35 PM, the facility exhibit 358 initial entity report documented on 9/8/23 at 12:33 PM, during the facility's outdoor lunch BBQ, [resident 9], fell and suffered a broken hip. As the residents and staff were finishing the lunch, another resident sitting next to [resident 9] softly said to her that she wanted to go inside. [resident 9], stood-up and motioned towards the other resident to provide assistance and fell to the ground on the grass outside. Staff immediately responded to the incident and provided further care and assistance. Resident 9 was sent to a local hospital and had a broken left hip. A request to review exhibit 359: follow-up investigation report. The 359 follow-up was reported to the SSA on 11/29/23 at 10:38 AM. This exceed the 5 business days to report the incident which was first reported on 9/9/23. On 12/6/23 at 4:33 PM, an interview was conducted with ADM 2. ADM 2 stated the allegation should have never been reported and investigated because the facility staff observed the fall. ADM 2 stated there was no need to investigate the incident as an allegation of abuse or neglect. 30563 3. Resident 121 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses which included congestive heart failure, chronic kidney disease, monoclonal gammopathy, transient cerebral ischemic attack, pulmonary fibrosis, and respiratory disorder. A form titled exhibit 358 was submitted to the SSA on 9/1/23 at 12:03 AM. The form revealed there was an allegation of Deprivation of Goods and Services by Staff. The form revealed what was reported On the morning of August 31sr [sic], 2023, aroujd [sic] 10:30am, I [ADM 1] rece]ived [sic] a call from [name removed]/APS [Adult Protective Services]; She informed me of an allegation her office had received regarding [resident 121],.and concerns with her 8-day respite stay from July 1st to 8th. [Name removed] provided the list of concerns regarding her care at [name of facility] during this period. Facility Administrator, following-up on requests for recorde [sic], etc. [Name removed] reported that the patient has improved, walking on own. Nurse, [initials removed]. placed on Admin. [Administrator] Leace [sic] pending further investigation details and findings. There was no exhibit 359 submitted to the SSA. The abuse log was reviewed. Resident 121's name was not listed on the log. On 12/5/23 at 12:21 PM, an interview was conducted with Regional Nurse Consultant (RNC) 1. RNC 1 stated that there were two facility reported abuse investigations since Administrator (ADM) 1 had started. RNC 1 stated the company was bought in March 2023 and there were no previous abuse investigations provided. RNC 1 stated there was a portal with facility reported allegations of abuse so she were trying to get access for it because it was under ADM 1's name and password. RNC 1 stated that ADM 1 was no longer the Administrator. On 12/6/23 at 10:34 AM, a follow-up interview was conducted with RNC 1. RNC 1 stated there was no investigation information located. On 12/6/23 at 2:07 PM, an interview was conducted with ADM 2. ADM 2 stated when there was an allegation of abuse, staff were to make sure resident was safe, the accused staff member was suspended, reported to the SSA within 2 hours and a 5 days to report was completed. ADM 2 stated staff interviews were conducted, resident interviews were conducted, family interviews interviews were conducted for the investigation. ADM 2 stated he was unable to find information that the exhibit 359 was completed and submitted to the SSA.

Based on interview and record review it was determined, for 1 of 47 sampled residents, that the did not ensure that each resident was free from abuse, neglect, misappropriate of resident property, and exploitation. Specifically, a resident was not provided medication, nutrition and fluids. Resident identifiers: 121. Findings include: 1. Resident 121 was admitted to the facility 7/1/23 and discharged on [DATE] with diagnoses which included congestive heart failure, chronic kidney disease, monoclonal gammopathy, transient cerebral ischemic attack, pulmonary fibrosis, and respiratory disorder. A form titled exhibit 358 was submitted to the State Survey Agency (SSA) on 9/1/23 at 12:03 AM. The form revealed there was an allegation of Deprivation of Goods and Services by Staff. The form revealed what was reported On the morning of August 31sr [sic], 2023, aroujd [sic] 10:30am, I [ADM 1] rece]ived [sic] a call from [name removed]/APS [Adult Protective Services]; She informed me of an allegation her office had received regarding [resident 121],.and concerns with her 8-day respite stay from July 1st to 8th. [Name removed] provided the list of concerns regarding her care at [name of facility] during this period. Facility Administrator, following-up on requests for recorde [sic], etc. [Name removed] reported that the patient has improved, walking on own. Nurse, [initials removed]. placed on Admin [Administrative]. Leace [sic] pending further investigation details and findings. There was no exhibit 359 submitted to the SSA. The abuse log was reviewed. Resident 121's name was not listed on the log. Resident 121's medical record was reviewed 12/4/23 through 12/6/23. A form titled Patient Medication Record printed 6/21/23 and signed by a hospice nurse dated 5/19/23 revealed the following medication orders: a. Bumetanide Oral 2 MG (Milligram) by mouth once daily for diuretics. b. Potassium Chloride Extended Release (ER) 20 MEQ (Milliequivalent) by mouth once daily for diuretic. c. Acetaminophen 325 MG 2 tablets as needed for pain. d. Morphine Sulfate Oral Solution 20 MG/5ML (milliliters) every 2 hours if needed for anxiety. e. Lorazepam Intensol Oral Concentrate 2 MG/ML every 2 hours if needed for anxiety. f. Ondansetron 4 MG every 4 hours if needed for nausea/vomiting. An order summary report of resident 121's medication dated 7/3/23 revealed the following orders: a. Acetaminophen Suppository 650 MG insert 1 suppository rectally every 4 hours as needed for pain. b. Biscodly Rectal Suppository insert 1 suppository rectally every 24 hours as needed for constipation c. Bumetanide Oral 1 MG give 1 tablet by mouth every 24 hours as needed for edema. d. Escitalopram 20 MG by mouth in the morning for depression. e. Haloperidol Lactase give 0.5 ml by mouth every 4 hours as needed for nausea agitation. f. Hyscyamine Sulfate give 0.125 mg by mouth every 4 hours as needed for excessive secretions. g. Lorazepam 2 MG/ML 0.5 ml by mouth every 2 hours as needed for anxiety. h. Morphine Sulfate solution 20 MG/ML. Give 0.25 ml by mouth every 1 hour as needed for shortness of breath (SOB)/pain. i. Morphine Sulfate Solution 20 MG/ML. Give 0.5 ml by mouth every 1 hours as needed for pain SOB. j. Morphine Sulfate Solution 20 MG/ML. Give 0.75 ml by mouth every 1 hours as needed for pain SOB. k. Morphine Sulfate Solution 20 MG/ML. Give 1 ml by mouth every 1 hours as needed for pain/SOB. l. Ondansetron tablet disintegrating. Give 4 mg by mouth every 4 hours as needed for nausea. m. Potassium Chloride ER table 10 MEQ. Give 10 MEQ by mouth every 12 hours as needed for supplement. n. Senna Plus oral tablet 8.6-50 MG. Give 1 tablet by mouth every 24 hours as needed for constipation. o. Senna Plus oral tablet 8.6-50 MG. Give 2 tablets by mouth every 24 hours as needed for constipation. p. Senna Plus oral 8.6-50 MG. Give 3 tablets by mouth every 24 hours as needed for constipation. q. Senna Plus oral 8.6- 50 MG. Give 4 tablets by mouth every 24 hours as needed for constipation. A physician's visit dated 7/4/23 revealed the following medications: a. Escitalopram 10 mg every day b. Escitalopram 20 mg every day b. Furosemide 20 mg once daily. Can increase to 2 tablets daily if needed. Use as needed for swelling. c. Metolazone 5 mg. One tablet by mouth every other day. d. Omeprazole 20 mg. Table 1 capsule once daily. e. Potassium Chloride ER 10 MEQ. One capsule orally three times a day by oral route once daily with food. f. Synthroid 88mcg every day. Take 1 tablet by oral route once daily. A form titled Client Medication Report dated 7/6/23 revealed the following medication orders: a. Acetaminophen 325 MG. Take two tablets by mouth every 6 hours as needed for pain. b. Acetaminophen 650 MG rectal suppository. Place 1 suppository rectally every 4 hours as needed for pain and fever. c. Bisacodyl 10 MG rectal suppository. Administer one suppository rectally daily as needed for constipation. d. Bumetanide 2 MG. Take one tablet by mouth daily for diuretic. e. Escutakioran 20 MG. Take one tablet by mouth daily for depression. f. Hyoscyamine 0.125 MG sublingually tablet take 1 tablet by mouth every 6 hours as needed for secretions. g. Lorazepam 2 MG/ML oral concentrate. Give 0.5 ML by mouth or sublingually every 2 hours as needed for anxiety or agitation. j. Morphine Concentrate 100 MG/5ML oral solution. Take 0.25 ML by mouth or sublingually every hour as needed for pain and dyspnea. k. Ondansetron 4 MG Disintegrating tablet . One tablet on tongue or in mouth every 4 hours as needed for nausea or vomiting. l. Potassium Chloride ER 20 MEQ. Take one tablet by mouth daily for supplement. m. Senna 8.6 mG-50 MG tablet. 1-4 tablets by mouth daily as needed for constipation. Resident 121's July 2023 Medication Administration Record (MAR) revealed resident 121 was Administered the following medications: a. Escitalopram Oxalate Oral tablet 20 MG daily for depression. Administered 7/1/23 through 7/8/23. b. Acetaminophen Suppository 650 MG. Administered 7/6/23 with a pain score of 3. Resident 121 had as needed (prn) orders according to the July 2023 MAR for the following medications: a. Bumetanide Oral tablet 1 MG. Give 1 tablet by mouth every 24 hours as needed for edema. b. Potassium Chloride ER tablet 10 MEQ. Give 10 MEQ by mouth every 12 hours as needed for supplement. c. Lorazepam oral concentrate 2MG/ML. Give 1 ml by mouth every 2 hours as needed for anxiety. A Nursing Admission/Readmission Medication Regimen Review dated 7/1/23 revealed No, medication inconsistencies have not been identified. On 12/6/23 at 11:36 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated medication scripts were faxed to pharmacy when a resident was admitted . LPN 3 stated medications were doubled checked by nursing staff. LPN 3 stated the double check process was a nursing staff entered medication into the medical record. LPN 3 stated then the medications were checked by a nurse manager. LPN 3 stated that a resident admitted with hospice services, the medication orders came from the hospice company. LPN 3 stated the double check process was the same for hospice residents as other admissions. On 12/6/23 at 11:40 AM, an interview was conducted with LPN 2. LPN 2 stated that the admission process for orders was recently changed. LPN 2 stated that the Assistant Director of Nursing (ADON), Unit Manager (UM), or Director of Nursing (DON) entered the medications into the electronic medical record, the floor nurse checked the medications entered into the medical record, then the nurse managers rechecked the medication orders. LPN 2 stated the admission orders were scanned into the medical record after they were inputted into the medical record. On 12/6/23 at 11:43 AM, an interview was conducted with the Director of Nursing (DON). The DON stated there was a nursing evaluation to double check admission orders. The DON stated usually the UM put the orders in the medical record from the hospital. The DON stated the nurse reviewed the order and if the orders were accurate, then the medication orders were activated. The DON stated that the orders were faxed to the pharmacy. The DON stated that the pharmacy completed a review when the orders were sent to the pharmacy. The DON stated if there were concerns with the medication orders, the pharmacy called the facility staff. The DON stated admission paper work was sent to the Central Admission office to review and upload into the the electronic medical record. The DON stated if a resident was admitted from home, medication orders were brought with the resident when the resident was admitted . The DON stated physician orders used for resident 121 upon admission were the from the form titled Patient Medication Record that was printed 6/21/23 and signed by a hospice nurse on 5/19/23. The DON stated the medications from that form and the medications in the MAR were different. The DON stated there was no Depakote ordered, the potassium was as needed, and the Furosemide was as needed. The DON stated no Depakote could cause increase in behaviors because it was an anti-depressant. The DON stated not receiving the Furosemide would cause increase in weight gain and concerns with the heart. The DON stated that the potassium was administered with the Furosemide so there was not as much of a concern that it was not administered during admission. On 12/6/23 at 2:27 PM, an interview was conducted with Regional Nurse Consultant (RNC) 1. RNC 1 stated that upon admission resident 121's medications were entered as needed and not scheduled. RNC 1 stated that medications should have been administered daily. 2. Resident 121 was admitted to the facility 7/1/23 and discharged on [DATE] with diagnoses which included congestive heart failure, chronic kidney disease, monoclonal gammopathy, transient cerebral ischemic attack, pulmonary fibrosis, and respiratory disorder. Resident 121's medical record was reviewed 12/4/23 through 12/6/23. A physician's order dated 6/30/23 and discontinued 7/9/23 revealed Encourage fluids to ensure adequate hydration and minimize uti [Urinary Tract Infection] risk. Offer 120 mls [milliliters] at least qid [four times a day] for hydrational support four times a day for offers fluids for hydrational support. A physician's order dated 6/30/23 and discontinued 7/9/23 revealed Mightyshakes every 24 hours as needed for [sic] offer mighty shakes for nutritional support. Resident 121's July Medication Administration Record (MAR) revealed that resident was administered fluids four times a day of 120 mls. The MAR further revealed mighty shakes were not administered from 7/1/23 through 7/9/23. An assessment titled Nutrition Screen dated 7/4/23 revealed no estimated fluid needs were calculated. Additional notes revealed [Resident 121] appears to be meeting nutritional needs at this time with intake of [greater than] 75% at meals and mighty shakes given daily. Fluids offered meets estimated needs. A nursing progress note dated 7/4/23 at 1:01 AM, the nutrition section was blank. A nursing progress note dated 7/7/23 revealed Called [name and phone number removed] with urine sample for [name of lab removed] to process. Hospice Company. It should be noted there was no follow-up information or laboratory values located in resident 121's medical record. On 12/6/23 at 2:30 PM, an interview was conducted with the DON. The DON stated she was not sure how fluid needs were calculated and stated she did not know if that was enough fluid to maintain resident 121's hydration status.

