Every finding on record at Monument Healthcare South Salt Lake

Based on interview and record review, for 1 out of 6 sampled residents, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident who was dependent on staff for bed mobility and repositioning fell out of bed during a bed bath while being assisted by one staff member. Resident identifier: 6.The facility developed and implemented a corrective action plan before the survey start date. The facility's corrective action plan, which was developed and implemented by 5/1/2026, included the following measures: conducting a house-wide audit on mechanical lifts, air mattresses, bed-bound residents, and heavier residents; updating care plans to ensure a two-person assist was required for positioning and bed baths for applicable individuals; increasing air mattress pressure settings to improve stability; and providing education to all staff regarding resident mobility and proper bed placement. The survey team verified that all these interventions were completed before the survey start date.Review of the medical record for Resident 6 revealed that the resident was admitted to the facility on [DATE], with diagnoses that included encephalopathy, chronic respiratory failure with hypercapnia, and severe obesity.Review of the comprehensive care plan for Resident 6 revealed an intervention initiated on 3/5/2026, stating that the resident required up to total assistance with bed mobility, sitting to lying, lying to sitting, or rolling.Review of the Minimum Data Set (MDS) assessment for Resident 6, dated 3/4/2026, revealed that the resident was completely dependent on staff to roll left and right while in bed.The surveyor reviewed a progress note dated 4/27/2026, at 1:36 pm. It was documented on the note that during a bed bath, a staff member reported that while repositioning Resident 6, the resident's lower body slipped off the edge of the bed. The staff member was unable to prevent the fall, and the resident fell off the left side of the bed, landing on their left side. The staff member notified a registered nurse and called for additional assistance. The resident was initially evaluated on the floor and then transferred back to bed using a mechanical lift. The resident did not have any apparent injuries. Due to uncertainty about a potential head injury, the decision was made to transfer the resident to the hospital for further evaluation. The surveyor reviewed an acute care progress note dated 4/30/2026, at 11:24 pm. It was documented on the note that staff were called into the room after a fall. During a bed bath, the bottom half of the resident's body slipped off the edge of the bed, resulting in a fall initially onto bilateral knees, after which the upper body hit the ground and presumably hit the head. The resident complained of diffuse pain in bilateral knees, collarbone, shoulders, cervical spine, and hip joints. Due to the fall, concurrent blood thinner therapy, and likely head trauma, the resident was sent to the emergency department for further evaluation and a head computed tomography (CT) scan to rule out a bleed and fractures.On 7/8/2026, at 11:00 AM, the surveyor interviewed Staff 1. Staff 1 stated that they were performing a bed bath for Resident 6 while the resident was laying on their side holding onto the grab bars. Staff 1 stated that they saw the resident's feet go forward, and the resident slipped down and out of bed. Staff 1 stated that the bed was in a low position. Staff 1 stated that they immediately obtained help from the nurse and followed orders from the nurse and provider. Staff 1 further stated that they believed that the resident was positioned correctly in the bed. Staff 1 stated that the [Unit Manager] educated them that day, and two days later, they received more education from the Director of Nursing (DON) and the Administrator regarding resident mobility and proper bed placement.On 7/8/2026, at 11:14 AM, the surveyor attempted to interview Resident 6 and left a voice message. Resident 6 did not respond to the voice message. On 7/8/2026, at 2:10 PM, the surveyor interviewed the DON. The DON stated that the resident was on a low-pressure air mattress and had large legs that provided leverage, causing the resident to move forward and slip out of the bed during the bed bath. The DON stated that the hospital emergency room found what appeared to be an older compressed chronic fracture that was not due to fall, and that the resident was subsequently transferred to another facility. The DON reported that Resident 6 did not sustain any injuries. The DON further stated that in response to the incident, the facility completed a house-wide audit on mechanical lifts, air mattresses, bed-bound residents, and heavier residents. Care plans were updated to ensure a two-person assist was mandated for positioning, bed baths, and other mobility tasks for affected residents. Additionally, the facility implemented a plan to increase air mattress pressures to provide more stability during care, and completed emergency preparedness and mobility education for all staff.The facility's Performance Improvement Plan was reviewed and was implemented by 5/1/2026. The plan included the following A facility-wide audit was conducted to identify residents requiring two-person assistance, ensuring care plans and Kardex were accurate and updates, and to confirm assistance levels were clearly documented and consistently followed. Care plans were updated for residents on air pressure mattresses to increase the pressure prior to beginning personal care and to return the mattress to the prescribed therapeutic setting. All residents who required a Hoyer lift were now a 2-person assist for all cares, including mobility in bed. Education on 2-person assist techniques, safe transfers, bed bath procedures, care plan/Kardex review, and proper use of mattresses was provided to all care staff Random daily audits by learning leadership that includes direct observation of care, and checks for documentation accuracy was started.