Based on observation, interview and record review, the facility did not ensure that food was prepared in a form designed to meet individual needs. Specifically, pureed foods were not prepared appropriately. Resident identifier: 36. Findings include: 1. On 11/27/23 at 10:41 AM, an interview was conducted with resident 36. Resident 36 stated he was on a pureed diet and the food taste did not taste good. 2. On 11/29/23 at 12:35 PM, a sample tray was requested from the facility. The tray was placed in the last cart to be passed to residents. After all residents had been served from the cart, as of 12:51 PM, the sample tray was observed and temperatures were taken. The pureed meal served was ground beef, refried beans, zucchini, and a pumpkin dessert. All of the items were brown. The pureed meat was 110 degrees Fahrenheit (F), and had a watery taste. The meat did not have any flavor and was bland. The zucchini was 96 degrees F, and had watery consistency instead of the appropriate pureed consistency. The pureed zucchini had run into the beans and meat on the plate. The pureed refried beans had a watery texture to them. The refried beans also tasted like cigarette smoke. The pureed dessert had a watery consistency. On 11/29/23 at 2:20 PM, an interview was conducted with the Dietary Manager (DM). When asked how he prepared the pureed foods, the DM stated that he used milk to puree the breads, gravy to puree the meats, and water for everything else. The DM stated he was not sure how the pureed foods had been prepared that day. The DM was shown the sample tray and confirmed that the consistencies were watery, and not consistent with what a puree diet should be. On 11/30/23 at 12:45 PM, the DM stated that the cook who was preparing the foods on 11/29/23, including the sample tray, thinned all of the foods with water. On 11/29/23 at 3:30 PM, an interview was conducted with the facility Registered Dietitian (RD). When asked about the pureed diet menu, the RD stated that there was not a specific menu for the dietary staff to follow to puree the diets. When the RD was asked about the menu system and if she could locate the pureed recipes provided by the company who wrote the menus, the RD stated she was unaware that there were specific recipes for residents receiving pureed diets. On 11/30/23 at 12:45 PM, the RD and DM were interviewed. The RD and DM stated that they had looked into their menu system, and were able to locate the specific recipes for items residents should be receiving if they were prescribed a pureed diet. The RD and DM confirmed that they were previously unaware that specific recipes were used to puree residents' foods, and therefore had not been serving the correct foods. On 11/29/23 at 2:13 PM, an interview was conducted with Administrator (ADM) 1. ADM 1 was shown the sample tray, and stated please cover that up. It's disgusting and unacceptable. 30563 .

Based on observation and interview, it was determined that the facility did not provide a safe, clean, comfortable, and homelike environment. Specifically, the facility environment was in disrepair which included resident safety hazards, there was lack of hot water, low water pressure in a sink and another sink did not have hot water. Resident identifiers: 36, 39, 40 and 64. Findings included: 1. On 11/30/23 at 1:44 PM, a tour of the facility was conducted. The following observations were made: a. A handrail was loose near the maintenance door and the double doors had a broken metal beam along the bottom of the door that projected out towards the hallway. b. The central bath shower room had: 3 missing cabinet handles, a counter with the first layer chipped off, the first layer of the drywall peeled off near the sink and light switch, chipped paint on four corners of the wall, eight holes in the wall near the toilet, and caulking that had pulled away from the wall with missing pieces around a sink. c. Plastic was peeling off the wall near the entrance of the central bath and the floorboards. d. A counter was broken off and had sharp edges exposed in the dining area near the microwave. e. Wires were exposed under a handrail near room [ROOM NUMBER]. f. room [ROOM NUMBER] had paint stripped off the wall near bed 105 A, blinds were broken and had missing slats, and it took three to four attempts of pulling the handle to flush the toilet. g. room [ROOM NUMBER] had broken blinds with missing slats and the overhead lights were dusty and contained dead bugs. h. room [ROOM NUMBER] B had paint peeling above the head of the bed. i. A metal piece was bent and protruding out, along the bottom of the door, and the plastic corner cover on the wall was peeling off near the exit doors and room [ROOM NUMBER]. j. room [ROOM NUMBER] had an area of paint, approximately 4 feet by 4 feet, that had peeled off the wall with chipped wood at the bottom. The bathroom had an exposed hole around a pipe behind the toilet and the baseboards had peeled away from the wall. k. The bathroom in room [ROOM NUMBER] had two sets of toilet paper holders, each set was missing the sister part which created a projection from the wall. Additionally, room [ROOM NUMBER] had a closet that was off its track and had soiled, dusty ceiling vents. l. In room [ROOM NUMBER], there was a floor vent that had missing metal pieces which created sharp edges at the foot of bed, a second floor vent was surrounded by cracked linoleum, and the sink near the entrance of the room had caulking that had pulled away from the wall. m. Paint was peeled off of the wall in the hallway near room [ROOM NUMBER]. n. In room [ROOM NUMBER] A, behind the head of the bed, the wall had scratches and an area of peeled paint. o. A wire shelf located at the head of the bed in room [ROOM NUMBER]B was loose. p. A handrail was loose in the hallway outside of room [ROOM NUMBER]. q. room [ROOM NUMBER] had a large crack, approximately 3 feet in length, under the window seal. r. A handrail was loose in the hallway outside of room [ROOM NUMBER]. s. A handrail was loose in the hallway that was two doors down from the entrance of the main activity room. On 12/5/23 at 11:09 AM, an interview was conducted with the Regional Plant Operational 1, he stated that he had probably not seen anything that needed repair because the facility's maintenance staff was no longer employed at the facility as of 11/30/23. On 12/5/23 at 11:09 AM, a facility walk through was completed with the Regional Plant Operational 1 and 2. All observed areas of disrepair listed were identified with Regional Plans Operational 1 and 2. No documentation was provided that indicated the facility had previously made an attempt to address the identified concerns. 2. On 12/4/23 at 11:15 AM, an observation was made in room [ROOM NUMBER]'s sink. The hot water was turned on and no water came out of the faucet. On 12/4/23 at 11:25 AM, an observation was made in the room [ROOM NUMBER]'s bathroom sink. The water was observed to trickle out. There was very little water pressures. On 12/04/23 at 2:32 PM, an interview was conducted with Regional Plant Operations 2. Regional Plant Operations 2 stated he was not aware that a resident did not have hot water and another faucet did not have water pressures. 3. On 12/4/23 at 11:01 AM, an observation was made of room [ROOM NUMBER]. The floor in front of the sink was sticky. 30563 45490 4. On 11/27/23 at 10:37 AM, an observation was made of the wall behind resident 36's headboard. The wall was scratched up and had paint peeling off of it. 5. On 11/27/23 at 2:56 PM, an interview was conducted with resident 64. Resident 64 stated that the cleaning on the weekends was not done, the weekend housekeeper sometimes did not clean the floors. 6. On 12/4/23 from 11:39 AM to 12:05 PM, a continuous observation was made of resident 40's room. Resident 40's room had a large amount bowel movement on the floor. Resident 40 was sitting in his bed in a just a brief, when questioned if someone was going to clean it up, he stated yes. When resident 40's was asked if he was ok resident 40 did not respond. An interview was conducted with Environmental Services (EVS) 1. EVS 1 stated that she had seen the bowel movement on resident 40's floor and had informed the Certified Nursing Assistant (CNA) in that hall at approximately 11:00 AM. EVS 1 stated that the CNA's were the ones who cleaned bowel movements so that CNA's were able to document them in the residents chart. On 12/4/23 at 12:05 PM, an observation of a CNA 8 entering resident 40's room was made. CNA 8 cleaned up the feces on resident 40's floor. CNA 8 stated that she was told that resident 40 had a bowel movement on the floor. CNA 8 stated that resident 40 was incontinent and removed his brief and had a bowel movement on the floor. CNA 8 stated that staff observed for any feces on the floor when they do their rounding. 22992 7. On 11/28/23 at approximately 10:00 AM, an interview was conducted with resident 39. Resident 39 stated that housekeeping staff did not clean her room adequately. Resident 39 stated that her floor was often dirty, specifically under her bed. Resident 39 stated that housekeeping staff did not move her bed to mop, and would just mop the middle of the room. Resident 39 stated that she could often see grime and debris where the floor met the wall next to her bed. Resident 39's bed was observed to have a metal frame, and was raised several feet off of the floor. An observation was made of resident 39's floor under her bed. There were pieces of cardboard, several dust bunnies, and a used wipe under resident 39's bed. The floor was observed to have a black grime around the corners and edges of the wall under the bed. There was a metal frame for a trapeze device that was behind resident 39's bed. Resident 39 stated that she did not use that equipment, nor had she ever used it. Additional observations were made of resident 39's room. There were several areas of missing paint and nicks in the walls at the head of resident 39's bed. There were several nails and screws in resident 39's walls. The metal air vents were observed to be broken and missing metal pieces, with missing linoleum around it. The bathroom was soiled with broken grab bars in the wall.

Based on interview and record review, it was determined, the facility did not inform each resident periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate. Specifically, for 3 out of 3 sampled residents, a resident was not issued a Notice of Medicare Non-coverage (NOMNC) when the Medicare part A services were terminated. Resident identifiers: 38, 62, and 124. Findings include: On 11/28/23, the facility provided a list of residents who were discharged from a Medicare covered Part A stay with benefit days remaining in the last 6 months. Resident 38 was as listed as having been discharged on [DATE]. Resident 62 was listed as having been discharged on [DATE]. Resident 124 was listed as having been discharged on [DATE]. On 12/4/23, the medical records for residents 38, 62, and 124 were reviewed. No NOMNC was located in any of the residents' medical records. On 12/5/23 at 1:05 PM, an interview was conducted with Regional Nurse Consultant (RNC) 1. RNC 1 stated that the NOMNCs were supposed to be completed by the facility Social Worker, but that they had not been completed for any of the three residents listed above.

Based on observation, interview and record review, it was determined that the facility failed to provide sufficient staffing to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, it was determined that the facility did not provide sufficient nursing staff to meet the resident's needs in the areas of answering resident call lights in a timely manner; obtaining resident weights; or assisting the residents with their bathing. Resident Identifiers: 9, 30, 39, 53, 63, and 64. Findings include: RESIDENT INTERVIEWS 1. On 11/27/23 at 11:33 AM, an interview was conducted with resident 9. Resident 9 stated that the CNA's get upset with her when she gets up on her own and they tell her to use her call light so she wont fall. Resident 9 stated that when she presses her call light it takes a long time for staff to answer it. Resident 9 stated that she will press the call light if she needs to go to the bathroom or wants to take a shower. Resident 9 stated that she was not sure if she had gotten out of bed and fallen after pressing the call light, she stated that it is possible that could have happened. 2. On 11/27/23 at 2:44 PM, an interview was conducted with resident 64. Resident 64 stated that her call lights were rarely answered timely. Resident 64 stated that when she has pressed her call light in her room it can take up to an hour for staff to come and check on her. She stated that she stopped using her call light and will try to go out into the hall to find a staff member. 3. On 11/28/23 at approximately 10:00 AM, an interview was conducted with resident 39. Resident 39 stated that the facility was cutting down on help . its not enough help and that she often waited 30 minutes for her call light to be answered. Resident 39 stated I can't get out of bed, so when I need to go to the bathroom, I have to go to the bathroom .I can't wait and I can't get up. there's been times I've peed myself waiting. Resident 39 stated that when staff did assist her, it was rushed and not being done appropriately. Resident 39 stated that her physician had recently found a fingerful of brown stuff up in my clit and that her physician had told her that's why she had been diagnosed recently with a urinary tract infection. 4. On 11/28/23 at 11:55 AM, an interview was conducted with resident 63. Resident 63 stated that she has stopped using her call light because staff took 30 minutes or longer to respond to the call light. STAFF INTERVIEWS 5. On 11/28/23 at 2:42 PM, an interview was conducted with CNA 10. CNA 10 stated that he was an agency CNA that had been working at the facility consistently for several months. CNA 10 stated that there may have been enough staff at the facility, but that it was a quantity vs quality issue. CNA 10 stated that facility staff members forget they are CNAs and are on their cell phones all day. CNA 10 stated that multiple staff members that worked the evening and night shift would load up the bed with chux and pad the beds? so they would not have to change the residents as often during the night. CNA 10 stated that multiple residents had complained about it. When asked about showers, CNA 10 also stated that once a resident is over 250 pounds, no one wants to touch them (bathe them), so its the bariatric patients that are left and not receiving showers. CNA 10 stated there's a lack of understanding on how to use the equipment and teamwork. There's a vibe of survival of the fittest here. CNA 10 stated that CNAs were documenting that residents were refusing showers, but often the truth was that a CNA would enter a resident's room and say something like, We have to use a hoyer and then its cold, and do you really want to do that right now. CNA 10 also stated that multiple residents would refuse showers when certain staff members were working. When asked about fingernail care, CNA 10 stated that he typically did not cut resident fingernails because it was the nurses' job, but I've cut nails here due to the level of disgustingness. When asked about trainings provided to CNAs, CNA 10 stated that there's no communication between the facility staff and agency. CNA 10 stated that if a training was conducted at the facility, the information was not passed on to other staff except you are required to read it, sign it and date it. When asked about how information was passed on regarding the amount of assistance a resident required or any special items of note for a resident, CNA 10 stated that the charting system was different from the white board which was different from what information was received in report, which was different from the binder at the nurses station, so it was unclear who required more assistance, which put the residents at risk. 30563 6. On 12/6/23 at 4:29 PM, an interview was conducted with CNA 6. CNA 6 stated she worked for a staffing agency company. CNA 6 stated she worked 2 days per week at the facility. CNA 6 stated she worked all over the facility and was familiar with all the residents. CNA 6 stated about forty percent of the staff were with agency. CNA 6 stated she worked one time by herself on the South hallway where there were 35 residents. CNA 6 stated the residents that reside on the South hallway required 1 to 2 assistance with activities of daily living. CNA 6 stated the South hallway needed 3 CNAs to meet the needs of the residents. CNA 6 stated the North hallway needed 2 CNA's. CNA 6 stated she was Normally able to get showers done on the north hallway. CNA 6 stated it was hard to complete showers on the Rehab hallway if there was no shower aide. CNA 6 stated if there was no shower aide on rehab then it was impossible to get the showers done. CNA 6 stated during the night shift, the rehab nurse had a lot of residents. CNA 6 stated at night the rehab nurse cared for the residents in the rehab hallway and north hallway which was the secured unit. 7. On 12/6/23 at 4:30 PM, an interview was conducted with LPN 6. LPN 6 stated she worked for a staffing agency. LPN 6 stated there was usually 1 nurse and 2 CNAs for north hallway. LPN 6 stated when she was worked the south hallway there were 3 CNA's for that hall. LPN 6 stated the north hallway required more hands-on nursing because it was the secured unit. LPN 6 stated it was harder to get all tasks completed when on the north hallway. 22992 ACTIVITIES OF DAILY LIVING (ADLs) 8. Resident 30 was admitted to the facility 6/14/18 with diagnoses that included cerebral infarction, acute kidney failure, hypertension, and personal history of traumatic brain injury. On 11/27/23 resident 30 was observed throughout the day to be wearing a gray sweatshirt that was greasy and had several soiled areas. Resident 30's hair was observed to be uncombed and greasy. Resident 30 had fingernails that extended approximately one-quarter inch past his fingertips. Resident 30 also had an intense smell of body odor. Resident 30's medical record was reviewed from 11/27/23 through 12/6/23. A quarterly MDS assessment dated [DATE] indicated that resident 30 required partial/moderate assistance with showering/bathing. Resident 30's ADL care plan dated 6/14/18 indicated that resident 30 required limited assistance with showers/bathing. Resident 30's bathing records were reviewed. Per the record, resident 30 received supervision assistance with a shower on 11/11/23, 11/29/23, and 12/6/23. This was a total of 3 showers in 30 days. WEIGHTS 9. Resident 53 was admitted to the facility on [DATE] with diagnoses that included crushing injury of right shoulder and upper arm, hemolytic anemia, congestive heart failure, vitamin B12 anemia, osteoporosis, epilepsy, atrial fibrillation, and prediabetes. Resident 53's medical record was reviewed from 11/27/23 through 12/6/23. On 8/31/23, facility staff completed a Skin and Nutrition Review (SNR) for resident 53. The most recent weight used for the SNR was from 8/11/23. The facility did not have a current weight in order to help assess resident 53's nutritional status. On 9/7/23, facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 8/11/23. The facility did not use the current weight taken on 9/7/23 listed in the Electronic Health Record (EHR) of 181.8 lbs. On 9/13/23 facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 9/7/13. The facility did not have a current weight in order to help assess resident 53's nutritional status. On 9/21/23 facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 9/7/13. The facility did not have a current weight in order to help assess resident 53's nutritional status. On 10/5/23 facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 9/28/23. The facility did not have a current weight in order to help assess resident 53's nutritional status. On 10/12/23 facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 9/28/23. The facility did not have a current weight in order to help assess resident 53's nutritional status. On 10/19/23 facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 9/28/23. The facility did not have a current weight in order to help assess resident 53's nutritional status. On 10/26/23 facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 9/28/23. The facility did not have a current weight in order to help assess resident 53's nutritional status. On 11/2/23 facility staff completed a SNR for resident 53. The most recent weight used for the SNR was from 9/28/23. The facility did not have a current weight in order to help assess resident 53's nutritional status. On 11/29/23 at 3:30 PM, an interview was conducted with the facility RD. When asked why current weights were not being used for the SNR meetings, the RD stated we've been struggling to keep up to date on the weights. There's not enough staff to have CNAs (Certified Nursing Assistants) get weights. I've talked to them multiple times about it. 10. An interview on 12/6/23 at 4:16 PM, was conducted with the Director of Nursing (DON). The DON stated the corporate staffing division decided the PPD (allotted nursing hours per day per resident). The DON stated that she could voice her concerns or requests, but it was corporate who decided the staffing. The DON stated the PDPM (Patient Driven Payment Model) was used to help identify acuity. The DON stated that ultimately, corporate was the one who looked at all of that by pulled reports from MDS (Minimum Data Set). The DON stated staffing depended on the day and the skills of the staff members, how many admits there were, falls, it depended on what is going on in the facility. The DON stated the management could help staff when needed. The staff who are licensed if it is resident care. The DON stated that her involvement with the facility assessment was, not a whole lot and that the facility assessment could be pulled from PCC (PointClickCare). On 12/6/23 at 4:33 PM, an interview was conducted with Regional Nurse Consultant (RNC) 1 and Administrator (ADM) 2. ADM 2 stated staffing needs were based on PPD and the clientele. ADM 2 stated there was usually one CNA for 10 or 12 residents in the north hallway (secured unit) and a one CNA to 15 ratio for the rehab hallway and the south hallway. RNC 1 stated every building considered acuity when staffing numbers were determined. RNC 1 stated staffing was done by a staff member at the corporate level. RNC 1 stated the ADM and DON worked together to communicate to the centralized staffing what their staffing needs were. RNC 1 stated staff scheduling was done at the corporate level so that the DON did not have to deal with staff calling in. ADM 2 stated the Facility Assessment was developed and reviewed every 6 months by the ADM, DON, and Medical Director. ADM 2 stated he was new and that he had not looked at the facility assessment. RNC 1 stated there was a nurse for each hallway and the south hallway had an additional medication pass nurse. A telephone interview on 12/6/23 at 4:02 PM, was conducted with the Corporate Staffer (CS). The CS stated that she did the nurse and CNA staffing for the facility. The CS stated, I just look at the census every morning to determine staffing. The CS stated she would look at the census every morning and then did the math every single day. The CS stated that she figured out the census by taking the total number of hours needed and then divided that by 24 which equaled x, then the census would be divided by x to get your PPD for the day which told you how many CNAs and nurses were needed. The CS stated she would talk with the DON or the Assistant Director of Nursing (ADON) when more CNAs were needed and then she would do the math. The CS stated she did not have anything to do with managing acuity and that she was, literally, only over the numbers. The CS stated the PPD came from the budget which was determined by corporate. The CS stated that depending on census and what was needed for that day, there was one nurse per hall during the day. There are two nurses and a medication pass nurse, who would go home when their shift was done, which left two nurses for the whole building at night. The CS stated the facility had one nurse for the rehabilitation unit and the north unit and one nurse for the south unit and the new unit. [Cross refer to F676, F677, F692, F838] 45490

Based on interview it was determined that the facility did not employ a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of food and nutrition services. Specifically, the facility did not a employ a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of food and nutrition services. Findings include: On 11/29/23 at 11:50 AM, an interview was conducted with the facility DM. The DM stated that he started his Certified Dietary Manager (CDM) course a month ago, after he was promoted to the DM position. The DM stated that he was employed as a cook prior to the promotion. The DM stated that there was a corporate CDM and Registered Dietitian (RD) that were in the facility, but that they were onsite only once a week. 30563

Based on observation, interview and record review it was determined, for 9 of 47 sampled residents, that the facility did not provide food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents complained of food quality, a test tray was bland and resident council minutes revealed complaints of food quality. Resident identifiers: 9, 10, 15, 17, 18, 32, 36, 39 and 64. Findings include: Interviews: 1. On 11/28/23 at 9:42 AM, an interview was conducted with resident 39. Resident 39 stated she lost 40 pounds because she cant eat this food. Resident 39 stated the food did not look good. Resident 39 stated the food was cold, there was no flavor and the food was the same thing everyday. Resident 39 stated she was served rotten lettuce and pears. Resident 39 stated she asked staff how do you expect us to eat this?. 2. On 11/27/23 at 11:18 AM, an interview was conducted with resident 18. Resident 18 stated she did not get any snacks of any kind and was not offered snacks after dinner. 3. On 11/28/23 at 9:28 AM, an interview was conducted with resident 17. Resident 17 stated the the food tasted bland and he used salt to even bare to eat the food. 4. On 11/27/23 at 2:42 PM, an interview was conducted with resident 64. Resident 64 stated that trays sat for 30 to 45 minutes before they were passed to residents. Resident 64 stated the food was cold, tasted bland and salt barely helped with the flavor. 5. On 11/27/23 at 10:41 AM, an interview was conducted with resident 36. Resident 36 stated he was on a pureed diet and the food taste did not taste good. 6. On 11/27/23 at 11:38 AM, an interview was conducted with resident 9. Resident 9 stated her food had to be chopped up. Resident 9 stated she wanted gravy on things to help her with swallowing. Resident 9 stated she needed her food moist because of her swallowing problems. Resident 9 stated she would like to have sauces with meals. Resident 9's ticket was observed to have extra gravy on it. 7. On 11/27/23 at 2:23 PM, an interview was conducted with resident 32. Resident 32 stated sometimes menus were not posted and she did not eat the food if she did not know what was being served. Resident 32 stated the food was cold and the meat was tough. Resident 32 stated sometimes there was not enough food. 8. On 11/28/23 at 9:54 AM, an interview was conducted with resident 15. Resident 15 stated the food was bland. 9. On 11/28/23 at 10:32 AM, an interview was conducted with resident 10. Resident 10 stated that the food served at the facility was lousy and said that they need new cooks and better food. Resident 10 stated he did not receive snacks at night. He stated he wants more fried eggs, the mashed potatoes taste like crap and the food is cold. 10. On 11/29/23, the kitchen trayline process was observed. At 11:55 AM, upon entry to the kitchen, there were approximately 40 glasses of milk sitting on a cart with no ice or way to keep them cold. The milks were added to the residents' trays during trayline. The last tray was served at 12:34 PM. 11. On 11/29/23, the kitchen trayline process was observed. The third cart was observed to be filled at 12:20 PM, and was pushed into the hallway for staff to distribute. At 12:34 PM, the fourth cart was observed to be filled and pushed into the hallway for staff to distribute. The third cart was observed to still be in the hallway waiting for staff to distribute the meals. A kitchen staff member stated, They haven't even come and got that last cart yet! [Note: The meals in the third cart had been sitting in the hallway for 14 minutes at that time.] 12. On 11/29/23 at 12:35 PM, a sample tray was requested from the facility. The tray was placed in the last cart to be passed to residents. After all residents had been served from the cart, as of 12:51 PM, the sample tray was observed and temperatures were taken. The regular meal served included ground beef inside a soft tortilla, refried beans, and a glass of milk. The meat was burned and crispy. There was no flavor to the beef. The temperature of the milk was 52.5 degrees Fahrenheit (F). The temperature of the regular refried beans was 105 degrees F. The pureed meal served was ground beef, refried beans, zucchini, and a pumpkin dessert. All of the items were brown. The pureed meat was 110 degrees F, and had a watery taste. The meat did not have any flavor and was bland. The zucchini was 96 degrees F, and had watery consistency instead of the appropriate pureed consistency. The pureed zucchini had run into the beans and meat on the plate. The pureed refried beans had a watery texture to them. The refried beans also tasted like cigarette smoke. The pureed dessert had a watery consistency. On 11/29/23 at 2:20 PM, an interview was conducted with the Dietary Manager (DM). When asked how he prepared the pureed foods, the DM stated that he used milk to puree the breads, gravy to puree the meats, and water for everything else. The DM stated he was not sure how the pureed foods had been prepared that day. The DM was shown the sample tray and confirmed that the consistencies were watery, and not consistent with what a puree diet should be. On 11/30/23 at 12:45 PM, the DM stated that the cook who was preparing the foods on 11/29/23, including the sample tray, thinned all of the foods with water. On 11/29/23 at 2:13 PM, an interview was conducted with Administrator (ADM) 1. ADM 1 was shown the sample tray, and stated please cover that up. It's disgusting and unacceptable. ADM 1 stated that a food committee had recently started at the facility that month due to complaints about food quality.