Based on observation, interview, and record review, 20 of 61 sampled resident, that the facility failed to ensure residents were providing supervision to prevent accidents. Specifically, hot water temperatures in resident rooms throughout the facility were observed to range in temperatures from 121.7-145.5 degrees Fahrenheit. This deficient practice occurred at an Immediate Jeopardy level. In addition, residents who were assessed as requiring supervision while smoking were observed smoking unsupervised, a resident was not evaluated for smoking and was observed smoking, residents with a history of wandering eloped from the facility without staff knowing, the front doorbell was not working and residents were locked outside unable to alert staff, and metal bed frames and boxes were stored in a dayroom that residents were observed to be in. Resident Identifiers: 3, 21, 24, 25, 32, 42, 48, 66, 71, 72, 73, 87, 100, 103, 110, 115, 119, 418, 421, and 424. NOTICE: Notice of Immediate Jeopardy (IJ) was given verbally to the Administrator on 6/10/25 at 2:30 PM. The Administrator was asked to develop an immediate plan to ensure resident safety related to hot water temperatures. PLAN: On 6/10/25 at 9:17 PM, the facility Administrator provided the following abatement plan for the removal of the IJ effective 6/10/25 at 8:30 PM. [Facility name] is providing the following information to demonstrate that the immediacy of the cited deficiency F689 has been removed. Summary of Actions Taken: Resident #3: Water temperature in the resident's room was measured by the Administrator/Maintenance Director to ensure it was at an appropriate temperature range. Skin check was completed on Resident by a licensed nurse and documented in medical record and no identified burns were present. Resident #24 Water temperature in the resident's room was measured by the Administrator/Maintenance Director to ensure it was at an appropriate temperature range. Skin check was completed on Resident by a licensed nurse and documented in medical record and no identified burns were present. Resident #25 Water temperature in the resident's room was measured by the Administrator/Maintenance Director to ensure it was at an appropriate temperature range. Skin check was completed on Resident by a licensed nurse and documented in medical record and no identified burns were present. Resident #66 Water temperature in the resident's room was measured by the Administrator/Maintenance Director to ensure it was at an appropriate temperature range. Skin check was completed on Resident by a licensed nurse and documented in medical record and no identified burns were present. Resident #71 Water temperature in the resident's room was measured by the Administrator/Maintenance Director to ensure it was at an appropriate temperature range. Skin check was completed on Resident by a licensed nurse and documented in medical record and no identified burns were present. Resident #72 Water temperature in the resident's room was measured by the Administrator/Maintenance Director to ensure it was at an appropriate temperature range. Skin check was completed on Resident by a licensed nurse and documented in medical record and no identified burns were present. Resident #73 Water temperature in the resident's room was measured by the Administrator/Maintenance Director to ensure it was at an appropriate temperature range. Skin check was completed on Resident by a licensed nurse and documented in medical record and no identified burns were present. Resident #87 Water temperature in the resident's room was measured by the Administrator/Maintenance Director to ensure it was at an appropriate temperature range. Skin check was completed on Resident by a licensed nurse and documented in medical record and no identified burns were present. Resident #100 Water temperature in the resident's room was measured by the Administrator/Maintenance Director to ensure it was at an appropriate temperature range. Skin check was completed on Resident by a licensed nurse and documented in medical record and no identified burns were present. Resident #103 Water temperature in the resident's room was measured by the Administrator/Maintenance Director to ensure it was at an appropriate temperature range. Skin check was completed on Resident by a licensed nurse and documented in medical record and no identified burns were present. Resident #110 Water temperature in the resident's room was measured by the Administrator/Maintenance Director to ensure it was at an appropriate temperature range. Skin check was completed on Resident by a licensed nurse and documented in medical record and no identified burns were present. Residents at Potential Risk: A plumber was dispatched to the facility on 6/10/25 to evaluate the water heater, mixing valve and holding tanks. The Plumber was able to make repairs that will maintain water temperature compliance. Full facility Skin check audit conducted on all other residents and a progress note was entered into the residents' medical record. No additional burns were identified. Full facility water temperature audit was conducted by Administrator/Maintenance Director to ensure it was at an appropriate temperature range. Audits were conducted on the evening of 6/10/25. A new thermometer was purchased that is compliant with testing water temperatures. Systemic Changes and Education Administrator and Maintenance Director were educated by Chief Operations Officer regarding safe water temperatures and proper temperature measurement, monitoring, and management. This education occurred on 6/10/25 at 16:15 [4:15 PM] hrs. [hours] Administrator and Maintenance Director were educated by Chief Operations Officer that regular water temperature checks must be performed, logged, and monitored to ensure resident safety. This education occurred on 6/10/25 at 16:15 hrs. Facility water temperature management logs are set up in the TELS [The Equipment Lifecycle System] system to be performed regularly by the Maintenance Director; Administrator will ensure this is completed appropriately and timely. Monitoring and Quality Improvement Measure: The Administrator/Maintenance Director/Designee will conduct full audits of facility water temperatures weekly x 4 weeks, followed by audits of 5 random resident rooms on each hallway monthly x 3 months to ensure water temperatures are within appropriate range for resident safety. Medical Director was informed of the incident an QAA [Quality Assessment and Assurance] Review & [and] Recommendations Results will be reported to the QAA committee for monitoring and follow-up The Administrator is responsible for substantial compliance of this Plan of Action The facility alleges the immediacy with the deficient practice has been removed on June 10, 2025 by 8:30 PM. The abatement was verified by the survey team on 6/11/25 at 10:30 AM. Findings included: WATER TEMPERATURES [Note: All temperatures were in degrees Fahrenheit and were obtained using a digital probe thermometer.] The surveyors' thermometers were calibrated in ice water on 6/9/25 at 1:00 PM. On 6/9/25 at 1:05 PM, room [ROOM NUMBER], occupied by 2 residents, had a sink in the room with a water temperature of 131.0 in 30 seconds. Residents in room [ROOM NUMBER] were ambulatory. One required a walker and had a diagnosis of Parkinson's disease. On 6/9/25 at 1:09 PM, room [ROOM NUMBER]'s bathroom sink had a water temperature of 142.7. Resident 72 resided in 315-A and used a walker to ambulate. Resident 24 resided in 315-B and stated he was able to ambulate to the bathroom on his own. Resident 24 had moderate cognitive impairment. On 6/9/25 at 1:13 PM, room [ROOM NUMBER]'s bathroom sink water was 145.5. Resident 25 resided in 320-A and used a wheelchair. Resident 66 resided in 320-B and used a manual wheelchair. Resident 66 had a moderate cognitive impairment. On 6/9/25 at 1:29 PM, room [ROOM NUMBER]'s bathroom sink water was 141.7. Resident 73 and resident 3 were ambulatory. Resident 3 had moderate cognitive impairment. On 6/9/25 at 2:23 PM, room [ROOM NUMBER] occupied by one resident who had a bathroom sink water temperature of 124.1. On 6/9/25 at 2:25 PM, room [ROOM NUMBER] occupied by two residents, had a bathroom sink water temperature of 123.5. An interview was conducted with resident 71. Resident 71 stated that the water got very hot in the bathroom sink. Resident 71 stated that she used the sink water to make noodles in a cup because of how hot the water was. On 6/9/25 at 2:32 PM, room [ROOM NUMBER], which had 2 residents who occupied the room, had a water temperature of sink water temperature was 121.7. Resident 87 had moderate cognitive impairment. On 6/9/25 at 2:47 PM, room [ROOM NUMBER], which had 2 residents who occupied the room, had a water temperature of sink water temperature was 126.0. Resident 100 and resident 103 resided in room [ROOM NUMBER]. Both residents had moderately impaired cognition. On 6/9/25 at 3:50 PM, room [ROOM NUMBER]'s bathroom sink was 130.1 and room [ROOM NUMBER]'s bathroom sink was 130.0. Resident in 313 B had paranoid schizophrenia. Resident in 313 and used an electric wheelchair for mobility. On 6/9/25 at 2:58 PM, a tour of the facility's water boiler room with the Maintenance Director was conducted. The Maintenance Director stated the facility received hot water from the boiler and the kitchen received hot water from a water heater. The Maintenance Director stated that the water temperatures for the facility should be between 105-115. On 6/9/25 at 3:02 PM, an observation was made of the boiler, The boiler showed a temperature of 188. The Maintenance Director stated the water went from the boiler to the mixing valve. There was no temperature gauge observed on the mixing valve. The Maintenance Director stated that there were two holding tanks for water and that there were no thermometer gauges on the tanks. On 6/9/25 at 3:09 PM, room [ROOM NUMBER]'s bathroom sink, the Maintenance Director tested the water temperature with an infrared thermometer. The Maintenance Director's thermometer read at 102. The surveyors thermometer read 122.2. On 6/9/25 at 3:13 PM, room [ROOM NUMBER]'s bathroom sink water was tested by the Maintenance Director. The Maintenance Director's infrared thermometer read 115. The surveyors thermometer read 128.9. On 6/9/25 at 3:16 PM, room [ROOM NUMBER]'s bathroom sink water was tested by the Maintenance Director. The Maintenance Director's infrared thermometer read 114.4. The surveyors thermometer read 121.7. On 6/9/25 at 3:19 PM, room [ROOM NUMBER]'s bathroom sink water was tested by the Maintenance Director. The Maintenance Director's infrared thermometer read 98.2. The surveyors thermometer read 123.1. On 6/9/25 at 3:50 PM, room [ROOM NUMBER]'s bathroom sink was 130.1 and room [ROOM NUMBER]'s bathroom sink was 130.0. On 6/10/25 at 9:17 AM, an interview was conducted with the Administrator (Admin). The Admin stated that last night and this morning the facility had tested the water with different probe thermometers and the infrared thermometer and the temperatures all varied. The Admin stated that the low temperatures from the monthly maintenance log should have been a red-flag with the water temperature. A review of the facility water temperature log over the past six months revealed the highest water temperature was 108 in room [ROOM NUMBER] on 4/28/25 and the lowest temperature was 81 in room [ROOM NUMBER] on 5/23/25. The weekly water temperatures for 6/2/25 in room [ROOM NUMBER] was 98, in room [ROOM NUMBER] was 96, in room [ROOM NUMBER] was 97, in room [ROOM NUMBER] was 98, and in room [ROOM NUMBER] was 87. SMOKING: 1. Resident 48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and nicotine dependence. On 6/11/25 at 12:56 PM, an observation was made of resident 48 smoking in the supervised area of the facility. On 6/11/25 at 1:38 PM, an observation was made of resident 48 smoking outside unsupervised on the facility lawn near the sidewalk. Resident 48's medical record was reviewed 6/9/25-6/19/25. A review of resident 48's smoking evaluation dated 4/15/25 revealed that resident 48 may smoke supervised by facility staff in the designated area and at supervised smoking times. The facility would store resident 48's smoking materials between designated smoking times. A care plan dated 4/16/25 revealed that resident 48 wished to smoke while remaining at the facility. The goal was that resident 48 would smoke safely through the review date. Interventions included Facility staff will supervise me while smoking at designated times and will store my smoking materials between designated times; I have been educated that smoking materials are for use only in designated smoking areas and; I will continually demonstrate safe smoking techniques including safe lighting materials, holding smoking materials safely, disposal of ashes, response to fallen ashes, secure storage of materials etc. 2. Resident 418 was admitted to the facility 6/2/25 and readmitted [DATE] with diagnoses which included aphasia following cerebral infarction, epilepsy, spastic hemiplegia, and difficulty walking. On 6/11/25 at 12:56 PM, an observation was made of resident 418 smoking in the supervised area of the facility. A review of resident 418's smoking evaluation dated 6/12/25 revealed that resident 418 required supervision while smoking. There was no care plan that addressed smoking located in resident 418's medical record. It should be noted that resident 418 received a smoking evaluation 10 days after he was admitted . 3. Resident 421 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia, muscle weakness, and asthma. On 6/9/25 at 12:04 PM, an observation was made of resident 421 remove a pack of cigarettes from his pocket and give resident 42 cigarettes in the dining room during lunch. On 6/12/25 at 6:31 AM, an observation was made of resident 421 outside the facility smoking by a dumpster in the parking lot. On 6/18/25 at 8:30 AM, an observation and concurrent interview was conducted with resident 421. Resident 421 was observed to have a pack of cigarettes in his shirt pocket and a lighter was on the floor next to his bed. Resident 421 stated that the facility let him smoke unsupervised but that he had to be outside the facility property. Resident 421 stated that he had his smoking supplies on him even though he knew that he was not supposed to. Resident 421's medical record was reviewed 6/9/25-6/19/25. A review of resident 421's smoking evaluation date 4/15/25 revealed that resident 421 required supervision while smoking. A care plan dated 4/16/25 revealed that resident 421 wished to smoke while remaining at the facility. The goal was that resident 421 would smoke safely through the review date. Interventions included Facility staff will supervise me while smoking at designated times and will store my smoking materials between designated times; I have been educated that smoking materials are for use only in designated smoking areas and; I will continually demonstrate safe smoking techniques including safe lighting materials, holding smoking materials safely, disposal of ashes, response to fallen ashes, secure storage of materials etc. 4. Resident 424 was admitted to the facility on [DATE] with diagnoses which included paraplegia, muscle spasms, and muscle weakness. On 6/11/25 at 7:35 AM, an observation was made of resident 424 outside the facility near the sidewalk smoking. On 6/12/25 at 7:57 AM, an observation was made of resident 424 outside of the facility near the sidewalk smoking. Resident 424's medical record was reviewed 6/9/25-6/19/25. A review of resident 424's smoking evaluation dated 5/21/25 revealed that resident 424 required supervision while smoking. A care plan dated 5/21/25 revealed that resident 424 wished to smoke while remaining at the facility. The goal was that resident 424 would smoke safely through the review date. Interventions included Facility staff will supervise me while smoking at designated times and will store my smoking materials between designated times; I have been educated that smoking materials are for use only in designated smoking areas and; I will continually demonstrate safe smoking techniques including safe lighting materials, holding smoking materials safely, disposal of ashes, response to fallen ashes, secure storage of materials etc. 5. Resident 21 was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia, tobacco use, adult failure to thrive, and epilepsy. On 6/12/25 at 7:15 AM, an observation was made of resident 21 wheeling in front of the facility in their wheelchairs. Resident 21 was observed to stop on the side walk east of the facility. Resident 21 was observed to use resident 89's lighter to light his cigarette. Resident 21 was not supervised by staff when smoking. Resident 21's medical record was reviewed 6/9/25 through 6/19/25. A quarterly smoking evaluation dated 4/15/25 revealed Resident may smoke SUPERVISED. A care plan dated 4/16/25 revealed resident 21 wished to smoke while residing at this facility. The goal was resident 21 would smoke safely through the review date. Interventions included Facility staff will supervise me while smoking at designated times and will store my smoking materials between designated times; I have been educated that smoking materials are for use only in designated smoking areas and; I will continually demonstrate safe smoking techniques including safe lighting materials, holding smoking materials safely, disposal of ashes, response to fallen ashes, secure storage of materials etc. On 6/19/25 at 9:36 AM, an interview was conducted with resident 21. Resident 21 stated he was able to smoke unsupervised any time. Resident 21 stated he was able to keep his smoking materials. Resident 21 stated if there were specific times that he had to smoke, he would not like that. On 6/19/25 at 9:46 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated there were set times for supervised smokers to smoke. LPN 2 stated there was a list of residents who smoked at each nurses station. LPN 2 stated resident who were evaluated to smoke independently could go outside into the community, off of facility grounds and smoke anytime. LPN 2 stated independent smokers needed to sign out at the front desk before leaving. LPN 2 stated resident 21 was on the list as requiring supervision while smoking. LPN 2 stated all residents had a smoking evaluation conducted upon admission and when there was a change in condition. LPN 2 stated residents who were not deemed as safe were not allowed to keep their smoking materials. LPN 2 stated residents who required supervision were not allowed to sign out and go off property to smoke. LPN 2 stated resident 21 kept his smoking materials and smoked independently when signed out because when a resident signed out they were responsible for themselves. On 6/12/25 at 9:03 AM, an interview was conducted with RN 2. RN 2 stated if a resident was capable of lighting their own cigarettes, then they can go smoke off property to smoke. RN 2 stated the resident needed to be able to sign themselves out and push themselves out the door to go off property. 6. Resident 32 was admitted to the facility on [DATE] with diagnoses which included polyneuropathy, need assistance with personal care, cognitive communication deficit and muscle weakness. Resident 32's medical record was reviewed 6/9/25 through 6/19/25. A smoking evaluation dated 4/15/25 revealed resident 32 scored a 0. There was no information if resident 32 was able to smoke independently or supervised. A care plan dated 6/30/23 revealed resident 32 was a smoker or used electronic cigarette/vape device. The goal was resident 32 would follow all smoking rules through review date. Intervention created on 6/12/25 revealed I have been educated that smoking materials are for use only in designated smoking areas and I have been oriented to smoking procedures and areas including designated supervised smoking times, if applicable. An intervention dated 10/19/24 revealed Resident was deemed an independent smoker. On 6/18/25 at 1:53 PM, an interview was conducted with DON (Director of Nursing) 2 and Regional Nurse Consultant (RNC). The RNC stated resident 32 was an independent smoker but the second question of the smoking assessment was not answered so the assessment was not completed on 4/15/25. The RNC stated the assessment was not completed so there was no information on the assessment if resident 32 required supervision or not. The RNC stated resident 21 was a supervised smoker according to the smoking evaluation. The RNC stated there resident 21 had leave of absence privileges, so he could sign out and smoke off property. The RNC stated the parking lot by the dumpster and the sidewalk on the east side of the facility were off the property. The RNC stated based on resident 21's smoking assessment and because he was trying to smoke outside on property so he was changed to a supervised smoker. The RNC stated that was based on the smoking policy. On 6/11/25 at 12:59 PM, an interview was conducted with Human Resources (HR). HR stated that every resident in the facility was a supervised smoker and that the facility kept the residents' smoking supplies in a locked box. HR stated that if residents refused to have their smoking supplies locked up then it was care planned that the resident kept their smoking materials. HR stated that there was not a written list of residents that required assistive devices while smoking and that it was more of a verbal list between staff. HR stated that nursing staff determined if residents required assistive devices. On 6/17/25 at 10:15 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that it the resident's Brief Interview of Mental Status (BIMS) score determined if the resident required supervision while smoking. RN 1 stated that resident's smoking materials were stored in a toolbox that was locked. RN 1 stated that any resident could sign themselves out of the facility and could smoke off property unsupervised. On 6/17/25 at 10:55 AM, an interview was conducted with the Certified Nursing Assistant (CNA) Coordinator. The CNA Coordinator stated that there were 5 scheduled times that residents could smoke at. The CNA Coordinator stated that there was a locked black box that was outside that smoking materials were kept in. The CNA Coordinator stated that lighters, cigarettes, and vapes were kept in the locked box. The CNA Coordinator stated that all residents in the facility should go outside to the designated smoking area at the scheduled times, but there were residents that signed themselves out of the facility and smoked off property. The CNA Coordinator stated that residents were not able to keep their smoking supplies with them. The CNA Coordinator stated that there was a list of supervised smokers that was observed to be dated 2/2/25 located at the 300 hallway nurse's station. The CNA Coordinator stated that the list was not current and needed to be updated. On 6/18/25 at 1:53 PM, an interview was conducted with the RNC and DON. The RNC stated when a resident admitted to the facility and they were a smoker, an evaluation was performed. The RNC stated there were both supervised and independent smokers currently in the facility. The RNC stated that if residents were supervised smokers, the facility kept their smoking supplies to ensure they were secured. The RNC stated that resident's signed a smoking contract upon admission which instructed residents to not share smoking materials. The RNC stated that residents could sign themselves out on a leave of absence (LOA) and smoke independently even if they were deemed to be supervised smokers by the facility. The RNC stated that a resident is able to leave on LOA based on their cognition. ELOPEMENT:1. Resident 115 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included traumatic brain injury, cognitive communication deficit, and vascular dementia. Resident 115's medical record was reviewed 6/9/25-6/19/25. On 2/14/24 a Minimum Data Set (MDS) Assessment for BIMS was conducted on resident 115. Resident 115 score was 6. A score of 0-7 would indicate severe cognitive impairment. Resident 115 had a care plan dated 6/22/21 and revised on 4/18/23, which had a care plan focus of, Resident is an elopement risk without exit seeking behaviors. [resident 115] is very impressionable and would leave with a friend or family member. Interventions included, Document wandering behavior and attempted diversional interventions in [electronic medical record] PRN [as needed] if resident is exhibiting exit seeking behaviors and Wander Guard in place to alert staff of exit seeking. On 10/8/23 a wander risk assessment revealed a score of 14 which indicated that resident 115 was at risk for wandering/elopements. On 3/31/24 at 8:53 PM, an alert note documented, At 1715 [5:15 PM], Medicare CNA answered a phone call from a person living in the area stating he saw a resident leave the facility. CNA looked outside for the resident and got in her vehicle and went down two blocks and the resident was walking on the sidewalk at 1718 [5:18 PM]. CNA safely helped the resident into her vehicle and brought the resident back to the facility. CNA notified DON of Elopement . On 6/19/25 at 8:18 AM, an interview was conducted with Unit Manager (UM) 2. UM 2 stated that resident 115 had dementia and was very sneaky about things and had had a few elopements while a resident. UM 2 stated that resident 115 would hide around corners and sneak out of the facility whenever she could. UM 2 stated that resident 115 had a wanderguard on and staff were educated that when they left the building to make sure resident 115 did not follow. UM 2 stated that resident 115 was not safe outside of the facility and would be unable to find her way back. UM 2 stated that the facility determined it was not secure enough for resident 115 and she was transferred to a facility with a locked unit. On 6/19/25 at 10:41 AM, an interview was conducted with the RNC. The RNC stated there was an elopement evaluation that nursing staff filled out and depending on the score interventions will be put in place to prevent elopement. The RNC stated once someone had eloped, staff should do an internal search to see of they could locate the resident. The RNC stated that resident 115 was an elopement risk and would not be safe out in the community on her own. The RNC stated that resident 115 had a wanderguard on and it was checked by nursing staff every shift to ensure that it was in place on the resident. The RNC stated that the wanderguard was checked twice on 3/31/24. On 6/19/25 at 11:02 AM, an interview was conducted with the Admin. The Admin stated that resident 115 was a wander risk. The Admin stated that resident 115 was spotted outside and was brought back to the facility and placed on a one to one until she was transferred the next day. The Admin stated he was not sure how resident 115 got out of the building while wearing a wanderguard. 2. Resident 119 was admitted to the facility on [DATE] with diagnoses which included intercranial injury with loss of consciousness, dementia with behavioral disturbance, delirium, dysphagia, and repeated falls. The medical record of resident 119 was reviewed 6/9/25 through 6/19/25. On 6/17/25 at 9:05 am, a Facility Reported Incident (FRI) report was reviewed and documented, on 4/20/2025 at 12:13 PM, the facility reported that on 4/19/2025 at 10:30 PM, At 10:00 pm [staff nurse] went to give [resident 119] his meds [medications]. She was not able to find him she [sic] staff started looking for him. At 10:15 pm facility got a call that looking for him. At 10:15 pm facility got a call that [resident 119] was outside harassing people so the police were called. Once the police arrived [resident 119] became combative so the police took him to the hospital. The FRI report documented resident 119 as being independent. An investigation was completed by the facility and documented the following: On 4/20/25 at 9:00 pm the nurse was passing medications and could not find the resident. She asked the CNA who stated they had seen him before his break which was about 20 minutes earlier. They both started to look for the resident and could not find him. On 4/20/25 at 9:20 pm a [local hospital] called and said that the resident had been brought to the hospital by the police. They said that he was following people down the road so they called the police. He was not harmed or injured. A progress note dated 4/19/25 at 11:03 PM documented, Patient was last seen walking around the facility at approximately 2100 [9:00 PM] At around 2130 [9:30 PM], patient was following a group of pedestrians in [local city], when they then called 911. Upon arrival, authorities encountered the patient, who then initiated an altercation with the responding police officers. The facility received a call from [local hospital] ED [emergency department] confirming that the patient had been brought in by law enforcement. No injuries were reported to the facility at the time of notification. Patients behavior was described as agitated and confrontational upon police contact. DON has been notified. [Local hospital]was going to get in contact with [hospice company] regarding the situation. Awaiting further updates from [hospital and hospice agency] staff regarding patients condition and potential return to facility. An admission MDS dated [DATE] indicated resident 119 had a

Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. Specifically, a staff and public restroom had extremely hot water temperatures. These findings were found to have occurred at an Immediate Jeopardy (IJ) Level. NOTICE:Notice of Immediate Jeopardy (IJ) was given verbally to the Administrator on 6/10/25 at 2:30 PM. The Administrator was asked to develop an immediate plan to ensure resident safety related to hot water temperatures. PLAN:On 6/10/25 at 9:17 PM, the facility Administrator provided the following abatement plan for the removal of the IJ effective 6/10/25 at 8:30 PM.[Facility name] is providing the following information to demonstrate that the immediacy of the cited deficiency F689 has been removed.Summary of Actions Taken: Water temperatures were measured by Administrator/Maintenance Director to ensure it was at an appropriate temperature range.Residents at Potential Risk: A plumber was dispatched to the facility on 6/10/25 to evaluate the water heater, mixing valve and holding tanks. The Plumber was able to make repairs that will maintain water temperature compliance. Full facility water temperature audit was conducted by Administrator/Maintenance Director to ensure it was at an appropriate temperature range. Audits were conducted on the evening of 6/10/25. A new thermometer was purchased that is compliant with testing water temperatures.Systemic Changes and Education Administrator and Maintenance Director were educated by Chief Operations Officer regarding safe water temperatures and proper temperature measurement, monitoring, and management. This education occurred on 6/10/25 at 16:15 [4:15 PM] hrs. [hours] Administrator and Maintenance Director were educated by Chief Operations Officer that regular water temperature checks must be performed, logged, and monitored to ensure resident safety. This education occurred on 6/10/25 at 16:15 hrs. Facility water temperature management logs are set up in the TELS [The Equipment Lifecycle System] system to be performed regularly by the Maintenance Director; Administrator will ensure this is completed appropriately and timely.Monitoring and Quality Improvement Measure: The Administrator/Maintenance Director/Designee will conduct full audits of facility water temperatures weekly x 4 weeks, followed by audits of 5 random resident rooms on each hallway monthly x 3 months to ensure water temperatures are within appropriate range for resident safety. Medical Director was informed of the incident an QAA [Quality Assessment and Assurance] Review & [and] Recommendations. Results will be reported to the QAA committee for monitoring and follow-up The Administrator is responsible for substantial compliance of this Plan of Action.The facility alleges the immediacy with the deficient practice has been removed on June 10, 2025 by 8:30 PM.The abatement was verified by the survey team on 6/11/25 at 10:00 AM. Findings included:On 6/9/25 at 12:49 PM, an observation was made of the staff and public bathroom. The door was locked with a code. The water temperature was taken with a digital thermometer which read 142.0 degrees Fahrenheit after 30 seconds of running the hot water. On 6/9/25 at 2:58 PM, a tour of the facility's water boiler room with the Maintenance Director was conducted. The Maintenance Director stated the facility received hot water from the boiler and the kitchen received hot water from a water heater. The Maintenance Director stated that the water temperatures for the facility should be between 105-115. On 6/9/25 at 3:02 PM, an observation was made of the boiler, the boiler showed a temperature of 188. The Maintenance Director stated the water went from the boiler to the mixing valve. There was no temperature gauge observed on the mixing valve. The Maintenance Director stated that there were two holding tanks for water and that there were no thermometer gauges on the tanks. The Maintenance Director stated he used an infrared thermometer to test the water temperatures by having a steady stream of water and then pointing it toward the water. On 6/10/25 at 9:17 AM, an interview was conducted with the Administrator (Admin). The Admin stated that last night and this morning the facility had tested the water with different probe thermometers and the infrared thermometer and the temperatures all varied. The Admin stated that the low temperatures from the monthly maintenance log should have been a red-flag with the water temperature. A review of the facility water temperature log over the past six months revealed the highest water temperature was 108 in room [ROOM NUMBER] on 4/28/25 and the lowest temperature was 81 in room [ROOM NUMBER] on 5/23/25. The weekly water temperatures for 6/2/25 in room [ROOM NUMBER] was 98, in room [ROOM NUMBER] was 96, in room [ROOM NUMBER] was 97, in room [ROOM NUMBER] was 98, and in room [ROOM NUMBER] was 87.On 6/11/25 at 9:53 AM, a follow up interview was conducted with the Maintenance Director. The Maintenance Director stated he was instructed to use the infrared thermometer from the Corporate Maintenance Director. The Maintenance Director stated he watched training videos on how to test water temperatures and the videos used a probe thermometer to test water temperatures. The Maintenance Director stated a plumber came on 6/10/25 and ordered parts for the hot water system.