Based on observation, interview, and record review, it was determined the facility did not ensure a resident who was unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, for 1 out of 32 sampled residents, a resident was not provided with the necessary services related to incontinence care, which resulted in the resident acquiring Moisture Associated Skin Damage (MASD). Resident identifier: 167. Findings included: Resident 167 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/22/22 at 12:43 PM, resident 167's family member was interviewed. Resident 167's family member stated they would come to visit resident 167 everyday for about three hours near lunch time. Resident 167's family member stated they were concerned about the amount of care resident 167 had received, and stated resident 167 had been in the same clothes as yesterday. The family member was nervous staff were not providing resident 167 with assistance at meals or with drinking fluids regularly, and resident 167's family member stated this was why they would come visit at lunch time. Resident 167's family member stated they had not seen staff enter resident 167's room every two hours to reposition him or provide incontinence care. Resident 167's family member stated if resident 167 needed to be provided cares they would have to ask staff to come assist resident 167. When asked about resident 167's care, the family member responded, it depends on who is here if they will take care of him. On 2/22/22 at 2:29 PM, resident 167 was observed to work with a Physical Therapist (PT) and Occupational Therapist (OT) who assisted resident 167 to the bathroom. At 2:37 PM, the PT and OT staff assisted resident 167 into his bed. Resident 167 was not on an air mattress at this time, and resident 167 was positioned flat on his back with the head of his bed slightly elevated. Resident 167's family member was observed to exit the facility. At this time a continuous observation began regarding resident 167's assistance from staff. On 2/22/22 at 4:04 PM, Certified Nursing Assistant (CNA) 1 entered resident 167's room. Resident 167 stated they would like to go to the bathroom, and CNA 1 stated to resident 167 that he had already been up for the day, and resident 167 was in a brief, so he could just go in that. CNA 1 did not reposition resident 167 or look to see if resident 167 may have needed a brief change at that time. On 2/22/22 at 5:01 PM, the continuous observation of resident 167's care was completed. [Note: Resident 167 was not provided with incontinence care, offered fluids, or repositioned for at least 2 hours and 24 minutes. The most recent care provided to resident 167 was from the PT and OT during this observational period.] On 2/28/22, a review of resident 167's medical record was completed. Resident 167 had a Care Plan with a Focus, initiated on 2/4/22, which read, The resident has potential for impairment to skin integrity r/t (related to). [Note: This Care Plan Focus did not include a related to statement.] There were no interventions put into place regarding this Care Plan Focus. Resident 167 had a Care Plan with a Focus, initiated on 2/22/22, which read, The resident has a Urinary Tract Infection results for c & s (culture and sensitivity) pending. Some interventions related to this Care Plan Focus read, Check at least every 2 hours for incontinence. Wash, rinse and dry soiled areas .Encourage adequate fluid intake .Give antibiotic therapy as ordered . Resident/family/caregiver teaching should include: Good hygiene practices: Females to wipe and cleanse from front to back, Clean peri area well after BM (bowel movement) in order to help prevent bacteria in urinary tract, cranberry juice or prune juice to help keep urine acidic, Void at first urge. Do not hold urine for extended amount of time, Wear clean underwear daily, Take the full course of antibiotic therapy even if much improved after a few days of therapy. A Nursing Admission/Readmission Evaluation dated 2/4/22, documented the reason resident 167 required skilled care was due to their need for help with activities of daily living. Resident 167 required extensive assistance by one staff to turn and reposition in bed. Resident 167 required limited assistance of one staff for eating. Resident 167 required extensive assistance of two staff for toilet use and total dependence on two staff for transferring. Resident 167's skin assessment documented cancer on top of scalp, missing left third and fourth finger, and neck skin cancer. [Note: Resident 167 was noted to not have any issues with MASD on admission.] A Braden Scale for Predicting Pressure Sore Risk assessment was completed on 2/4/22. Resident 167 was assessed at a score of 14, which indicated resident 167 was at MODERATE RISK for development of a pressure sore. A Skilled Nursing Note dated 2/5/22, documented that resident 167 was incontinent of bowel and brief dependent. Resident 167 had a urinary Foley catheter. Resident 167 was weak and requested two to three staff to transfer and maximum assistance for showers. Resident 167 was dependent with bed mobility, transfers, eating, toileting, walking, and locomotion. [Note: Resident 167 was identified as incontinent of bowel and brief dependent. Resident 167 would need staff assistance regarding brief changes due to his ADL assistance of dependent with bed mobility and toileting.] A Braden Scale for Predicting Pressure Sore Risk assessment was completed on 2/11/22. Resident 167 was assessed at a score of 12, which indicated resident 167 was at HIGH RISK for development of a pressure sore. [Note: Resident 167's score on the Braden Scale indicated resident 167 was at higher risk of pressure sore development on 2/11/22, than when resident 167 was admitted .] A Skilled Nursing Note dated 2/12/22, documented that due to general fatigue, resident 167 was unable to vocalize his needs when spoken to during his medication administration. Resident 167 was very fatigued and spent his time sleeping. Resident 167 was incontinent. Resident 167 did not demonstrate motor skills this shift. At baseline resident 167 was able to independently move extremities. Resident 167 required extensive assistance with bed mobility, transfers, and toileting. Resident 167 required supervision with eating. [Note: At the time of this assessment, resident 167 was noted to be very fatigued, incontinent of bowel, and unable to vocalize his needs when spoken to. Resident 167 remained extensive assistance with most ADLs particularly bed mobility, toileting, and transfers.] A Skilled Nursing Note dated 2/16/22, documented Resident 167 was alert and oriented to self and unable to make needs known. Resident 167 was checked by nurse and CNA every hour to make sure resident 167 was comfortable. Resident 167 was incontinent of bowel movement and every 2 hour (q2h) brief changes performed by CNAs with proper peri care. Resident 167 had an indwelling catheter in place. Resident 167's skin assessment documented a rash. Resident 167 was dependent with bed mobility, eating, and toileting. [Note: Resident 167, at the time of this assessment, was assessed to now be dependent on staff for bed mobility, eating, and toileting. Per this Skilled Nursing Note, staff were aware of resident 167's need for, every hour checks, and, q2h brief changes due to incontinence. Resident 167 was also not noted to have skin issues of MASD.] A Skilled Nursing Note dated 2/18/22, documented Resident 167 was alert and oriented to self and able to make needs known. Resident 167 was incontinent of bowel and had an indwelling Foley catheter in place. Resident 167 was dependent with bed mobility, eating, and toileting. A Skin and Wound Total Body Assessment was completed on 2/18/22, and indicated resident 167 had no new wounds at the time of the assessment. A Braden Scale for Predicting Pressure Sore Risk assessment was completed on 2/19/22. Resident 167 was assessed at a score of 10, which indicated resident 167 was at HIGH RISK for development of a pressure sore. [Note: Resident 167's score on the Braden Scale indicated resident 167 was at higher risk of pressure sore development on 2/19/22, when compared to the previous assessments completed on 2/4/22 and 2/11/22.] A Nursing Note dated 2/22/22 at 6:34 PM, read Note Text: [name of Resident 167 removed] had BM WNL (within normal limits), while changing res (resident), noticed skin break break (sic) down around coccyx area. Cleaned and dry area cont.(continue) to monitor. An Alert Note dated 2/23/22 at 4:47 PM, read Note Text: family notified of excoriation to coccyx, advised that pt (patient) will have an air mattress, will be turned more and assisted, and [MEDICATION(S)] ordered for coccyx cares. care plan placed . Within resident 167's Treatment Administration Record (TAR) was an order placed on 2/23/22 at 6:00 PM, which read air mattress; every shift for check air mattress function q (every) shift. [Note: Resident 167 was noted to have acquired the excoriation to the coccyx prior to this Physician Order.] Within resident 167's TAR was an order placed on 2/23/22 at 6:00 PM, which read turn q 2 hrs (hours) and prn (as needed); every 2 hours for turn patient q 2 hrs regardless of with visitors. [Note: Resident 167 was noted to have acquired the excoriation to the coccyx prior to this Physician Order.] A Skin and Wound Evaluation, completed by the facility's Wound Nurse, was documented on 2/24/22. The assessment read, Type: Moisture Associated Skin Damage . Location: Right buttocks; Acquired: Present on Admission; How long has the wound been present: unknown . [Note: On admission resident 167 was not noted to have MASD present; the MASD present on the skin evaluation from 2/24/22, was acquired while the resident was within the facility, and MASD was first noted in resident 167's chart on 2/22/22 at 6:34 PM.] A Skilled Nursing Note from 2/25/22, documented Resident 167 was responsive and able to make needs known. Res is bed changed incont. (incontinent); Resident 167 could sit up at the edge of the bed slowly. Resident 167 required limited assistance with bed mobility and eating, extensive assistance with transfers, and was dependent with toileting, and walking. [Note: The nursing assessment near after discovery of excoriation on resident 167's coccyx indicated resident 167 was incontinent, and resident 167 required limited assistance from staff for bed mobility and was dependent on staff with toileting.] An Interdisciplinary Team (IDT) Note from 2/25/22, read, Note Text: Skin excoriation to coccyx was discussed in IDT meeting. Air mattress applied, Skin Tx (treatment) in place with wound nurse following and routine repositioning assistance and toileting needs addressed routinely and as needed. Within resident 167's TAR was an order, started on 2/28/22, which read, For wounds to the bilateral buttocks: Cleanse well with Ns (normal saline) or wound spray. Gently pat dry. Apply skin prep to the peri wound and allow to dry. Warm [MEDICATION(S)] between hands for approx. (approximately) 30 seconds. Apply wound wounds. If hydrocolloids are well adhered and not saturated, leave in place for 7 days. May also change PRN. WHEN REMOVING [MEDICATION(S)], PLEASE BE EXTREMELY SLOW AND GENTLE TO AVOID MORE TEARING OF THE SKIN. USE NS TO HELP LOOSEN IT BEFORE REMOVING. every day shift every Monday. On 2/23/22 at 2:52 PM, Licensed Practical Nurse (LPN) 3 was interviewed. LPN 3 stated resident 167 had been declining. LPN 3 stated staff had noticed resident 167's urine was a dark wine color and a Urine Analysis had been ordered to identify if resident 167 had suffered a urinary tract infection. LPN 3 stated resident 167 was started on [MEDICATION(S)] for 7 days while the physician was awaiting final test results. LPN 3 stated resident 167 had been changed to soft/puree foods with thickened liquids on 2/22/22. LPN 3 stated they were unaware if resident 167 had an open area on their skin. LPN 3 stated if resident 167 did have an open area LPN 3 would have read or heard about the open area during report at the beginning of their shift. [Note: The Nursing Note from 2/22/22 at 6:34 PM, indicated resident 167 had skin break down present around his coccyx area.] On 2/23/21 at 2:54 PM, the COVID-19 Unit Manager (UM) was interviewed. The COVID-19 UM stated resident 167 had been cleared from a COVID-19 standpoint, but the facility was working with the family to determine discharge placement. The COVID-19 UM stated resident 167 had needed total assistance with most of his ADLs recently. The COVID-19 UM stated just within the past three to four days resident 167 had been more attentive. The COVID-19 UM stated resident 167 still needed at least extensive assistance with transferring, standing, personal hygiene and pericare. The COVID-19 UM stated they had tried to train nurses to complete an e-Interact assessment whenever a resident had a change in condition like new antibiotics, cognitive change, a fall, new infection, a medication change, or a new open skin area. The COVID-19 UM stated this form helped to remind the nurses to notify family of changes in condition. [Note: No e-Interact Assessment was completed for resident 167's skin breakdown noted on 2/22/22 at 6:34 PM.] On 2/23/22 at 3:17 PM, the COVID-19 UM was interviewed. The COVID-19 UM stated the facility physician completed telehealth visits with the residents on the COVID-19 unit every Tuesday and Thursday. The COVID-19 UM stated the physician did not come over to the COVID-19 unit, but the nursing staff would round on the residents with the physician joining via telehealth. The COVID-19 UM stated it was not ideal, but the unit made it work. The COVID-19 UM stated it was hard to find reliable staff for the COVID-19 unit. The COVID-19 UM stated there was a high turnover with staff, so the unit had trouble developing continuity of staff. The UM stated some agency staff that could be consistent were wonderful, but once the agency staff started to understand what the UM expected the agency staff were leaving to begin a different posting. The COVID-19 UM stated the turnover and lack of ability to have consistent staff made the difference between excellent care versus less than [NAME]. On 2/23/22 at 3:44 PM, LPN 3 and the COVID-19 UM were interviewed further. LPN 3 stated incident reports were developed when a resident had a fall, when there was a resident to resident or resident to staff altercation, or if there was a skin change. The COVID-19 UM stated the Wound Nurse did become notified of skin issues and the Wound Nurse would evaluate and track the progress and treatment. The COVID-19 UM stated they would communicate with the Wound Nurse via Tiger Text or an email, and the COVID-19 UM stated the communication between the COVID-19 unit and the wound nurse could be better. On 2/23/22 at 3:48 PM, the COVID-19 UM was interviewed. The COVID-19 UM stated resident 167 should be turned and repositioned and checked for incontinence care every two hours. The COVID-19 UM stated staff should know to provide this service, and the UM stated they wondered if staff were nervous to go into a room when family was there. The COVID-19 UM stated staff would need to be re-educated that when family were visiting staff should, be the super aide, and enter the resident rooms to provide cares or ensure the resident did not need anything. On 2/24/22 at 3:25 PM, CNA 2, who was an agency CNA, was interviewed. CNA 2 stated when they had a resident who needed extensive assistance with cares and was incontinent CNA 2 would round on the resident every two hours to reposition and provide or check for the resident's need of incontinence care. On 2/24/22 at 3:27 PM, CNA 3, who was an agency CNA, was interviewed. CNA 3 stated resident 167 had definitely declined since he got here. CNA 3 stated resident 167 was a one person assistance with activities like transfers when he admitted , but now he required two staff members. CNA 3 stated they did not typically work with resident 167 because they took the other side of the unit, but CNA 3 stated resident 167 was a Q2 check even prior to the order. [Note: On 2/23/22, resident 167 had an order placed within his medical record for, turn q 2 hrs and prn; every 2 hours for turn patient q 2 hrs regardless of with visitors.] CNA 3 stated the CNA should check on resident 167 every 2 hours, provide repositioning, and determine if resident 167 needed a brief change. CNA 3 stated, it could have been hard to get to him because of staffing, but I can't say. I wasn't his CNA. On 2/24/22 at 3:39 PM, Registered Nurse (RN) 1 was interviewed regarding resident 167's status and the use of Braden Scales. RN 1 stated they were an agency RN and had not worked with resident 167 often. RN 1 stated the Braden Scale assessment took into account what a resident's risk was for developing a wound. RN 1 stated the assessment took into account a residents incontinence, nutrition and physical ability. RN 1 stated the assessment could help staff to assess how often a person may need to be turned or changed to prevent wounds. RN 1 stated the change in resident 167's Braden Scale scoring indicated resident 167 was at a higher risk for a pressure ulcer. RN 1 stated the change in resident 167's Braden Score Assessment would indicate staff need to monitor resident 167 more to get him moving, provide incontinence care, or provide encouragement with eating. On 2/28/22 at 9:09 AM, the Wound Nurse was interviewed. The Wound Nurse stated they were informed of resident 167's wound and had completed an assessment with a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Wound Nurse stated the wounds were incontinence related and resident 167 definitely needed incontinence care more often to heal his wounds. On 2/28/22 at 9:51 AM, CNA 4, who was an agency CNA, was interviewed about resident 167's care. CNA 4 stated resident 167 was, pretty dependent, with cares. CNA 4 stated they provided resident 167 with catheter care on 2/26/22, and CNA 4 stated they noticed resident 167's catheter care had not been getting done completely. CNA 4 stated they had pulled back resident 167's foreskin to clean beneath, and it, looked like it hadn't been done in a long time. CNA 4 stated resident 167 had never refused care from them, and CNA 4 stated resident 167 did rely on brief changes versus going to the toilet. CNA 4 stated they would provide resident 167 with a brief change, Usually once a day. More in the evening. At least every other day.

Based on interview and record review it was determined the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, for 1 out of 32 sampled residents, a resident that was dependant on [CONDITION(S)] missed a day of [CONDITION(S)] and had two critical potassium lab values with no interventions which resulted in death. Resident identifier: 111. Findings included: Resident 111 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 111's medical record was reviewed on [DATE]. A review of the Nurse to Nurse Forms dated [DATE], documented that resident 111 had [CONDITION(S)] that morning, [DATE]. [Note: Resident 111 went to [CONDITION(S)] the day prior to admission.] A care plan Focus initiated on [DATE] and revised on [DATE], documented [Name of resident 111 removed] needs [CONDITION(S)] hemodialysis r/t (related to) renal failure. The goals initiated on [DATE] and revised on [DATE], included [Name of resident 111 removed] will have immediate intervention should any s/sx (signs or symptoms) of complications from [CONDITION(S)] occur through the review date and [Name of resident 111 removed] will have no s/sx of complications from [CONDITION(S)] through the review date. The interventions initiated on [DATE] and revised on [DATE], included Check and change dressing daily at access site. Do not draw blood or take B/P (blood pressure) in arm with graft. Monitor intake and output. Monitor VITAL SIGNS . Notify MD (Medical Doctor) of significant abnormalities. Monitor/document/report PRN (as needed) any s/sx of infection to access site: Redness, Swelling, warmth or drainage. Resident is on [CONDITION(S)]. Work with resident to relieve discomfort for side effects of the disease and treatment. (Cramping, fatigue, headaches, itching, [CONDITION(S)], bone demineralization, body image change and role disruption.) The Blood Pressure Summary and the Pulse Summary were reviewed and the following were documented: [Note: The blood pressure (BP) measurements were taken in millimeters of mercury and heart rate (HR) measurements were taken in beats per minute. A normal blood pressure for most adults was defined as a systolic pressure of less than 120 and a diastolic pressure of less than 80. A normal resting heart rate for adults ranges from 60 to 100 beats per minute.] a. On [DATE] at 12:56 PM, BP ,d+[DATE] and HR 76 regular b. On [DATE] at 1:59 PM, BP ,d+[DATE] and HR 70 regular c. On [DATE] at 3:59 AM, BP ,d+[DATE]. At 4:00 AM, HR 97 regular d. On [DATE] at 3:30 PM, BP ,d+[DATE]. At 3:31 PM, HR 95 regular e. On [DATE] at 4:23 AM, BP ,d+[DATE]. At 4:24 AM, HR 93 unable to determine f. On [DATE] at 8:33 AM, ,d+[DATE] and HR 93 regular g. On [DATE] at 3:56 PM, ,d+[DATE]. At 3:57 PM, HR 93 regular h. On [DATE] at 4:14 AM, ,d+[DATE] and HR 99 regular On [DATE] at 1:08 AM, a Skilled Nursing Note documented . Color appears slightly jaundiced . On [DATE] at 1:28 PM, an Alert Note documented labs (Laboratory) order placed for admit labsd (sic) for tomorrow cbc (complete blood count) cmp (comprehensive metabolic panel) hga1c (hemoglobin A1c) and renal panel and lft's (liver function test) pt (patient) has [CONDITION(S)] (end stage renal disease) and will need [CONDITION(S)] will check w (with) social worker for times/ (and) days On [DATE] at 5:08 AM, a Skilled Nursing Note documented . colour (sic) jaundiced slightly does have [CONDITION(S)] waiting on lab results; . A review of the [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . every day shift every Tue [Tuesday], Thu [Thursday], Sat [Saturday] for pre [CONDITION(S)] assessment. On [DATE], the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .) A CMP collected on [DATE] at 12:20 PM, documented a potassium level of 5.8 millimoles per liter (mmol/L). The reference range for potassium was noted to be between 3.5 and 5.0 mmol/L. The lab value was documented as high. The lab results were printed on [DATE] at 3:10 PM. [Note: MD notification and response was unable to be located in the medical record. According to the Mayo Clinic, a normal range of potassium is between 3.6 and 5.2 mmol/L of blood. A potassium level higher than 5.5 mmol/L is critically high, and a potassium level over 6 mmol/L can be life-threatening. Small variations in ranges may be possible depending on the laboratory.] A Telemedicine visit by the MD dated [DATE], documented that resident 111 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation regarding the CMP lab draw. [Note: It was documented in the medical record that resident 111 be sent to [CONDITION(S)] on Tuesday, Thursday, and Saturday.] On [DATE] at 6:04 AM, an Order - Administration Note documented [MEDICATION(S)] Tablet 4 MG [milligrams] Give 4 mg by mouth every 6 hours as needed for nausea / vomiting Pt c/o (complains of) nausea. A review of the [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . [Note: According to https://medlineplus.gov/ency/article/ 9.htm a symptom of [CONDITION(S)] would include nausea and vomiting.] A CMP collected on [DATE] at 3:30 PM, documented a potassium level of 6.9 mmol/L. The reference range for potassium was between 3.5 and 5.0 mmol/L. The lab value was documented as high. It was noted on the form critical value notification and read back at: 1957 (7:57 PM) to [name of medical assistant removed] with [name of doctor removed] on [DATE]. A hand written note on the form documented Notified MD [name of MD removed] [DATE] check The Note. The lab results were printed on [DATE] at 11:28 AM. [Note: The critical value notification and read back was made by the lab. The hand written note on the form was made by a facility staff member and the MD notification and response was unable to be located in the medical record. According to https://www.mayoclinic.org/symptoms/[CONDITION(S)]/in-depth/sym- 776 Having a blood potassium level higher than 6.0 mmol/L can be dangerous and usually requires immediate treatment.] A Re-occurring [CONDITION(S)] Form from a local transportation company documented that resident 111 had a pick up appointment and pick up time at 5:00 AM. Resident 111 had an appointment time at the local [CONDITION(S)] center at 5:45 AM on Tuesdays, Thursdays, and Saturdays. The schedule start date was to begin on [DATE]. On [DATE] at 5:32 AM, an Alert Note documented Note Text: pt was transferred to [name of local hospital removed] by ambulance this morning at 0515 (5:15 AM). ambulance came to take pt to [CONDITION(S)] this morning. while entering pts room team noticed pt had removed oxygen cannula from nose. the team put oxygen back on pt and called pt and asked pt his name, the pt stated his name was [unidentified name removed]. we then prepared the pt to be transferred from his bed to the gurney. while transferring the pt he then went unconscious. the team elected to send him to the ER (emergency room ) in [name of local hospital removed]. we called the administrator on call and informed him of what was being done. contacted doctor and we are trying to find pt family information On [DATE] at 12:14 PM, a Nursing Note documented Res (resident) family stopped by to pick up charger and phone. Asked res family for update. Res's family stated that res passed away. The local hospital Emergency Department note dated [DATE], documented [AGE] year-old male presents to the emergency department as a critical patient with ongoing CPR (cardiopulmonary resuscitation). Was supposed to have [CONDITION(S)] today and had not had any [CONDITION(S)] since Monday [[DATE]]. Initially presumed likely hyperkalemic as source of his [CONDITION(S)] and patient was therefore given 2 g (grams) of [MEDICATION(S)] and 1 amp of [MEDICATION(S)]. ABG (arterial blood gas) was obtained demonstrating a metabolic acidosis with pH (potential hydrogen) of 6.970. His potassium was elevated to 8.7 and his [MEDICATION(S)] was 6.0, no other abnormalities. After receiving [MEDICATION(S)] and ABG rhythm was noted to change to [CONDITION(S)] and had pulses. We were unable to restore pulses but we did obtain repeat VBG (venous blood gas) has (sic) we were unable to obtain an ABG. This demonstrated a pH of 6.935, potassium of 4.9, and [MEDICATION(S)] of 4.2. Despite the improving potassium and [MEDICATION(S)] patient remained pulseless. At 0623 (6:23 AM) resuscitative efforts were halted and patient was declared deceased . The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 1:26 PM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated the residents who needed [CONDITION(S)] had their [CONDITION(S)] chair time and transportation scheduled by the Social Worker. LPN 4 stated the Social Worker was no longer employed at the facility but the administrator was responsible for that now. LPN 4 stated there was a calendar put out when the resident went to [CONDITION(S)] and when they came home. LPN 4 stated the schedule depended on the chair time what medications were sent with the resident. LPN 4 stated the nurse completed the pre-[CONDITION(S)] assessment form. LPN 4 stated when the resident came back from [CONDITION(S)] the nurse completed the post [CONDITION(S)] assessment, vital signs, check their access fistulla, pain, and check the dressing for drainage. LPN 4 stated the residents were sent to [CONDITION(S)] with a face sheet, list of medications, and a [CONDITION(S)] sheet. LPN 4 stated then the [CONDITION(S)] center would fill out their part and send the [CONDITION(S)] sheet back with the resident. LPN 4 stated the resident would be sent with food or snacks if they did not eat a meal before [CONDITION(S)]. LPN 4 stated when the resident returned from [CONDITION(S)] they would get a snack. On [DATE] at 2:10 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated it had been less than a year ago since the facility stopped doing [CONDITION(S)] at the facility. The ADON stated the social worker set up the [CONDITION(S)] appointments. The ADON stated the social worker would find a chair before the resident was admitted to the facility, so it was taken care of. The ADON stated the social worker set up the chair time and then she set up the transportation. The ADON stated it was possible that a resident missed their chair time because of transportation not being scheduled. On [DATE] at 11:56 AM, an interview was conducted with the Director of Nursing (DON). The DON stated this morning ([DATE]) he had called the previous Long Term Care Facility (LTCF) where resident 111 resided. The DON stated that resident 111 had been dialyzed on the Tuesday prior to admission ([DATE]). The DON stated that he had called the prior social worker that had worked at the facility and the social worker had stated that the [CONDITION(S)] center was unable to fit resident 111 in for [CONDITION(S)] on Thursday ([DATE]) and that was why resident 111 had missed [CONDITION(S)]. The DON stated the next scheduled [CONDITION(S)] for resident 111 was on Saturday ([DATE]). The DON stated the social worker was in charge of transportation and scheduling. On [DATE] at 12:24 PM, an interview was conducted with a staff member at the local [CONDITION(S)] center. The staff member stated that resident 111 did come to [CONDITION(S)] on [DATE]. The staff member stated that resident 111 was expected for [CONDITION(S)] on [DATE], but the staff member did not know why resident 111 did not show up. The staff member stated that resident 111 was scheduled to come to [CONDITION(S)] on [DATE], but resident 111 did not make it. On [DATE] at 1:12 PM, an interview was conducted with LPN 3. LPN 3 stated resident labs were drawn by staff from the local lab. LPN 3 stated if the labs were ordered urgent the facility staff would draw the lab and the local lab picked up the sample. LPN 3 stated she would send the doctor a secured text message or call him if the lab was critical value. LPN 3 stated the doctor response was documented in a progress note and any new orders were entered into the electronic medical record. On [DATE] at 1:15 PM, a follow up interview was conducted with the DON. The DON stated the local lab called the MD directly and the local lab did not call the facility. The DON stated if the lab called the facility, the staff would notify the MD. The DON stated he was told not to add notes to the medical record after the resident went out and did not return. On [DATE] at 2:06 PM, an additional interview was conducted with the DON. The DON stated that he was unsure of when the critical lab was faxed to the facility without making several phone calls. The DON verified that the facility staff noted on the critical lab form that the MD was contacted but the DON was unable to verify who the staff member was. The DON stated that he wished the staff member had initialed the lab note. On [DATE] at 8:30 AM, an interview was conducted with the MD. The MD stated that he did not recall being notified about the critical lab on [DATE]. The MD stated he had looked in his office system yesterday ([DATE]) to see if there was a note that would indicate that he had been contacted and what was said but there was nothing. The MD stated the labs were drawn through a local lab and he was unsure how those were communicated with the facility. The MD stated he had instructed the DON yesterday ([DATE]) to look at the nurses notes and vital signs to see how resident 111 was responding to the critical lab value. The MD stated he was aware of the critical lab the day prior when resident 111's potassium was at 5.8. The MD stated there would have been an intervention for the high potassium. The MD stated he would have questioned if the sample was a good sample or was resident 111 hemolyzed. The MD stated that the potassium lab was a sensitive lab. The MD stated an electrocardiogram would have been ordered for resident 111 and something would have been done dependant on resident 111's other clinical findings. Additional information was provided by the Administrator on [DATE] at 10:34 AM. The additional information included the following statement: The statement from the DON documented . Wednesday, [DATE] The resident admitted to the facility from [name of local LTCF removed] at about 1240 PM. He was assessed by nursing staff who noted his [CONDITION(S)] and need for [CONDITION(S)] and recognized the lack of a [CONDITION(S)] time and transportation arrangements. The appointment made with [CONDITION(S)] was for 9am (9:00 AM) Thursday morning, and facility staff where (sic) aware of the [CONDITION(S)] chair time. [Note: The transportation agreement with the local transportation company documented a schedule start date to begin on [DATE], Saturday. There was no documentation located in the medical record regarding the appointment made Thursday morning at the [CONDITION(S)] center.]