Based on observation, interview, and record review, it was determined that for 2 of 61 sampled residents, the facility did not ensure residents who displayed or were diagnosed with mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Specifically, a resident who was diagnosed with mental disorders was observed to be at the end of a hallway for hours with a urine odor yelling at staff and residents, was not provided her psychotropic medication, and did not follow up on a Nurse Practitioner's recommendation of inpatient psychiatric admission. Resident identifiers: 48 and 59.Findings included:Resident 59 was admitted to the facility on [DATE] with diagnosis which included severe dementia with agitation, paranoid schizophrenia, type 2 diabetes, generalized anxiety disorder, delusional disorders, insomnia, schizoaffective disorder, and essential hypertension.Resident 59's medical record was reviewed on 6/9/25 through 6/19/25.On 6/9/25 at 10:14 AM, an observation was made of resident 59's room. The room did not contain any personal items.On 6/9/25 at 10:29 AM, an observation was made of resident 59 wandering up and down the hallways carrying 2 packages of briefs and a sack with toilet paper. Resident 59 was observed to be talking to herself which was not understandable.On 6/9/25 at 10:55 AM, an observation was made of resident 59 yelling out. During this time an interview was conducted with resident 48, who resided in the same hallway as resident 59. Resident 48 stated that this behavior was normal for resident 59 and resident 59's screaming often woke him up. Resident 48 stated that resident 59 could be verbally aggressive with other residents.On 6/10/25 at 8:45 AM, an observation was made of resident 59 in the west side 100 hallway near an exit. Resident 59 had plastic bags and blankets. Resident 59 had a strong urine odor. Resident 59 told surveyor to shut up when approached. Resident 59 appeared to be trying to exit the facility, however the door was locked. At 9:55 AM, resident 59 remained at the west side door intermittently screaming. At 11:03 AM, resident 59 remained at the west side door yelling out. [Note: Resident was observed for over 2 hours in the corner with a strong urine odor, yelling at staff and residents.]On 6/11/25 at 9:43 AM, an observation was made of resident 59 in her room yelling out and she could be heard from the hallway.On 6/11/25 at 10:09 AM, an observation was made of resident 59 in her room yelling out and she could be heard from the hallway.On 6/11/25 at 2:20 PM, an observation was made of resident 59 in her room yelling out and she could be heard from the hallway.A review of resident 59's progress notes revealed: a. On 4/10/25 at 4:21 PM, a medication administration note documented, Invega Sustenna Intramuscular Suspension Prefilled Syringe 117 MG [milligram]/0.75ML [milliliter] Inject 117 mg intramuscularly every day shift every 21 day(s) related to PARANOID SCHIZOPHRENIA (F20.0) Notify management if [resident 59] refuses Injection has not arrived, willadminister it when it does arrive within the facility. b. On 5/27/25 at 12:45 PM, a Psychiatric Follow Up note documented, .Continue with overall plan as stated. The patient does require continued monitoring due to their currentsituation [sic]/circumstance and potential forchange [sic] in presentation and need forpsychotropic [sic] options. Going forward willcontinue [sic] to round on patient, coordinate with staffand [sic] assessfor medication updates. Per today's visit:- Patient continues to yell/ screamoccasionally [sic] during the day andfrequently [sic]throughout the night, which is upsettingmultiple [sic] other residents. The pt [patient] could benefit from medication stabilization viainpatient [sic] care at a behavioral health facility where they can utilize specificmedications [sic] and psychiatric care which are not available at the current facility. c. On 6/9/25 at 3:35 PM, a progress note documented, Patient was due for her Invega injection today. Medication is currently unavailable. This nurse called the pharmacy to reorder the medication, and it is set to arrive by tomorrow per pharmacy.On 6/11/25 at 11:33 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that staff always tried to redirect resident 59 and find out what was bothering her when she screamed out. LPN 2 stated that resident 59 responded better to familiar staff.On 6/11/25 at 2:276 PM, an interview was conducted with Certified Nursing Assistant (CNA) 10. CNA 10 stated that staff did not try and stop resident 59 from carrying around items but did try to redirect her when she got upset.On 6/19/25 at 8:22 AM, a follow-up interview was conducted with LPN 2. LPN 2 stated that resident 59's medication was one of those injections that insurance would not cover repeat orders close together and staff were forgetting to contact the pharmacy. LPN 2 stated that she spoke with Unit Manager (UM) 1 about getting a reminder in the chart in May 2025, but the reminder had not been added to the chart. LPN 2 stated that resident 59 had been on the medication since she had worked at the facility and that was over 8 months.On 6/19/25 at 10:08 AM, an interview was conducted with UM 1. UM 1 stated that staff would try and redirect resident 59 when she was having behaviors. UM 1 stated that resident 59 missed her medication injections in April and June of 2025 because of insurance issues. UM 1 stated that resident 59 had to have an injection because she would not take oral medications. UM 1 stated that resident 59 had not been referred to an inpatient facility because it was difficult to find one that would take the resident.On 6/19/25 at 1:27 PM, an interview was conducted with the Director of Nursing (DON) 2 and Regional Nurse Consultant (RNC). The RNC stated that there was not a way for resident 59 to get an inpatient stay without going through the emergency room at a hospital. The RNC stated that resident 59 was sent to the emergency room for her behaviors and the emergency room senther back. The RNC stated she would send the hospital report. It should be noted that no additional hospital information was received.

Based on observation, interview and record review it was determined the facility did not provide or obtain laboratory services to meet the needs of its residents. If the facility provided its own laboratory services, the services must meet the applicable requirement for laboratories. Specifically, facility glucometers were not being calibrated according to the manual. Findings included:1. The facility's 500 hall glucometer calibration and quality control tracking sheet was reviewed. The glucometer was calibrated on 4/24/25 at 6:30 AM, 5/4/25 at 9:45 AM, 5/17/25 at 4:40 PM, 6/1/25 at 1:00 AM, and 6/4/25 at 11:00 PM. On 6/12/25 at 10:08 AM, a phone interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the night shift calibrated the facility glucometers weekly and documented the results in the narcotics binder. LPN 1 stated that, to his knowledge, the facility glucometer was working and accurate. On 6/12/25 at 10:40 AM, an interview was conducted with LPN 2. LPN 2 stated the glucometers were calibrated weekly by the graveyard shift nurse and the calibration log was kept in the narcotic binder. 2. On 6/12/25 at 10:38 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated Certified Nursing Assistants (CNA's) could be passed off to check glucose levels of residents, but he personally liked to do his own blood sugar checks. RN 2 stated that his medication cart had two glucometers to test resident's glucose levels. RN 2 stated that the glucometers in the facility were not required to be calibrated. RN 2 stated that the weekend manager was the one that signed the log when calibration was done.The medication cart for the 100/200 hall way odd side had a glucometer calibration log with the dates 4/24/25, 5/4/25, and 5/17/25. On 6/12/25 at 10:51 AM, an interview was conducted with RN 4. RN 4 stated that the nursing night shift performed calibration for the glucometers. RN 4 stated that she was unsure how often this was performed. RN 4 stated that she was unsure where the calibration log was kept and was unable to locate one on her medication cart for the 100/200 hallway even side. On 6/12/25 at 11:36 AM, an interview was conducted with the Director of Nursing (DON) 1. DON 1 stated that CNA's were not able to perform blood sugar checks because they had not been passed off. 3. On 6/12/25 at 10:30 AM, the 300 and 400 hallway glucometer calibration form was reviewed calibration was done 4/24/25, 5/4/25 at 10:30 AM, 5/9/25 at 4:45 PM, 5/17/25 at 4:45 PM, 5/30/25 at 11:30 PM, and 6/5/25 at 2:00 AM. On 6/12/25 at 10:40 AM, an interview was conducted with Certified Medication Aide (CMA) 1. CMA 1 stated medication aides were able to obtain blood glucose levels. CMA 1 stated that calibrations were done during the night shift weekly. On 6/12/25 at 10:45 AM, an interview was conducted with CMA 2. CMA 2 stated glucometers were calibrated weekly during the night shift. On 6/18/25 at 12:40 PM, an interview was conducted with the Regional Nurse Consultant (RNC) and DON 2. The RNC stated according to the manufacturer requirements glucometers needed to be calibrated weekly. The RNC stated they were not being calibrated according to the manufacturer instructions. The glucometer manual revealed controlled solution testing should be done when using the meter the first time, once per week to ensure the meter and test strips were working properly, using a new bottle of testing strips, or if it was suspected the testing strips and meter were not working properly.

Based on observation, interview and record review the facility did not ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Specifically, sanitizer solution was not measuring on the testing strips, there were soiled areas in the kitchen and spices were left open to air. Findings included:1. On 6/9/25 at 9:23 AM, an initial kitchen tour was conducted. The following was observed: a. The area behind the steamer had a white substance splattered on it, debris and grease splatter. The table it is sitting on is rusty, has a white splatter on the legs and the bottom shelf. b. The area under the storage shelves and under the storage carts in the dish room were soiled. The floor had a white substance on it. 2. On 6/18/25 at 11:54 AM, an observation was made of the Registered Dietitian (RD) in the kitchen without a hairnet, in the food preparation area. 3. On 6/19/25 at 11:19 AM, a follow-up tour of the kitchen was conducted. The following was observed: a. The sanitizer solution in the cooking area was tested. The test strip turned blue. Using the test strip comparing it to test strip container revealed there was no blue color to determine parts per million (PPM) of the quats sanitizer solution. The highest was 400 PPM of quats sanitizer solution which was the color was green. The preparation area sanitizer solution was tested and the strip turned blue. According to the label on the sanitizer it should be testing at 150 to 400 PPM. An observation was made of sanitizer solution container. The container revealed it was a quats sanitizer and needed to be 150-400 PPM for food surfaces. An interview was immediately conducted with the Dietary Manager (DM). The DM stated the sanitizers were just changed because the solution was warm. The DM stated the blue color meant it was 400 PPM. The DM confirmed there was no blue color on the sanitizer strips check. b. There were plastic drawers with serving utensils that was soiled. c. Behind the steamer there was debris and black substance. d. There was white substance on the floor under the preparation sinks. e. There was tape on the ceiling above the preparation sink. f. There were 4 large bins labeled powdered milk, sugar, flour and oatmeal. The bins were soiled around the tops that opened. g. Spices labeled cajun and thyme leaves were open to air. h. The steamer was broken and not available for use. On 6/29/25 at 12:01 PM, an interview was conducted with the DM. The DM stated the steamer had been broken for about a year. The DM stated the steamer was used for vegetables, pork ribs and mashed potatoes. The DM stated staff had to boil everything which took longer. The DM stated it was hard to get the same results with boiling foods over steaming. The DM stated every 2 weeks staff cleaned behind the steamer, stove and grill. The DM stated floors were cleaned daily. The DM stated the white containers were cleaned daily after the cook finished tray line and cleaning up. The DM stated the drawers with scoops should be cleaned weekly.