Based on observation, interview and medical record review it was determined, for 3 of 45 sample residents, that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being of the residents. Specifically, one resident was not assessed timely after having a change in condition, one resident had a delay in treatment and continued to have [MEDICAL CONDITION] due to a low [MEDICATION NAME] level. Additionally, two of the residents' [MEDICAL CONDITION] were not called in to the physician and one resident did not have pain medications available. Resident identifiers: 3, 27 and 94. Findings include: HARM 1. Resident 94 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/2/17 resident 94's medical record was reviewed. A nursing progress note dated 9/2/17 at 1:58 PM revealed the following entry: Note text 07:30: Went into resident's room to check her blood sugar levels and administer her AM (morning) meds (medications). Resident noted to be sleeping. Checked her blood sugars and they were at 221, she was given her long acting and short acting insulins. Did not administer any other AM meds. V/S (vital signs) checked and stable at that time. Resident still sleeping. CNA (Certified Nursing Assistant) went into room to bring breakfast tray and resident would not arouse or wake up when called or patted on shoulders. Nurse went in and assessed resident she was diaphoretic across her whole body and unresponsive. V/S taken: BS (blood sugar) 240, T (temperature) 97.9, P (pulse) 120, BP (blood pressure) 72/45, 02 (oxygen) 94% (percent) on 3 liters 02, R (respirations) 22. MD (name of physician) notified. T.O. (telephone order) send to (hospital ER (emergency room )) via 911. EMS (emergency medical services) called. (Name of contact # 1) and (name of contact # 2) called a few times. (Contact # 1) phone services message, phone number no longer in service or unavailable. (Contact # 2) voicemail box full. Unit manager and DON (Director of Nursing) notified of situation and given updates. Unit manager told nursing to search resident's phone and phone book for numbers to contact and inform family, (contact # 1) or (contact # 2), no such luck finding phone numbers. Information faxed to (name of hospital ER). (Name of hospital) nurse called and gave us an update: resident went septic, and remained unresponsive in ER. POA (power of attorney) decided to put her on hospice at this time and have her stay in the (name of hospital). POA and family present at hospital and aware of situation. The September 2017 MAR (Medication Administration Record) for resident 94 revealed that resident 94 received an injection of [MEDICATION NAME] 37 units at 7:00 AM and an injection of Humalog Insulin 5 units at 7:30 AM. Resident 94's blood sugar monitoring on the Medication Administration Record [REDACTED]. (NOTE: The nursing progress note indicated that the blood sugar and the two injections were all completed at the same time.) No documentation could be located in the medical record to show that the facility nurse had completed a comprehensive assessment on resident 94 when resident 94 did not respond to the blood sugar sample being obtained nor when she did not respond to the two insulin injections. On 10/2/17 at 2:10 PM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that he did not know what had happened with resident 94 nor why the facility nurse did not do an assessment immediately on resident 94 since resident 94 did not waken when her blood sugar was tested nor when she was injected with two separate injections. The facility DON stated that resident 94 had a quick, brief change in condition, went out to the hospital and got put on hospice [MEDICAL CONDITION]. On 10/2/17 at 2:34 PM, an telephone interview was conducted with contact # 2 for resident 94. Contact # 2 stated that resident 94 had gone into the hospital on [DATE] and was diagnosed as being septic again. Contact # 2 stated that resident 94 never regained consciousness and passed away at the hospital on the night of 9/2/17. On 10/3/17 at 12:28 PM, LPN 4 was interviewed via telephone. LPN 4 stated that she remembered resident 94 and that she had taken care of resident 94 the day that she was sent to the hospital. LPN 4 stated that resident 94's mentation was normal the morning of 9/2/17. When this surveyor informed LPN 4 that per her nursing progress note dated 9/2/17, resident 94 was noted to be sleeping, LPN 4 confirmed that resident 94 was sleeping. LPN 4 stated that she would not have considered doing a comprehensive assessment on resident 94 because resident 94 was groggy most mornings when LPN 4 administered the resident's insulins. LPN 4 stated that a comprehensive assessment consisted of checking V/S, blood sugar, checking for diaphoresis, and checking their level of consciousness and should be done for any resident who had a change in condition. LPN 4 stated that she just thought resident 94 was sleeping and that there was nothing out of the ordinary for resident 94. LPN 4 stated that she completed a comprehensive assessment about an hour later when the CNA informed her that resident 94 was unresponsive. LPN 4 stated that resident 94's blood sugar was noted to be slightly higher, that her blood pressure was noted to be lower and that her pulse was noted to be higher. When asked how resident 94's mentation would have been assessed if she was sleeping, LPN 4 stated I don't know. (NOTE: No other V/S could be located in the medical record to show a decline from the set of V/S taken at 7:30 AM when resident 94's BP was noted to be low at 72/45 and resident 94's pulse was noted to be high at 120.) On 10/2/17 the facility Policy and Procedure regarding a change in condition was reviewed and revealed the following: Change in a Resident's Condition or Status Policy Statement Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, bulling/payments, resident rights, etc.) Policy Interpretation and Implementation 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: a. An accident or incident involving the resident; b. A discovery of injuries of an unknown source; c. A reaction to a medication; d. A significant change in the resident's physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly; f. Refusal of treatment or medications (i.e. two (2) or more consecutive times); g. A need to alter the resident's medical treatment significantly; h. A discharge without proper medical authority; and/or i Instructions to notify the Physician of changes in the resident's condition. 2. A 'significant change' of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not 'self-limiting'); b. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument and 42 CFR 483.20 (b)(ii). 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the SBAR (Situation, Background, Assessment, Recommendation) (Interact Version 4.0) Communication Form. 4. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative (sponsor) when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source; b. There is a significant change in the resident's physical, mental, or psychosocial status; c. There is a need to change the resident's room assignment; d. A decision has been made to discharge the resident from the facility; and/or e. It is necessary to transfer the resident to a hospital/treatment center. 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. 6. Regardless of the resident's current mental or physical condition, the Nursing Supervisor/Charge Nurse will inform the resident of any changes in his/her medical care or nursing treatments. 7. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 8. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA (Omnibus Budget Reconciliation Act) regulations governing resident assessments and as outlined in the MDS (minimum Data Set) RAI Instruction Manual POTENTIAL FOR HARM 2. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/27/17 resident 3's medical record was reviewed. Resident 3's nursing progress notes revealed the following entries: a. 8/17/17 at 11:00 AM, At approximately 1100 hours today, (Resident 3) had what appeared to be an absent [MEDICAL CONDITION] that lasted about 5 minutes while standing at bedside with physical therapist. He had a vacant stare and didn't respond to any stimuli. He was assisted back into bed and had a postichtal (sic) period [MEDICATION NAME] 10 minutes. After about 10-15 minutes he stood up from the bed and was his normal (sic) in appearance and alertness, responding to all questions appropriately. MD (medical doctor) notified and apprised of the change of condition b. 8/20/17 at 7:38 AM, Received report from night nurse that resident had a [MEDICAL CONDITION] early this AM, he had fallen off the couch and was not responsive. He was put back onto couch, he would track with his eyes but was not talking. After another 1/2 hr (hour), he was sitting up and answering questions be (sic) remained very sleepy. He is now up in chair, alert and oriented to person only, blood glucose checked, 508, called to MD who ordered an extra 4 units with other sliding scale insulin. Will monitor closely. c. 8/23/17 at 6:41 AM, Lab results received Levetiracetam level is L (low) at 8.3. MD notified. d. 8/25/17 at 3:51 AM, Resident experienced [MEDICAL CONDITION] while in bed. RN (Registered Nurse) and CNA heard resident gurgling and snorting. Found resident in bed on R (right) side seizing. Surrounding objects removed for safety, SN (skilled nurse) and CNA stayed at bedside. [MEDICAL CONDITION] lasted for 2 minutes, initially unresponsive, then after a few minutes was able to follow commands and answer questions. Very lethargic. VS are WNL (within normal limits), 02 95%, sleeping at this time. Will continue to monitor. Family and Doctor notified. e. 8/28/17 12:55 AM, At 00:38 (12:38 AM), pt (patient) was heard gurgling and snorting loudly from his room. Upon entering room, noticed that pt was having [MEDICAL CONDITION], lying down, curled on his L (left) side. Bed placed on lowest position. Removed nearby objects. [MEDICAL CONDITION] lasted for 4 minutes. After 4 minutes, pt (patient) started to remain quiet in bed, but continues to be minimally responsive. Pt eyes open, no verbal response noted. Blood sugar was checked, 93 was result. Fmaily (sic) and (name of physician) notified. Pt is continuously monitored. f. 8/28/17 at 8:18 AM, MD ordered [MEDICATION NAME] level to be drawn today d/t (due to) history of [MEDICAL CONDITION] g. 8/28/17 at 11:16 AM, MD changed [MEDICATION NAME] dose to 750 mg (milligrams) BID (twice daily) and recheck [MEDICATION NAME] level on 9/25/17 h. 9/10/17 at 12:28 AM, Res (resident) was in his bed and staff heard him yell out. Res was found to be having a [MEDICAL CONDITION]. Lasted approx (approximately) 30 seconds. No injury reported. Res now resting in his bed. i. 9/13/17 at 1:31 AM, Res roommate called out to staff to alert us to res. Res was found laying on his bed with his feet off the side. Res was having a [MEDICAL CONDITION]. When finished, res was awake but unable to speak, r/t (related to) extreme exhaustion. Res resting well at this time j. 9/24/17 at 14:10 PM (2:10 PM), CNA reported finding res on the floor in the activity room on the north hall. CNA stated that when she found res he was making a jerking motion and stopped jerking just before nurse arrived. When nurse arrived found res on the floor on his side with emesis on the floor beside him. No jerking motion noted. Res assessed and found to be alert and responsive. Color was pink. 02 sats (saturations) 97% RA (room air) (Temperature) 97.2, (respirations) 16, (blood pressure) 100/79; BG (blood glucose) 124. Small bump on right side of forehead noted. Res assisted into bed. Neurochecks started. MD notified. Attempted to notify mother but there was no answer. Physician orders [REDACTED]. Physician orders [REDACTED]. Lab results dated 8/22/17 for resident 3 revealed that resident 3's [MEDICATION NAME] level was low at 8.3. (Normal range for a [MEDICATION NAME] level was considered to be between 10.0 and 40.0.) Additionally, the lab was signed and dated that resident 3's physician was notified of the low [MEDICATION NAME] level on 8/24/17, three days after the lab was drawn and two days after the lab had been returned to the facility. (The nursing progress note revealed that resident 3's physician had been notified of the low [MEDICATION NAME] level on 8/23/17, one day after the lab had been returned to the facility.) On 9/27/17 at 3:47 PM, an interview was conducted with the facility DON. The facility DON stated that if a lab was critical then it would be called into the physician immediately but if it was a routine lab and had no problems, the lab would go into the physician's file for him to get to when he could. The facility DON stated that I can tell you right now why the physician did not change (resident 3's) [MEDICATION NAME] immediately, because it takes time for the [MEDICATION NAME] to become therapeutic in the blood and he felt like there was no need for a knee jerk reaction to increase the [MEDICATION NAME]. The DON was reminded that resident 3 had been on [MEDICATION NAME] 500 mg BID during his hospitalization prior to coming to the facility. On 9/28/17 at 9:40 AM, an interview was conducted with the facility DON. The facility DON stated that resident 3's physician had ordered a [MEDICATION NAME] level on 8/28/17 and that the lab was discontinued after resident 3's physician was reminded that there was a [MEDICATION NAME] level drawn on 8/21/17 and that the lab was low at 8.3. The facility DON stated that resident 3's physician felt that the [MEDICATION NAME] level on 8/21/17 was recent enough to use and increased resident 3's [MEDICATION NAME] to 750 mg BID. 3. Resident 27 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 10/2/17 at 12:05 PM resident 27 informed this surveyor that he was out of his [MEDICATION NAME] pain medication. Resident 27 stated he has been out since he requested it this morning and the last dose he received was last evening. Resident 27 stated his pain level was a 7 out of 10 (on a scale of 1 to 10) and located in his right hip. Resident 27 further stated that he was supposed to go out on leave with his mother, but was unsure if he should leave the facility without his pain medication. Resident 27 stated he requested to have the medication obtained from the emergency kit. On 10/2/17 at 12:15 PM an interview was conducted with nursing student (NS) 1. NS 1 stated that resident 27 requested his PRN (as needed) [MEDICATION NAME] this morning during medication pass, at 8:05 AM, and that it was out of stock. NS 1 stated she informed Licensed Practical Nurse (LPN) 1 that the medication was not available. LPN 1 stated that at approximately 8:45 AM the Medical Doctor (MD) was notified and a new prescription was requested. LPN 1 further stated that the medication could not be obtained from the emergency kit without a code from the pharmacy and that the pharmacy was awaiting an order from the MD. LPN 1 stated that the medication supply ran out of stock last evening and the information was passed on to her at change of shift this morning. On 10/2/17 resident 27's electronic medical record was reviewed. Review of the physician orders [REDACTED]. a. [MEDICATION NAME] tablet 15 mg (milligram), Give 15 mg by mouth at bedtime related to chronic pain. b. [MEDICATION NAME] tablet 15 mg, Give 15 mg by mouth every 3 hours as needed for pain related to chronic pain. Review of the Medication Administration Record [REDACTED] a. In July 2017 resident 27 received his PRN [MEDICATION NAME] 38 times. The pain scores reported was between 3 to 7 out of 10 (on a scale of 1 to 10) with the average being 7. b. In August 2017 resident 27 received his PRN [MEDICATION NAME] 49 times. The pain scores reported was between 3 to 7 out of 10 (on a scale of 1 to 10) with the average being 7. c. In September 2017 resident 27 received his PRN [MEDICATION NAME] 44 times. The pain scores reported was between 4 to 9 out of 10 (on a scale of 1 to 10) with the average being 7. Review of resident 27's care plan revealed a focus area of .has pain r/t (related to) Chronic Physical Disability in lower body and neck, Depression, Parasthesia. (Resident's name) currently has: fantanyl (sic) patch change q (every) 72 hours topically and [MEDICATION NAME] for breakthrough pain. A goal identified on the care plan was that resident 27 would voice a level of comfort of < (less than) 5 (on a scale of 1 to 10) with regards to his pain level. The care plan further revealed interventions of Anticipate the resident's need for pain relief and respond immediately to any complaint of pain., and Help (resident's name) find comfort and relief by Administer [MEDICATION NAME] per orders. This care plan was initiated on 8/18/17. On 10/2/17 at 12:50 PM an interview was conducted with the Director of Nursing (DON). The DON stated that resident 27 just received his PRN dose of [MEDICATION NAME]. The DON further stated that his expectation of staff was that they obtained pain medication from the Medical Doctor (MD) when it was unavailable immediately irregardless of time of day. (Note: It should be noted that resident 27 waited 4 hours and 45 minutes for his pain medication to be administered.)

Based on observation, interview and record review it was determined that for 6 of 45 sample residents, the facility did not ensure that the resident environment remained as free from accident hazards as was possible; and each resident received adequate supervision and assistive devices to prevent accidents. Specifically, a hoyer lift was not working properly and a resident fell from the lift and sustained a fracture; another resident was observed to be transferred without a lift; and other residents eloped from the facility secured unit and windows were not secured. Resident identifiers: 3, 40, 55, 74, 92 and 112. Findings include: HARM 1. Resident 40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 40's medical record was reviewed on 9/28/17. A quarterly Minimum Data Set ((MDS) dated [DATE] revealed that resident 40 required two person extensive assistance for transfers. Resident 40's nurses notes revealed the following entries: a. 5/4/17 at 1:03 PM, .Res (resident) fell in shower room. Resident was transferring from shower back to wheel chair and the hoyer lift tipped over. Resident has small skin tear on right ankle. Res and situation assessed and vitals taken. Dressing placed on wound. No other injuries noted at this time. Resident does not have s/s (signs or symptoms) of increased pain at this time. wctm (will continue to monitor). b. 5/4/17 at 9:47 PM, Resident was put to bed and cna (Certified Nursing Assistant) noticed bruising on Lt (left) ankle and foot. Also bruising on Lt inner lower leg. Cries out in pain with slightest movement of leg or touch of foot. Didn't show pain earlier in shift. Has routine pain patch and routine hydrocodone/tylenol at HS (hours of sleep). The agency cna attempted to notify the hospice nurse and then came and notified floor nurse when nurse returned from assisted living med (medication) pass. Call placed to hospice to get permission for X-ray. c. 5/4/17 at 11:45 PM, Return results of X-Ray: has Acute nondisplaced oblique fractures of distal tibia and fibula diahyses (sic). Notified hospice and discussed pain control needs. Nurse is being contacted right now and pain management is being sought.Got in contact with son.Informed him of Fracture. he expressed that he wants his mom to be kept comfortable and wondered about a brace for her leg. d. 5/5/17 at 10:34 AM, Continues on alert charting r/t (related to) fall yesterday. Purplish discoloration and swelling continues to left foot and ankle. Ice pack applied. Res in bed with slight changes in positioning for comfort and brief change, but care taken so as not to move left foot and ankle. Scheduled pain med administered. A care plan dated 10/24/16 and updated on 5/15/17 revealed a Focus of Limited physical mobility: (resident 40) has limited physical mobility r/t Alzheimer's Dz (Disease). One of the goals developed was, The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. Interventions for this identified problem included, The resident is non-weight bearing (and) non-ambulatory. An incident report revealed the same nurses note from above on 5/4/17. There was no additional information documented on the incident report. A review of the facility's Maintenance Work Orders was completed. One Maintenance Work Order revealed, Hoyer is shorting out. This work order did not include a date, which Hoyer lift, or location of the Hoyer lift. The work order included a check mark under the Finished section. There was no other clarifying documentation on the work order. A written statement signed by the hospice CNA on 5/5/17 was provided by the facility. The statement revealed, On May 04 (yesterday) when I tried to sit (resident 40) in the wheechair after a tub shower, the hoyer machine didn't open its legs to place it in the right position. I turn to pull the light on and per (sic) assistance. When I turn (sic) back I saw the hoyer coming down with the patient hanging there. I berily (sic) grabbed the patient who hit the floor with her feet. the right foot was twisted. I screamed for help, and some CNA just came to throw trash and helped me to lift the patient and put her in the wheelchair. On 9/27/17 at 2:32 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that she was the nurse on the rehab hall at the time resident 40 fell from the Hoyer lift on 5/4/17. LPN 2 stated she responded to the shower room after the resident fell . LPN 2 stated resident 40 resided on the North hall but the shower room on that hall was not big enough for the Hoyer lift, so the hospice CNA showered resident 40 in the rehabilitation hall shower room. LPN 2 explained the hospice CNA had told her she had been showering resident 40 when the lift did not work properly. LPN 2 stated the hospice CNA informed her that she pressed the call light. According to LPN 2, the hospice CNA explained that when she turned to press the call light the Hoyer lift fell forward with resident 40 hitting the floor. LPN 2 stated another CNA helped the hospice CNA transfer resident 40 into her wheelchair. LPN 2 stated that she was called to assess resident after the fall. LPN 2 stated that resident 40 was in her wheelchair when she assessed resident. LPN 2 stated resident 40 was not in distress and her vital signs were stable. LPN 2 stated she did not observe any bruising or sores on resident 40 at that time. LPN 2 stated the hospice CNA had transferred resident 40 alone with the Hoyer lift. LPN 2 stated the hospice CNA told her the feet on the Hoyer lift did not work correctly, which made the lift tip. On 9/27/17 at 3:22 PM, an interview was conducted with LPN 3. LPN 3 stated she was not working when resident 40 fell from the Hoyer lift on 5/4/17, but that she had worked the shift following the fall. LPN 3 stated resident 40 was totally dependent with all Activities of Daily Living (ADLs). LPN 3 stated staff were to use two people when transferring resident 40 with the Hoyer lift. LPN 3 stated that during the afternoon shift, following the fall, resident 40 cried out in pain later. LPN 3 stated she obtained a physician order [REDACTED]. LPN 3 stated the x-ray revealed resident 40 had a fracture to her tibia and fibula. On 9/28/17 at 8:18 AM, an interview was conducted with Maintenance Director (MD). The MD stated that prior to May 2017, he checked the facility's mechanical lifts only when a lift was reported to be broken. The MD stated since May he has been inspecting at the lifts weekly. Relative to the mechanical lift that was used to shower resident 40 on 5/4/17, the MD stated he had installed the wrong pendent controller on the lift. The MD stated he installed the wrong pendent controller because the facility did not have the correct controller. The MD stated the pendent limited the functioning of the lift, and only allowed the operator to control the up and down movement. The MD stated the controller did not include buttons for the operator to extend the base outward, as the lift was designed to function. The MD stated he had informed some of the CNAs to be careful with the lift because of the wrong pendent on the lift. The MD stated he was not sure how long the wrong pendent had been on the lift. On 9/28/17 at 8:25 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that she use common sense when determining to use 1 or 2 people to transfer residents. CNA 1 stated she did not know how residents were assessed for a lift and how many people to use when transferring residents. On 9/28/17 at 8:30 AM, an interview was conducted with CNA 2. CNA 2 stated that she was aware of each resident's level of assistance. CNA 2 stated that managers have e-mailed staff regarding the needs of residents and CNAs discuss each resident's needs in a CNA huddle during shift changes. On 9/28/17 at 8:40 AM, an interview was conducted with the Corporate Resource Nurse (CRN) 1 and Administrator. CRN 1 stated that there was not an investigation conducted into the resident 40's fall from the Hoyer lift. CRN 1 confirmed that if a resident was assessed as requiring 2 person extensive assistance that even with a lift 2 people should be used to transfer with a Hoyer lift. The Administrator stated that there was no additional information that the staff had been trained regarding the Hoyer lifts. POTENTIAL FOR HARM 2. Resident 55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/25/17 at 10:30 AM, an observation was made of resident 55 in his wheelchair. Resident 55 was taken to his room by the Activities Director (AD) for a brief change. The AD called for help and was assisted by the CNA (Certified Nursing Assistant) Coordinator. The CNA Coordinator placed a gait belt around resident 55's waist to assist in the transfer. Resident 55 was transferred by the AD and the CNA Coordinator as they placed one arm onto resident 55's arms and then used one hand to grab hold of the gait belt and to grab the seat of resident 55's pants. Resident 55 was observed to not participate in the transfer. On 9/27/17 resident 55's medical record was reviewed. Resident 55's Admission MDS (Minimum Data Set) assessment dated [DATE] revealed that resident 55 was totally dependent on facility staff for a two person transfer. Resident 55's care plan dated 5/9/17 and revised on 8/9/17 revealed that resident 55 had a focus problem of (Resident 55) has potential for impairment to skin integrity, decreased mobility, contractures. The goal for resident 55 included (Resident 55) will not sustain thermal burn injury related to hot beverage consumption through the next review. The interventions for resident 55 included the following: - Use a draw sheet or lifting device to move resident. On 9/27/17 at 4:42 PM, an observation was again made as CNA 4 and agency CNA 1 transferred resident 55. CNA 4 and agency CNA 1 used one arm each under resident 55's arms, then used one hand each to grab hold of the seat of resident 55's pants for the transfer. No observation was made of the use of a gait belt nor of a lifting device. Resident 55 was observed to not participate in the transfer. On 9/27/17 at 2:18 PM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated that because of the difficult transfer of resident 55, she was going to put in a referral to therapy to have him evaluated for the use of a Hoyer lift since resident 55 is dead weight. The CNA Coordinator stated that she had not yet made the evaluation. When the CNA Coordinator was informed that according to resident 55's care plan, he should be transferred with the use of a draw sheet or a lifting device, the CNA Coordinator stated that she was not aware of that and that the information probably did not get placed into the task area of the online medical record. On 9/27/17 at 4:55 PM, an interview was conducted with CNA 4. CNA 4 stated that she had never been told that resident 55 required the use of a draw sheet nor a lifting device for transfers. ELOPEMENTS 3. Resident 92 was admitted to the facility 5/26/17 with [DIAGNOSES REDACTED]. Resident 92's medical record was reviewed on 9/28/17. A nurses note dated 7/5/17 at 12:30 AM revealed, Nurse was notified by CNA that she was unable to locate res. Hall was searched (times) 2. When this nurse entered a room search, noticed emergency lights outside the window. When we went outside to investigate, res was sitting on the curb and medics were with him. Witness stated that they had seen him fall on the side of the road so they call 911. Res appeared to be unhurt but was saying that he was in pain. Medics were given a report of res history, med list given, etc. Res requested to go to the ER for evaluation. The incident report dated 7/5/17 and revised on 7/20/17 revealed the same nurses note. There was no additional information documented on the report. On 9/27/17 at 11:03 AM, a telephone interview was conducted with LPN 5. LPN 5 stated that resident 92 eloped from the secured unit on 7/4/17 after 10:00 PM. LPN 5 stated that the CNA on the unit reported that resident 92 was missing. LPN 5 stated that she looked out resident 92's window that was open and saw flashing lights. LPN 5 stated that she ran outside and resident 92 was on the curb. LPN 5 stated that she did not know that resident 92 was outside and thought he was outside of the facility for about 30 minutes. LPN 5 stated that several other residents eloped through the windows. LPN 5 stated that there was 1 CNA on the unit from 10:00 PM until 6:00 AM. LPN 5 stated that there were not enough staff during the night shift. On 9/27/17 at 12:40 PM, an interview was conducted with the Director of Nursing (DON). The DON stated they were search for the resident for 15 minutes in the building, then notify police family and emergency contacts if a resident was missing. The DON stated that residents 92 and resident 74 broke the window in a room in the secured unit and eloped out the window. The DON stated that upon admission each resident was assessed with [REDACTED]. The DON stated that staff have done 15 minutes checks for residents that have eloped. On 9/27/15 at 12:45 PM, an interview was conducted with CRN 1. CRN 1 stated that faciliy staff should try to get the residents more involved with activities. CRN 1 stated that if a resident eloped then the residents should have been re-evaluated. CRN 1 stated that if a resident eloped then an investigation and follow up should have been done. On 9/28/17 at 8:40 AM, an interview was conducted with CRN 1 and the Administrator. CRN 1 stated that quality assurance meetings were completed on 9/27/17. CRN 1 stated that staff were not aware what an elopement was. The Administrator stated that if a resident was still on the facility grounds it was not considered an elopement. The Administrator stated that the elopements had not been investigated. The Administrator stated that no interventions were in place. 4. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/27/17 resident 3's medical record was reviewed. A nursing progress note dated 9/9/17 at 9:21 PM revealed This nurse rec'd (received) a phone call from (Name of police department) police. They had found res (resident) a few blocks down the road. They brought him back to facility. When res was asked what happened, he stated that he was going home to his mothers house (Name of City). No injuries found on assessment. Unit manager notified. Res was placed on secured unit for his safety. MD notified. VM (voice message) left for his mother to call the facility. The facility incident report dated 9/9/17 did not reveal any additional information. The Admission MDS (Minimum Data Set) assessment dated [DATE] revealed that resident 3's BIMS (brief interview for mental status) score was 11 which indicated that resident 3 had moderate cognitive impairment. No Elopement Risk Assessment could be located in resident 3's medical record. The facility Wander Risk assessment dated [DATE] revealed that resident 3 was assessed with [REDACTED]. No care plan could be located in the medical record regarding resident 3's potential of wandering. A care plan for resident 3 dated 9/9/17 revealed a focus area of (Resident 3) moved to North (Secured Unit) hall r/t (related to) wandering out of the building looking for his mother. The goal for resident 3 included, (Resident 3) will not leave building unattended through next review.) The intervention for resident 3 included, (Resident 3) will be monitored closely r/t wandering off of grounds. 