Based on observation, interview, and record review the facility did not ensure that policies were established and implemented to ensure that identified deficiencies were corrected. Specifically, areas of immediate jeopardy (IJ) were identified and not identified through the Quality Assurance and Performance (QAPI) process. In addition, multiple areas of non compliance were cited on the previous survey and again during the current recertification survey. Findings included:1. Based on observation, interview, and record review it was determined, for 12 out of 61 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, hot water temperatures in resident rooms throughout the facility were observed to range in temperatures from 121.7-145.5 degrees Fahrenheit. The deficient practice identified, in regards to the hot water, was found to have occurred at an Immediate Jeopardy level. In addition, residents who were assessed as requiring supervision while smoking were observed smoking unsupervised, a resident was not evaluated for smoking and was observed smoking, and residents with a history of wandering eloped from the facility without staff knowing. Resident Identifiers: 3, 5, 21, 24, 25, 32, 48, 66, 71, 72, 73, 87, 100, 103, 110, 113, 115, 119, 418, 421, 424 A review of the facility's weekly water temperature logs from 5/9/25-6/2/25 revealed: a. On 5/9/25 the hottest water temperature recorded was 98 degrees Fahrenheit. b. On 5/15/25 the hottest water temperature recorded was 93 degrees Fahrenheit. c. On 5/23/25 the hottest water temperature recorded was 88 degrees Fahrenheit. d. On 5/27/25 the hottest water temperature recorded was 95 degrees Fahrenheit. e. On 6/2/25 the hottest water temperature recorded was 98 degrees Fahrenheit.A review of the facility QAPI plan dated 10/18/24 regarding supervised smoking revealed: a. The facility was not following its policy regarding supervised smoking b. Actions taken were to post signs specifically noting residents that were required to use assistive devices while smoking c. Audits were performed of the smoking area to ensure the smoking policy and procedures were being followed (staff supervising smoking, protective/safety equipment available and used appropriately)[Note: After the QAPI identified concerns with smoking, there were no updated lists of residents who required supervision, residents were not assessed for safety of smoking, residents who were assessed as requiring supervision while smoking were observed smoking independently during the survey.]A review of the facility QAPI plan dated 3/31/24 regarding resident elopements revealed: a. The Director of Nursing (DON) would review residents who were elopement risks to ensure appropriate interventions were in place b. Doors were checked to ensure that they were functioning properly c. Residents with adult electronic monitoring safety devices were checked daily to ensure the device was in place and functioning[Note: After the QAPI identified concerns with elopement, there was an elopement as recent as 4/22/25.][Cross refer to F689]2. There were repeat deficiencies from the survey on 1/25/24 that were recited on the current survey. Those regulations included F689, F609, F755, F761 and F880. On 6/19/25 at 1:12 PM, an interview was conducted with the Administrator (Admin). The Admin stated that QAPI was held monthly. The Admin stated that based off of concerns from residents, complaints, negative trends, or something that was consistently happening an action plan would be put in place. The Admin stated that the facility had done action plans for supervised smoking and elopements. The Admin stated that the facility had not identified hot water concerns. The Admin stated that any concerns for action plans were adjusted and then reviewed the following month.

Based on interview and observation, the facility did not treat residents with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, residents dining in the dining room were served beverages in Styrofoam cups and prepackaged juice cups. Findings included: On 6/9/25 at 11:55 AM, an observation was made of residents in the dining room for the lunch meal. Staff members were passing out beverages as residents entered the dining room and took their seats. Juices were being served in 4 ounce (oz), foil-covered cups and 4 oz. cartons, chocolate milk was served in a carton, white milk and water was being served in a Styrofoam cup. Coffee and tea were being served in a coffee cup. On 6/9/25 at 12:00 PM, an observation was made of resident 2 sitting at the dining table with 2 cartons of chocolate milk, 2 cartons of orange juice, 2 containers of red juice, a Styrofoam cup with a brown liquid in it and a coffee cup with a brown liquid in it. On 6/10/25 at 8:18 AM, an observation was made of the dining room during the breakfast meal. Staff members were passing beverages as residents entered the dining room and took their seats. Milk and water were being served in Styrofoam cups. Juices were being served in 4 oz. cartons and foil covered cups, coffee and tea was being served in coffee cups, chocolate milk was served in cartons. On 6/12/25 at 8:32 AM, an observation was made of the 200 hallway lunch service. There were strawberries served in a disposable container on the trays. On 6/18/25 at 11:55 AM, an interview was conducted with the Dietary Manager (DM) who stated the mugs in the dining room were used for hot drinks. The DM stated the Styrofoam cups were being used in the dining room because several cups had gone missing and it took several weeks for those to arrive once they are ordered. The DM stated they had some cups, but not enough for everyone.

Based on interview and record review, for 3 out of 61 sampled residents, the facility did not ensure that all alleged violations involving abuse and neglect were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, notification to the SSA and APS was not done when a resident eloped from the facility and another resident alleged that a Certified Nursing Assistant (CNA) put their fingers into her private parts. Additionally, a resident eloped from the facility and APS was not notified. Resident identifiers: 64, 113, and 115.Findings included:1. Resident 115 was admitted to the facility on [DATE] with diagnoses which included, unspecified focal traumatic brain injury, cognitive communication deficit, and vascular dementia.Resident 115's medical record was reviewed 6/9/25-6/19/25.On 3/31/24 at 8:53 PM, an alert note documented, At 1715 [5:15 PM], Medicare CNA answered a phone call from a person living in the area stating he saw a resident leave the facility. CNA looked outside for the resident and got in her vehicle and went down two blocks and the resident was walking on the sidewalk at 1718 [5:18 PM]. CNA safely helped the resident into her vehicle and brought the resident back to the facility. CNA notified DON [Director of Nursing] of Elopement . On 6/19/25 at 11:02 AM, an interview was conducted with the Administrator (Admin). The Admin stated that resident 115 had been in the facility for a while and was a wander risk. The Admin stated that resident 115 was spotted walking down the street by a member of the community and was brought back into the facility and placed on a 1:1 (one to one). The Admin stated that he was unsure if he contacted APS about the elopement and would look to see if he had.It should be noted that no further documentation was submitted regarding APS notification. 2. Resident 113 was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia, major depressive disorder, generalized anxiety disorder, cutaneous abscess of left lower limb, muscle weakness, and difficulty in walking. Resident 113's medical record was reviewed 6/9/25 through 6/19/25. A Medication Administrative Note dated 3/21/25 at 9:04 PM indicated, Pt [patient] checked out at 1300 [1:00 PM] today, and has not yet returned. A Medication Administrative Note dated 3/22/25 at 1:01 AM indicated, As of 3/22/25 @0101 [at 1:01 AM], patient has not yet returned to the facility. A Medication Administrative Note dated 3/22/25 at 6:23 AM indicated, resident is LOA [leave of absence]. A Progress Note dated 3/22/25 at 6:04 PM indicated, Resident continues to be LOA throughout shift. Residents phone called with no answer. Management aware. A Medication Administrative Note dated 3/25/25 at 7:45 PM indicated, resident has not returned to the facility. A Medication Administrative Note dated 3/26/25 at 8:29 AM indicated, pt is away. A Progress Note dated 3/27/25 at 2:39 PM indicated, [Resident 113] left the facility with a friend on 3/21 and has not returned. Attempts to contact him has been unsuccessful. A Social Services Quarterly & Annual Note dated 1/15/25 at 10:26 AM indicated, [Resident 113] has appeared to become more confused. He is pleasant and enjoys socializing. [Resident 113] has outside support. He has been approved for long term care and participates well in his care plan. A provider Progress Note dated 1/23/25 indicated, .he would like to think about discharging the facility he states. will have the discharge planner and others help w [with]/ this. will need to recheck BIMS [Brief Interview for Mental Status] to ensure able to make this decision for himself . On 6/19/25 at 9:47 AM, an interview was conducted with the Admin. The Admin stated a relative came and signed resident 113 out and he did not return the next day. The Admin stated he was not sure if resident 113 needed someone to sign him out. The Admin stated they called him on his phone, but they were unable to get a hold of him. The Admin stated that after a couple of days, resident 113 came back to the facility to get some of his items and told them that he would not be returning and then left again. The Admin stated he did not provide resident 113 with an AMA (leaving against medical advice) form or discharge instructions because resident 113 was in a rush. The Admin stated resident 113 had a BIMS of 10 (a BIMS of 10 indicated a moderate cognitive impairment) and was alert and oriented x3 (times 3). The Admin stated resident 113 had been unhappy about his share of cost and kept talking about discharging. The Admin stated it had not crossed his mind to call law enforcement. The Admin stated if a resident had a BIMS that was a 12 or higher, they could sign themselves out, but other circumstances were taken into consideration and the Director of Nursing would be consulted to make that decision. On 6/19/25 at 10:01 AM, an interview was conducted with the Admissions Marketing Director (AMD). The AMD stated resident 113's friend came to sign him out LOA and he decided not to come back. The AMD stated he would consider that leaving AMA because they expected him to come back. The AMD stated when he asked resident 113 about a discharge plan during his stay, resident 113 told him multiple times that he was fine and did not have anywhere else to go. On 6/19/25 at 10:43 AM, a concurrent interview was conducted with the Admin and the RNC. The Admin stated if a resident eloped they would notify the doctor, family, and the police. The RNC stated if a resident signed themselves out on an LOA they should try to call and contact them if they did not return when they were expected and that if they could not get a hold of them they would call in a wellness check with law enforcement. The Admin stated if the resident stated they were coming back the day they signed out that they would start to get concerned if they were not back by that same evening and start calling. On 6/19/25 at 11:38 AM, an interview was conducted with DON 2. DON 2 stated if a resident was approved for LOA the resident would indicate how long they intended to be gone and if it went over that time, she would start to call the resident or family. DON 2 stated she would notify the police if the resident or family did not answer those calls. On 6/19/25 at 1:12 PM a follow-up interview was conducted with the Admin. The Admin stated the reason police were not called was because he signed out with someone and it was their responsibility to keep an eye on him. The Admin stated he did not think he contacted the Ombudsman about resident 113 leaving and not returning to the facility. It should be noted that no further documentation was provided regarding resident 113's elopement. 3. Resident 64 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, schizoaffective disorder, chronic respiratory disease, dementia, and morbid obesity. On 6/9/25 at 10:40 AM, an interview was conducted with resident 64 who stated that while receiving cares approximately one month ago, a CNA had inserted her fingers into her private parts and then bragged about it. Resident 64 stated she told the director of the CNA's about the incident. Resident 64 stated she did not know the name of the CNA, but that the CNA was still providing cares for her. Resident 64 stated the incident made her feel awful and that nobody aided her when the incident happened. On 6/18/25 at 9:38 AM, an interview was conducted with the CNA Coordinator who stated resident 64 briefly mentioned the incident to her. The CNA Coordinator stated if the DON and the Admin were busy they asked her to talk to the resident. The CNA Coordinator stated she did not remember who the CNA involved was, but that she ended up changing resident 64's brief and bed and wanted to talk with the DON and administrator about it. Later in the interview, the CNA Coordinator stated she believed the CNA involved was CNA 3. The CNA Coordinator stated CNA 3 no longer worked with resident 64. The CNA Coordinator stated resident 64 told her that CNA 3 was wiping her too aggressively and put her finger in her anus. The CNA Coordinator stated resident 64 no longer wanted CNA 3 to work with her and that CNA 3 hurt her. The CNA Coordinator stated the way that scheduling worked was that if CNA 3 was scheduled on that hallway, she would just switch residents with another CNA that was working on the same hallway so she was not working with resident 64. The CNA Coordinator stated the schedulers try not to schedule CNAs on hallways where there are residents that prefer not to work with them but sometimes they forget. The CNA Coordinator stated that she spoke with the DON specifically about the particular situation but she did not know if the DON spoke with resident 64 or told the administrator about the situation. The CNA Coordinator stated she did not know if the incident was investigated. The CNA Coordinator stated she did not talk to CNA 3 about the incident or ask her what happened. The CNA Coordinator stated she felt that those conversations should come from the DON or administrator. On 6/18/25 at 9:19 AM, an interview was conducted with CNA 4 who stated some categories of resident abuse were psychological, physical, and sexual. CNA 4 stated some symptoms of abuse to watch for could be a change in resident behavior, the resident being withdrawn, bruises, a resident refusing cares or not wanting cares from a certain person. CNA 4 stated his role in preventing resident abuse included answering resident call lights quickly, being aware of changes in resident's behavior, reporting immediately to a nurse if he became aware of something, or reporting to the administrator who is the abuse coordinator immediately. On 6/18/25 at 10:06 AM, an interview was conducted with Registered Nurse (RN) 4 who stated resident 64 did not like to have male aides in her room. RN 4 also stated she was not aware of resident 64 not wanting to work with any specific CNAs or making any allegations of abuse. On 6/18/25 at 10:08 AM, an interview was conducted with RN 1 who stated resident 64 had not made any allegations of inappropriate touching by CNAs. An attempt was made to contact DON 1, but the call was not returned. On 6/18/25 at 2:30 PM, an interview was conducted with the Admin who stated he was not made aware of resident 64's allegations until earlier in the day. The Admin stated he was aware of a prior complaint about a month ago by resident 64 that a CNA was not cleaning her well enough. The Admin stated he self-reported to the state agency the allegations that resident 64 made about the incident a month ago, and had begun an investigation. The Admin stated the CNA involved had been suspended until the investigation had been completed. The Admin stated he had spoken with the DON 1 who told him she did not remember resident 64's allegations. The Admin stated his process as the abuse coordinator was to educate all staff to report any abuse immediately. The Admin stated if the allegation was about staff, the staff member would be suspended immediately pending the investigation. The Admin stated he would interview the resident, interview other residents for other claims or complaints, and interview other staff members to collect more information. If there were additional complaints, the Admin stated the employee would be terminated. The Admin stated if there were no other concerns, the employee would be re-educated. The Admin stated when there was an allegation of abuse, the physician would be notified, the responsible party or family member, and based on the allegation, the police, adult protective services, and the ombudsman. The Admin stated there was a 2 hour time frame for initial reporting of abuse, and 5 days to submit the investigation report. The Admin stated that it was not reported to the state and that he was not aware that it was an abuse allegation until earlier in the day.

Based on observation, interview, and record review, it was determined for 4 of 61 sampled residents, that the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable. Specifically, three resident's eye drops and one resident's insulin were expired. Resident identifiers: 31, 44, 106, and 107. Findings included: On [DATE] at 8:17 AM, an observation and interview were conducted with Registered Nurse (RN) 7. RN 7 was observed to pull Ketotifen Fumarate eye drops out of the Long Term [NAME] Medication Cart. The eye drops were labeled with an open date of 4/11. RN 7 stated eye drops were good for 28 days after they were opened and that the eye drops were expired. At 8:39 AM, RN 7 was observed to administer the Ketotifen Fumarate eye drops into resident 31's eyes. At 10:41 AM, RN 7 stated they talked with the nurse manager and the eye drops expired 30 days after they were opened. RN 7 stated they got rid of the eye drops and ordered more. On [DATE] at 1:18 PM, an observation and interview were conducted with Licensed Practical Nurse (LPN) 2. An opened bottle of Latanoprost Ophthalmic Solution 0.05% eye drops, labeled with resident 44's name, were located in the 400 Hall Medication Cart. There was no opened date labeled on the eye drops. LPN 2 stated there was supposed to be an open date written on the eye drops and that it should be discarded because it could be expired. Resident 44 had a physician order dated [DATE] at 1:13 PM which indicated, Latanoprost Ophthalmic Solution 0.005% (Latanoprost) Instill 1 drop in both eyes at bedtime for dry eye Instill 1 drop OU [both eyes] QHS [every night at bedtime]. A Medication Administration Record dated [DATE]-[DATE] indicated resident 44 was administered 1 drop of Latanoprost Ophthalmic Solution 0.005% (Latanoprost) in both eyes at bedtime from [DATE] through [DATE]. On [DATE] at 1:36 PM, an observation and interview were conducted with LPN 2. Located inside the 500 Hall Medication Cart was a used medication pen of Insulin Aspart for resident 107 with an open date labeled [DATE]. LPN 2 stated the Insulin Aspart pen expired on [DATE]. An open bottle of Olopatadine Hcl (hydrochloride) 0.2% eye drops for resident 106 with no open date was also located in this medication cart. LPN 2 stated all eye drops expire 28 days after opening. Resident 107 had a physician order dated [DATE] at 4:41 PM which indicated, Insulin Aspart Subcutaneous Solution Pen-injector 100 UNIT/ML [milliliters] (Insulin Aspart) Inject subcutaneously four times a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. A Medication Administration Record dated [DATE]-[DATE] indicated resident 107 was administered Insulin Aspart Subcutaneous Solution Pen-injector six times prior to [DATE]. Resident 106 had a physician order dated [DATE] at 5:20 PM which indicated, Pataday Ophthalmic Solution 0.2% (Olopatadine Hcl) Instill 1 drop in right eye in the morning for itching and redness. On [DATE] at 1:50 PM, an observation and interview were conducted with RN 2. Three over the counter artificial tears and 1 bottle of Systane eye drops were located inside the Medicare Odd Medication Cart. All four eye drops were opened and they were not labeled with open dates. RN 2 stated they only go by the expiration date on the box, even if it was opened. RN 2 stated the opened Systane eye drops would expire on 2/27, which was observed to be the manufacturer's expiration date on the bottle. On [DATE] at 1:35 PM, an interview was conducted with the Director of Nursing (DON) 2. DON 2 stated all opened eye drops, including over the counter, were good for 28 days. DON 2 stated insulin expired 28 days after being opened and should have been discarded.

Based on observation, interview and record review, for 1 out of 61 sampled residents, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and resident's choices. Specifically, a resident's diabetes was not managed with required documentation, timely referral to outside services or diet management according to physician's orders and resident's choice. Resident identifier: 36.Findings included: Resident 36 was re-admitted on [DATE] with diagnoses of hemiplegia/hemiparesis, chronic respiratory failure, morbid obesity, major depressive disorder, type 1 diabetes, epilepsy and generalized anxiety disorder.On 6/12/25 at 8:07 AM, an interview was conducted with resident 36. Resident 36 stated he was not doing so great. Resident 36 stated he had a reminder on his amazon echo in the evening on 6/11/25, to take his blood glucose level which was reading Hi (high) on his continuous monitor, indicating his blood glucose level was over 400 milligrams per deciliter (mg/dL). Resident 36 stated he called for the graveyard nurse, Licensed Practical Nurse (LPN) 1, to check his blood glucose level using the facility's glucometer. Resident 36 stated LPN 1 tested his glucose level at about 10:30 PM and his blood glucose level was over 400 mg/dL. Resident 36 stated he did not recall the specific results. Resident 36 stated he asked LPN 1 to contact the Physician's Assistant (PA) to get an order for insulin to reduce his glucose level. Resident 36 stated LPN 1 said it was too late to call and refused to contact the PA. Resident 36 stated LPN 1 suggested resident 36 was eating snacks after dinner which accounted for the high blood glucose results. Resident 36 stated he did not eat snacks after dinner and reported that the meals he received from the facility were very high in carbohydrates. Resident 36 stated he wanted lower carbohydrate food as he had type 1 diabetes and that it was hard for him to keep his blood glucose level low like they should be especially considering he was bed bound and didn't get much exercise. Resident 36 stated he did not have an as needed (PRN) order for insulin so he did not receive an insulin shot through the night and stated he was still high in the morning. Resident 36 stated he asked LPN 2 to check his blood sugar this morning 6/12/25 at about 7:30 AM due to his continuous monitor still reading Hi. At 8:10 AM, resident 36's Freestyle Libre 3 monitor was observed to read Hi.On 6/12/25 at 1:30 PM, an observation was made of resident 36's lunch meal which consisted of ham, corn, scalloped potatoes, a roll and bread pudding with caramel. Resident 36 did not have fruit instead of dessert as the meal ticket stated and he stated he would prefer lower carbohydrate food options.On 6/12/25 at 8:27 AM, an interview was conducted with resident 36's family member. The family member asked resident 36 if he was still alive. Resident 36 told the family member about the Hi blood glucose reading on the continuous monitor and that the facility's monitor read 389 mg/dL. The family member stated resident 36's high glucose had been going on for a long time. Resident 36's family member stated resident 36 was a type 1 diabetic and the facility did not allow insulin pumps. Resident 36's family member stated resident 36's glycated hemoglobin (A1C) was 6.2 prior to admission to the facility but had been 8.1 or higher and was routinely above 9 since admission. Resident 36's family member complained that resident 36 was given a flat amount of insulin before meals, regardless of the carbohydrates in the meal. Resident 36's family member stated his glucose level was 393 initially then 400 when tested later in the night on 6/11/25. The family member stated that resident 36 should have an insulin shot if blood glucose levels were higher than 250.On 6/12/25 at 10:08 AM, a phone interview was conducted with LPN 1. LPN 1 stated that he did not contact the PA as resident 36 requested since there was no order to notify the PA of a high blood glucose level. LPN 1 stated he would generally notify the PA for guidance if the glucose level was unusually high for a resident or there was an order to do so. LPN 1 stated the facility had two after hours providers to contact in an emergency. LPN 1 stated he took blood glucose levels if asked by a resident and usually documented it in the electronic medical record and a progress note if the levels were high, above 400. LPN 1 stated resident 36's continuous monitor read Hi but the facility's glucose monitor read resident 36's glucose level in the 200's. LPN 1 stated he did not recall what the specific number was on the glucometer and stated he did not document the results. LPN 1 stated he did not know how resident 36's continual glucose monitoring system worked or if there were sometimes different readings than the facility glucometer. LPN 1 stated the night shift calibrated the facility glucometers weekly and documented the results in the narcotics binder. LPN 1 stated that, to his knowledge, the facility glucometer was working and accurate. LPN 1 stated he checked Resident 36's glucose level around midnight and again about 2:30 AM. LPN 1 stated he did not know why he checked it again at 2:30 AM when the glucose was normal for resident 36 at 12:30 AM.Resident 36's medical record was reviewed 6/12/25 through 6/19/25.Resident 36's laboratory Hemoglobin A1C results were as follows: a. On 2/18/25 was 8.9, reference rate <5.7 b. On 5/23/25 was 9.8, reference rate <5.7On 6/12/25 at 8:52 AM, documentation showed the blood glucose level was still high. The following were documented levels: a. On 6/11/025 at 12:42 PM 272.0 mg/dL b. On 6/11/25 at 4:20 PM 264.0 mg/dL c. On 6/12/25 at 8:52 AM 397.0 mg/dL[Licensor note: no blood glucose level was documented in the evening on 6/11/25 by LPN 1].On 6/12/25 at 10:40 AM, an interview was conducted with LPN 2. LPN 2 stated the glucometers were calibrated weekly by the graveyard shift nurse and the calibration log was kept in the narcotic binder.The facility's 500 hall glucometer calibration and quality control tracking sheet was reviewed. The following was observed: a. 4/24/25 at 6:30 AM, low control: 48, high control: 195 b. 5/4/25 at 9:45 AM, low control: 48, high control: 185 c. 5/17/25 at 4:40 PM, low control: 42, high control: 187 d. 6/1/25 at 1:00 AM, low control: 53, high control: 214 e. 6/4/25 at 11:00 PM, low control: 53, high control: 210On 6/12/25 at 10:46 AM, an observation was made of resident 36's continuous glucose monitor which read 372. The history on the continuous monitor revealed resident 36 had glucose level above 350 mg/dL (top of graph) on the monitor's line graph starting about 5:00 PM on 6/11/25, continuing until midnight when the data ended.On 6/12/25 at 11:00 AM, resident 36's progress notes were reviewed and there was no documentation from LPN 1 from 6/11/25 through 6/12/25.On 6/12/25 at 11:05 AM, resident 36's blood glucose level continuous monitor was at 394.On 6/18/25 at 10:50 AM, LPN 2 stated the facility did not have any standing protocols or instructions for contacting the physician when blood glucose levels were high. LPN 2 stated that if she observed resident 36's blood glucose level was close to 400 she would call the doctor and typically write a progress note. LPN 2 stated she typically contacted the doctor when a person was over 400 which she considered best practice. LPN 2 stated that whenever a resident's blood glucose was taken it was documented in the electronic medical record.On 6/18/25 at 11:54 AM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated they were working on a facility wide change to have standing protocol for notifying the physician whenever patients had high blood glucose levels. UM 1 stated this would be typically above 400.On 6/18/25 at 12:40 PM, an interview was conducted with the Director of Nursing (DON) 2. DON 2 stated there were no standing orders and nurses used their judgement for when to contact the physician related to unusual blood sugar level results. DON 2 stated diabetic residents should have orders of when to notify the physician for their blood glucose. DON 2 stated the range was usually to notify if under 60 or over 400.On 6/18/25 at 1:20 PM, an interview was conducted with resident 36's Medical Doctor (MD). The MD stated that when blood glucose was over 400 then typically the nurse should notify the doctor. The MD stated he had frequently been contacted about glucose levels and that it would be unusual for a diabetic resident to not be on a sliding scale. The MD stated that if resident 36 was above 450 or 500 then he would expect the nurse to call the doctor. The MD stated that low blood glucose was a bigger concern than high glucose levels but the A1C target was below 8.5. The MD stated that A1C above 8.5 was considered under treated diabetes. The MD stated that he did not know if resident 36 had a PRN insulin order for when glucose levels were high but stated a PRN order would help when resident 36's level was high. The MD stated resident 36's last A1C was at 12.On 6/18/25 at 1:59 PM, a follow-up interview was conducted with UM 1. UM 1 stated he received a referral from the PA on 5/27/25 for resident 36 to be evaluated by a preferred endocrinologist. UM 1 stated he had been the UM for a couple months and was unaware of previous endocrinology referrals. UM 1 stated a nurse with the local endocrinology clinic assessed resident 36 on 6/9/25 and resident 36 had an appointment with the endocrinologist on 7/1/25. On 6/19/25 at 12:01 PM, an interview was conducted with the Dietary Manager (DM). The DM stated all information about a resident's diet was at the bottom of the production sheet. The DM stated for Controlled Carbohydrate Diet (CCHO) diet, the dietary staff would send sugar free juice. The DM stated if the resident was on a renal diet, no tomato and other high potassium foods would be served. The DM stated residents were served foods listed on the menu. The DM stated the system automatically eliminated items that were not on the therapeutic diet. The DM stated he was not sure how many carbohydrates were served per meal for CCHO diets. The DM stated resident 36 was on a CCHO diet with no dessert but fruit was okay. The DM stated resident 36 had a blond brownie on the meal ticket for dinner at the time of the interview. The DM stated the planned dessert could not be removed from the production ticket so the dietary staff rely on the notes on the production ticket to adjust the foods delivered to the resident.On 6/19/25 at 12:20 PM, an interview was conducted with the Registered Dietitian (RD). The RD stated that a CCHO diet should be between 225 to 250 grams of carbohydrates per day, which was according to CCHO diet guidelines. The RD stated that residents who were not supposed to get a dessert should have it left off their tray and a substitute offered. The RD stated the management of the meals, meal computer system, meal cards, and meal prep is left up to the DM. The RD stated that she was not aware that resident 36 desired to have lower carbohydrate meals. The RD stated if a resident requested that, then the facility should provide what was requested.