5. Resident 112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/28/17 resident 112's medical record was reviewed. A nursing progress note dated 7/7/17 at 9:56 PM, revealed, 64 yo (year old) male resident admitted to secure unit states wife found him one day in a catatonic state and call 911 He (sic) wife states that at some point he tried to take a handful of her meds (medications) for Lupus and that she grabbed them away and their (sic) was resistence (sic) from him that ended in police being called of which he attempted to grab their gun. Being determined to take his own life, he was placed in a secure unit and had belt and shoelaces removed from him A nursing progress note dated 7/8/17 at 12:12 PM, revealed, Resident has begun to pace the halls and state the FBI (Federal Bureau of Investigation) was on their way and he wasn't sure which entrance they would be coming in through A nursing progress note dated 7/9/17 at 12:46 PM, revealed, Resident is currently pacing the halls talking to himself stating, 'the negotiations are closed' A Social Services progress note dated 7/10/17 at 10:15 AM, revealed, (Resident 112) was born in (Name of City), and presents with a history of Alzheimer's disease with behavioral disturbances and short term memory impairments. (Resident 112) presents a harm to himself through unsafe decision making and exit seeking A nursing progress note dated 7/10/17 at 13:30 (1:30 PM), revealed, Early this AM res was found in another res room attempting to open the window and stated he needed to 'get out of here'. Res was redirected to the activity room on the unit to await breakfast. A few minutes later res was seen outside amb (ambulating) away from the facility. Staff members ran to try to assist res back to facility. Police were notified for assistance. Res was found across the street, but would not return stating 'I'm going to my death if I go back. They are going to execute me'. Res reassured and staff members were eventually able to talk res into returning to facility and into the secured unit. Police arrived and unit manager and police spoke with res. When checking unit it was determined that res opened a window in another res room and climbed out. Maintenance Manager notified to secure windows. Res has been monitored 1:1. CNA reports that res has made several attempts to return to the room where he climbed out earlier today. Res tried to push or shove CNA out of the way in order to enter that room. Redirected at that time. Res apologized later to CNA A nursing progress note dated 7/10/17 at 3:01 PM, revealed, Res followed the pharmacy delivery man out as he was leaving the secure unit. Res was redirected back into the unit by staff members. Res is very confused and unaware of safety. Will continue to monitor closely. A nursing progress note dated 7/12/17 at 7:01 AM, revealed, Res went through the bathroom into the next room, took the window off and went out the window. CNA heard something and went in to check and res was going through. She was unable to convince him to come back into the room. She alerted staff for assistance. Res went around the building, and down the street. Staff followed him for safety. A staff member got a car and res was willing to get into the car. Res was persuaded to go back into the facility safely. Res suffered an approx (approximately) 1 inch diameter abrahsion (sic) to the inside of his right elbow. A Social Service progress note dated 7/12/17 at 9:43 AM, revealed, SW (Social Worker) called intake at (Behavioral Hospital), and asked if they were still willing to honor their policy of readmitting discharged residents that were still needing help. This phone call came at the request of the administrator, based on (Resident 112's) ability to escape from the Memory Care Community and the facility's inability to prevent elopement for (Resident 112). (Resident 112's) recent escape led to him getting outside and onto the facility grounds, which also included hopping an 8 foot retaining wall The facility incident report dated 7/10/17 did not reveal any additional information. The facility incident report dated 7/12/17 did not reveal any additional information. No Elopement Risk Assessment could be located in resident 112's medical record. The facility Wander Risk assessment dated [DATE] revealed that resident 112 was assessed with [REDACTED]. A care plan for resident 112 dated 7/10/17 revealed a Focus area of (Resident 112), is constantly exit seeking, has poor safety skills, attempts to go out windows to exit. The goal for resident 112 included (Resident 112) will no (sic) untreated injury related to exit seeking thru next review. The interventions for resident 112 included Staff will monitor (Resident 112's) whereabouts closely and attempt to redirect him as he will allow. and (Resident 112) will reside on North (Locked Special Needs Unit) Hall secure unit for safety. On 9/27/17 at 11:00 AM, an observation was made of the facility's locked special needs unit windows. The window in room 404 revealed that it had a window guard, but the window was able to be opened about 11 inches. One window in the locked special needs unit did not have a window guard in place. On 9/27/17 at 12:00 PM, an interview was conducted with the facility Maintenance Director (MD). The facility MD confirmed that the elopements took place out of the windows in room 402 and that the one casing around the window was broken. The facility MD stated that he had replacement windows ordered but they had not been installed yet as they were not finished. The MD stated that he was not aware of the actual date that he was notified to secure the windows, nor what the actual date was that the windows were made secure but confirmed that the windows had been secured. When the facility MD was informed and observed the two windows in the secured unit, he stated that sometimes residents will take a knife and remove the screws in the window stops and remove them. On 9/28/17 at 8:30 AM, an interview was conducted with the facility DON (Director of Nursing). The facility DON stated that they did not ask about wandering risk prior to a resident being admitted to the facility. The facility DON stated that there was no documentation to show that residents who were determined to be a high risk for wandering, were monitored closely to prevent elopements. The facility DON stated that they did not have a specific elopement risk assessment. On 9/28/17 at 8:40 AM, an interview was conducted with the facility Administrator. The facility Administrator stated that if a resident got out of the facility, he did not consider it to be an elopement if they were still on the facility property. The facility Administrator stated that he was not aware that there were two windows in the secured unit that were not secured. The facility Administrator stated, they will be fixed today. 6. Resident 74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/27/17 the medical records were reviewed. Medical records revealed that the facility performed Minimum Data Set (MDS) assessments on the following dates: a. 6/5/17-admission MDS assessment, b. 6/12/17-medicare 14 day MDS assessment, and c. 9/16/17-quarterly MDS assessment. The Admission MDS assessment, section C (Cognitive Patterns), revealed that resident 74's Brief Interview for Mental Status (BIMS) score was 6, meaning that resident's 74 cognition was severely impaired. Medical records revealed that on 6/2/17 the facility staff assessed resident 74 to be at high risk for wandering and elopement. Medical records further revealed that the facility created the care plan for resident 74 on 5/31/17 with revision date of 12/22/17. In the care plan facility listed that resident 74 had the following problems: a. Was an elopement risk/wanderer, b. Was exit seeking, and multiple times verbalized intent to leave the building unattended, c. Was admitted to the secured unit for their own safety. The facility listed the following interventions in the care plan: a. Resident 74 would not leave the facility unattended through the review date, b. Resident 74 would be moved away from the room with the window facing the road, c. The staff would report to the unit manager and social worker any changes in resident 74's mood and behavior, d. The staff would provide reorientation when resident 74 would be in a questionable spot. The Incident Report Log was reviewed. The Incident Report Log revealed that on 7/10/17 resident 74 eloped from the facility. Incident Report revealed that on 7/10/17 at 11:53 PM, resident 74 Was found to be missing from his room. His window was open and his roommate had received an injury from the window falling down onto his arm. Nursing progress notes were reviewed. Nursing progress notes revealed the following: a. On 7/11/17, Resident 74 . was found missing from his room. Staff searched inside and outside of building without finding him. Police, administrator and family notified. Police was given info and picture to help identify him and left for search. Daughter called his cell phone and was able to make contact with him. He agreed to come back if someone would come and get him but he didn't know where he was. Said he was by a church and a mountain. Search centered on that and the administrator found him and brought him back to facility. Police were notified that he was back and message left with daughter. Was shown to another room, his previous room was 409B. Was angry about moving rooms and wanted to return to the room he had escaped from. Administrator working to lock that room for tonight. Res has been in bed all night and appears to be resting well. Adjusting to new room, away from exit door and secured window. b. On 7/11/17, Resident 74 . is on alert charting for elopement and check for skin breakdown. Resident has spent the majority of this shift in his room angry and quiet. He is angry because he feels there is nothing to do and really wants to be outside. He states that he wished he hadn't come back to the facility. The windows have been checked and no signs of manipulation are apparent. No attempts at the front door have been witnessed by the nurse either. c. On 8/11/17, Resident 74 . is on alert charting for behaviors. This shift, nurse overheard him telling his roommate that he would love to leave the facility and that he could have someone waiting for him to take him home. Nurse also abserved (sic) him looking out the windows that lead to the outside of the building as though he was looking for something. Nurse kept extra close eye on him, but did not see any further behaviors. d. On 8/24/17, Staff report that resident 74 .has been in room 402 talking with 'another resident' about 'getting out of this place.' (Resident 74) was previously living in room 402 until he escaped out of it. (Resident 74) has broken the window in that room and escape it. SW (social worker) myself (UM) spoke with (resident 74) and he admitted he tried it but he wouldn't do it again and he couldn't get the window back where it was supposed to be. Explained to (resident 74) that we were trying to keep him safe and asked him not to go in that room again. We told him that his roommate could visit him in his new room. He agreed and denied he had ever left building. Conversation with (resident 74) ended. Message left for Administrator and notifed (sic) the DON. e. On 8/31/17, This shift, nurse overheard resident (74) talking to his roommate about trying to break out of the nurses station door, but that the alarm would go off and everyone would come running. He also stated I wonder if there would be a good place to hide out there till they stopped looking. Resident (74) has also had the door to his room closed the majority of the shift. Nurse would go in and check on him many times but never witnessed any attempts to manipulate the window. f. On 9/3/17, Resident (74) continues on alert charting for behaviors. This shift, resident was overheard by the nurse talking with his roommate about how he had been looking at the windows and he saw some pins that could be pulled out to pop the windows out and get the f*** out of here. He then proceeded to tell his roommate about places that they could hide when everyone came looking for them. This got his roommate and other residents in the facility worked up. Nurse also witnessed him looking at the windows in other rooms and looking around to see who might be watching him. When he was asked what he was doing and if he needed help, resident stated, No, I'm fine, just looking out the window. He then went back to his room and was overheard making more comments about leaving. CNAs were informed of his increased anxiety about leaving and the decision was made to make sure staff looked at him and knew where he was at least every 15 minutes. g. On 9/4/17, Res (74) agitated and restless today. Exit seeking and restless. Ativan given. Some improvement in mood noted. Later after lunch observed res and his room mate going into an empty room at the end of the hall with an packed dufflebag in hand. When asked what they were doing they seemed surprised and responded just looking for some root beer. Then quickly left the room and went back into their room. Watching TV at this time. h. On 9/12/17, Nurse overheard resident talking to his roommate about breaking out of the facility and that there (sic) just youngsters watching the doors and we could take 'em out. He was also heard telling roommate about punching in series of numbers into the pad to learn what the code to the doors is. Resident told nurse he is sick of this place. i. On 9/16/17, He (resident 74) was overheard sitting in his room using extreme profanities and talking with his roommate about breaking out of the facility. Nurse noticed him at the double doors looking at the code box. Resident has a piece of paper with multiple number sequences on it. When he was approached, he walked away. Resident was also going into room 402 and when he was told multiple times that he could not go in there, he became angry and stood outside the door talking to the resident. On 9/27/17 the facility provided a copy of the Resident Elopement Guideline. In the guideline, under training section, the facility listed that each employee should be informed of their responsibility in regard to: a. Door alarms and security measures to prevent resident elopement. b. Reporting behavior of residents which may indicate they are at risk for elopement. c. Implementation of Action Checklist to a Suspected Resident Elopement. On 9/27/17 at 12:40 PM the Director of Nursing (DON) was interviewed. He stated that if there was an episode of an elopement, the facility would search for r (TRUNCATED)