Based on interview and record review, it was determined for 2 of 61 sampled residents, that the facility failed to ensure each resident had the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. Specifically, one resident representative was not informed in advance of starting an antidepressant medication and another resident representative was not informed in advance of a wanderguard being placed. Resident identifiers: 82 and 103.Findings included:1. Resident 82 was admitted to the facility on [DATE] with diagnoses which included severe vascular dementia, hypertension, attention and concentration deficit following cerebral infarction, depression, and cognitive communication deficit.Resident 82's medical record was reviewed 6/9/25 through 6/19/25.A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated resident 82's Cognitive Skills for Daily Decision Making was, Severely impaired-never/rarely made decisions.A nurse's note dated 10/12/24 at 1:13 PM indicated, New orders received from [behavioral health services] to start Lexapro [antidepressant medication] 5 mg [milligrams] QD [every day]. [Physician name redacted] agreed with recommendation.A physician order dated 1/8/25 at 3:54 PM indicated, Escitalopram Oxalate Oral Tablet 10 MG .Give 1 tablet by mouth one time a day for Depression.An interview was conducted on 6/18/25 at 3:15 PM with the Administrator. The Administrator stated resident 82's representative was her sister.An interview was conducted on 6/19/25 at 9:44 AM with the Regional Nurse Consultant (RNC). The RNC stated they were unable to find a consent notifying the resident representative before starting the Escitalopram. 2. Resident 103 was admitted to the facility on [DATE] with diagnoses which included atherosclerotic heart disease, essential hypertension, type 2 diabetes, bipolar disorder, muscle weakness, and difficulty in walking.Resident 103's medical record was reviewed on 6/9/25 through 6/19/25. According to a facility investigation, resident 103 eloped from the facility on 4/22/25 and was returned to the facility on 4/23/25.On 4/23/25 at 3:38 PM, an order was started to Check skin integrity around wanderguard on R [right] ankle every shift for Skin integrity. Beginning on the 4/23/25, nursing staff began to document in the Treatment Administration Record that this order was being completed every shift. On 4/23/2025, the intervention Wander guard to R ankle was initiated in Resident 103's care plan.No progress note was located in resident 103's medical record regarding when the wanderguard was placed. On 4/25/25, an informed consent for a wanderguard restraint was dated 4/25/25 and contained resident 103's signature, a facility representative's signature, and a note that stated verbal consent from her guardian [name redacted] obtained.On 4/25/25 at 8:05 PM, a progress note stated Resident signed her consent for the wanderguard today. UM [Unit Manager] manager called her State Guardian to inform her the need of it and to get a verbal. She is in agreement. Wander guard is on her right ankle.On 6/19/25 at 11:10 AM, an interview was conducted with the Administrator and the RNC. The Administrator stated that the wanderguard was placed on resident 103 on the day she returned to the facility after the elopement. The Administrator further stated that he was present when the wanderguard was placed on resident 103. The RNC stated that consent for the wanderguard should be given before the wanderguard was placed.

Based on interview and record review, it was determined, 1 of 61 sampled residents, the facility failed to keep residents free from abuse. Specifically, a Registered Nurse (RN) employee had a sexual relationship with a resident who resided in the facility. Resident identifier: 118Based on interview and record review, it was determined, 1 of 61 sampled residents, the facility failed to keep residents free from abuse. Specifically, a Registered Nurse (RN) employee had a sexual relationship with a resident who resided in the facility. Resident identifier: 118Findings included:On 3/28/25 at 12:22 PM, the facility reported that on 3/28/25 at 10:00 AM an investigator from the Division of Professional Licensing (DOPL) came into the facility on a complaint from resident 118. It was reported to DOPL that RN 3 had been sexually inappropriate with resident 118. On 3/28/25 at 11:00 AM, RN 3 was placed on leave from the facility while an investigation was conducted. The form titled 359, the final investigation, was submitted to the State Survey Agency (SSA) on 4/2/25. The form revealed the Administrator (Admin) interviewed RN 3. RN 3 stated that he had been having a consensual sexual relationship with resident 118. RN 3 stated that inappropriate messages and images were sent by both parties. RN 3 stated that there had been physical contact between him and resident 118. On 6/18/25 at 8:32 AM, an interview was conducted with the Admin. The Admin stated that he was notified about the abuse about one month after resident 118 discharged from the facility. The Admin stated that the DOPL investigator would not disclose a lot of information regarding the complaint or investigation. The Admin stated that RN 3 was suspended and then later terminated from the facility. The Admin stated that he interviewed RN 3 via telephone and RN 3 confirmed that he had been having a sexual relationship with resident 118 and that he should have let the facility know. On 6/18/25 at 9:21 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that staff should not have any type of relationship with residents. The RNC stated that even if a resident agreed to have a consensual relationship, it should not occur.On 6/18/25 at 9:28 AM, a follow-up interview was conducted with the Admin. The Admin stated he did not know about the relationship so he was unable to prevent the abuse. The Admin stated resident 118 consented to the relationship so it was not abuse. A review of the facility Resident Rights/Dignity Policy documented:Policy StatementResidents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.Policy Interpretation and ImplementationThe resident abuse, neglect and exploitation prevention program consists of a facility-widecommitment and resource allocation to support the following objectives:1. Protect residents from abuse, neglect, exploitation or misappropriation of property byanyone including, but not necessarily limited to:a. facility staff;b. other residents;c. consultants;d. volunteers;e. staff from other agencies;f. family members;g. legal representatives;h. friends;i. visitors; and/orj. any other individual.2. Develop and implement policies and protocols to prevent and identify:a. abuse or mistreatment of residents;b. neglect of residents; and/orc. theft, exploitation or misappropriation of resident property.3. Ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates.4. Conduct employee background checks and not knowingly employ or otherwise engage any individual who has:a. been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law;b. had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; orc. a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.6. Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.7. Implement measures to address factors that may lead to abusive situations, for example:a. adequately prepare staff for caregiving responsibilities;b. provide staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation;c. instruct staff regarding appropriate ways to address interpersonal conflicts; andd. help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts.8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.9. Investigate and report any allegations within timeframes required by federal requirements.10. Protect residents from any further harm during investigations.11. Establish and implement a QAPI review and analysis of reports, allegations or findings of abuse, neglect mistreatment or misappropriation of property.12. Involve the resident council in monitoring and evaluating the facility's abuse prevention program.

Based on interview and record review, it was determined for 2 out of 61 sampled residents, that the facility did not notify the resident of the discharge and the reasons for the move in writing and in a language and manner they understand; or send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman as soon as practicable or when a resident had not resided in the facility for 30 days. Specifically, the Ombudsman was not notified when one resident was discharged to the hospital and the ombudsman was not notified of a resident's discharge and the reasons why the resident left the facility. Resident identifiers: 54 and 113.Findings included:1. Resident 54 was admitted to the facility on [DATE] with diagnoses which included type 1 diabetes mellitus and end-stage renal disease. Resident 54's medical record was reviewed 6/9/25-6/19/25.On 3/15/24 at 2:45 AM, a nursing progress note documented, .Patient was handed off with report to EMS [emergency medical services] and resident left the facility at approx. [approximately] 0245 [2:45 AM] with no new complaints.On 4/1/24 at 10:22 AM, a nursing progress note documented, .[resident 54] was admitted to [local hospital] on Saturday .On 10/16/24 at 7:33 AM, a nursing progress note documented, Resident was found unresponsive at 0650 [6:50 AM] when aide went to take vitals, aide called for assistance, on assessment residents BG [blood glucose] was 29, skin was cold and clammy, presented w/ [with] labored breathing and thready pulse. EMS called immediately after injection was given resident remained unresponsive, at time of EMS arrival BG was at 41,Resident Transferred to [local hospital] .On 12/6/24 at 12:51 AM, a nursing progress note documented, Resident is still c/o [complaining of] SOB [shortness of breath] and difficulty breathing feels that breathing treatment did not help, and wants to be sent out for further evaluation, called the on call and they said to have her be sent out resident presents as non emergent, she is having her mom come and get her to take her to[local hospital] .On 6/17/25 at 11:05 AM, an interview was conducted with the Admissions Marketing Director (AMD). The AMD stated that he kept a log of all the residents that were discharged from the facility. The AMD stated that he notified the Ombudsman monthly regarding the residents that left the facility AMA (against medical advice) or discharged to the community. The AMD stated that he did not notify the Ombudsman when a resident was discharged to a hospital. On 6/18/25 at 9:11 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that the Ombudsman should be notified monthly of all residents that were discharged home, AMA, and hospital transfers. 2. Resident 113 was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia, major depressive disorder, generalized anxiety disorder, cutaneous abscess of left lower limb, muscle weakness, and difficulty in walking.Resident 113's medical record was reviewed 6/9/25 through 6/19/25.A Medication Administrative Note dated 3/21/25 at 9:04 PM indicated, Pt [patient] checked out at 1300 [1:00 PM] today, and has not yet returned.A Progress Note dated 3/27/25 at 2:39 PM indicated, [Resident 113] left the facility with a friend on 3/21 and has not returned. Attempts to contact him has been unsuccessful.On 6/19/25 at 9:47 AM, an interview was conducted with the Administrator (Admin). The Admin stated a relative came and signed resident 113 out and he did not return the next day. The Admin stated they called him on his phone, but they were unable to get a hold of him. The Admin stated that after a couple of days, resident 113 came back to the facility to get some of his items and told them that he would not be returning and then left again. The Admin stated he did not provide resident 113 with an AMA form or discharge instructions because resident 113 was in a rush. The Admin stated resident 113 had been unhappy about his share of cost and kept talking about discharging.On 6/19/25 at 10:01 AM, an interview was conducted with the AMD. The AMD stated resident 113's friend came to sign him out LOA (leave of absence) and he decided not to come back. The AMD stated he would consider that leaving AMA because they expected him to come back. The AMD stated when he asked resident 113 about a discharge plan during his stay, resident 113 told him multiple times that he was fine and did not have anywhere else to go.On 6/19/25 at 10:43 AM, a concurrent interview was conducted with the Admin and the RNC. The Admin stated if a resident eloped they would notify the doctor, family, and the police. The RNC stated if a resident signed themselves out on an LOA they should try to call and contact them if they did not return when they were expected and that if they could not get a hold of them they would call in a wellness check with law enforcement. The Admin stated if the resident stated they were coming back the day they signed out that they would start to get concerned if they were not back by that same evening and start calling.On 6/19/25 at 11:38 AM, an interview was conducted with the Director of Nursing (DON) DON 2. DON 2 stated if a resident was approved for LOA the resident would indicate how long they intended to be gone and if it went over that time, she would start to call the resident or family. DON 2 stated she would notify the police if the resident or family did not answer those calls.On 6/19/25 at 1:12 PM a follow-up interview was conducted with the Admin. The Admin stated the reason police were not called was because he signed out with someone and it was their responsibility to keep an eye on him. The Admin stated he did not think he contacted the Ombudsman about resident 113 leaving and not returning to the facility.

Based on interview and record review, it was determined for 1 of 61 sampled residents, that the facility failed to ensure the assessment accurately reflected the resident's status. Specifically, a diagnosis of depression was not included on the assessment. Resident identifier: 82.Findings included:Resident 82 was admitted to the facility on [DATE] with diagnoses which included severe vascular dementia, hypertension, attention and concentration deficit following cerebral infarction, depression, and cognitive communication deficit.Resident 82's medical record was reviewed 6/9/25 through 6/19/25.A Psych (psychiatric) Follow Up note dated 10/4/24 at 6:00 AM indicated, .suggest Lexapro 5mg [milligrams] daily for depression and anxiety A Nursing note dated 10/12/24 at 1:13 PM indicated, New orders received from [mental health services] to start Lexapro [antidepressant medication] 5 mg QD [every day]. [Physician name redacted] agreed with recommendation.A Psych Follow Up note dated 10/18/24 at 6:30 AM indicated, .Endorses depression, poor appetite, no interest in ADL's [activities of daily living]. She is tolerating the lexapro 5mg well.A Psych GDR (Gradual Dose Reduction) note dated 11/15/24 at 8:15 AM indicated, .Escitalopram Oxalate [antidepressant medication] Tablet 5 MG Give 1 tablet by mouth one time a day for Depression .A physician order dated 1/8/25 at 3:54 PM indicated, Escitalopram Oxalate Oral Tablet 10 MG .Give 1 tablet by mouth one time a day for Depression.A review of resident 82's medical diagnoses list did not include depression.A Quarterly Minimum Data Set (MDS) dated [DATE] did not include a diagnosis of depression.On 6/18/25 at 9:42 AM, an interview was conducted with Registered Nurse (RN) 6. RN 6 stated they were not sure if resident 82 had depression. RN 6 reviewed resident 82's physician orders and stated she had escitalopram ordered for depression.On 6/18/25 at 12:55 PM, an interview was conducted with RN 7. RN 7 stated resident 82 did not have depression.On 6/18/25 at 1:19 PM, an interview was conducted with the Social Service Worker (SSW). The SSW stated resident 82's face sheet did not indicate she had depression.On 6/18/25 at 3:10 PM, an interview was conducted with the Director of Nursing (DON) 2. The DON 2 stated resident 82 was diagnosed with depression in February of 2025 but it did not get updated in the medical chart. The DON 2 stated the MDS should have been updated with the diagnosis of depression.

Based on interview, and record review, it was determined that for 1 of 61 sampled residents, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, a resident did not have an Invega injection available when it was scheduled to be administered. Resident identifiers: 59.Findings included:Resident 59 was admitted to the facility on [DATE] with diagnosis which included severe dementia with agitation, paranoid schizophrenia, type 2 diabetes, generalized anxiety disorder, delusional disorders, insomnia, schizoaffective disorder, and essential hypertension.Resident 59's medical record was reviewed on 6/9/25 through 6/19/25.On 4/10/25, a 117 milligram (mg) Invega intramuscular injection was scheduled for administration. This order, which was started on 2/6/25 and discontinued on 4/14/25, was scheduled to be administrated every 21 days. On 4/10/25 at 4:21 PM, a Medication Administration Note stated that the ordered Invega injection was not administered because Injection has not arrived, will administer it when it does arrive within the facility. According to the Medication Administration Record (MAR) a 117 mg Invega intramuscular injection was administered on 4/15/25. This order, which was started on 4/15/25 and discontinued on 5/7/25, was scheduled to be administered every 21 days. On 5/6/25, a 117 mg Invega intramuscular injection was scheduled for administration. On 5/6/25, it was documented in the MAR that the Invega injection was not administered, citing chart code 9, defined as Other/See Nurse Notes. No note could be found in resident 59's medical record providing a reason why the medication was not administered on 5/6/25. On 5/8/25, a 117 milligram (mg) Invega intramuscular injection was scheduled for administration. This order was started on 5/8/25 and ended on 5/9/25.On 5/8/25 at 1:52 PM, a Medication Administration Note stated that the ordered Invega injection was not administered because Patient refused multiple times today. On 5/9/25 an order was placed to administer a 234mg Invega intramuscular injection every 28 days starting 5/12/25. According to the MAR the medication was administered as scheduled. On 6/1/25, an order was started to call the pharmacy every 25 days and order the Invega medication. It was documented in the MAR that the Invega medication was ordered on 6/1/25. On 6/9/25, a 234mg Invega intramuscular injection was scheduled for administration. On 6/9/25 at 3:35 PM, a Progress Note stated that the Invega injection was currently unavailable and the pharmacy was called to reorder the medication. On 6/10/25, it was documented in the MAR that a 234mg Invega intramuscular injection was administered. On 06/19/25 at 10:08 AM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that the Invega injection was unavailable for administration due to issues with insurance coverage. UM 1 stated that the dosage and administration schedule for the Invega injection had been adjusted in an effort to accommodate insurance requirements.

Based on observation, interview and record review, for 2 out of 61 sampled residents, the facility did not ensure that residents were offered a therapeutic diet when the therapeutic diet was ordered. Specifically, a resident on a diabetic diet was not provided a low carbohydrate option. In addition, a resident complained of not being provided a renal diet. Resident identifier: 36 and 79. Findings included: 1. On 6/12/25 at 8:07 AM, an interview was conducted with resident 36. Resident 36 stated he was not doing so great. Resident 36 stated he had a reminder on his amazon echo in the evening on 6/11/25, to take his blood glucose level which was reading Hi (high) on his continuous monitor, indicating his blood glucose level was over 400 milligrams per deciliter (mg/dL). On 6/12/25 at 8:27 AM, an interview was conducted with resident 36's family member. The family member asked resident 36 if he was still alive. Resident 36 told the family member about the Hi blood glucose reading on the continuous monitor and that the facility's monitor read 389 mg/dL. The family member stated resident 36's high glucose had been going on for a long time. Resident 36's family member stated resident 36 was a type 1 diabetic and complained that Resident 36 was given a flat amount of insulin before meals, regardless of the carbohydrates in the meal. The family member stated they had requested low carbohydrate food options but resident 36 was usually given a high carbohydrate meal. On 6/12/25 at 1:30 PM, an observation was made of resident 36's lunch meal. The meal was ham, corn, scalloped potatoes, a roll and bread pudding with caramel sauce on top. Resident 36 did not have fruit instead of dessert as the meal ticket stated. Resident 36 stated he would prefer lower carbohydrate food options. Resident 36's medical record was reviewed 6/9/25-6/19/25. Resident 36's diet order was carbohydrate controlled. On 3/19/2025 at 2:17 PM, the interdisciplinary team (IDT), met with resident 36 and a family member. The IDT note stated they discussed resident 36's diabetes and adjustments that were needed to his insulin and diet. On 6/19/25 at 12:01 PM, an interview was conducted with the Dietary Manager (DM). The DM stated all information about a resident's diet was at the bottom of the production sheet. The DM stated for Controlled Carbohydrate Diet (CCHO) diet, the dietary staff will send sugar free juice. The DM stated if the resident was on a renal diet, no tomato and other high potassium foods would be served. The DM stated residents were served foods listed on the menu. The DM stated the dining computer software automatically eliminated items that were not on the therapeutic diet. The DM stated he was not sure how many carbohydrates were served per meal for CCHO diets. The DM stated resident 36 was on a CCHO diet with no dessert but fruit was okay. The DM stated resident 36 had a blond brownie on the meal ticket for dinner at the time of the interview. The DM stated the planned dessert could not be removed from the production ticket so the dietary staff relied on the notes on the production ticket to adjust the foods delivered to the resident. On 6/19/25 at 12:20 PM, an interview was conducted with the Registered Dietitian (RD).The RD stated that a CCHO diet should be between 225 to 250 grams of carbohydrates per day, which was according to CCHO diet guidelines. The RD stated that residents who were not supposed to get a dessert should have it left off their tray and a substitute offered. The RD stated the management of the meals, meal computer system, meal cards, and meal prep was left up to the DM. The RD stated that she was not aware that resident 36 desired to have lower carbohydrate meals. The RD stated if a resident requested that, then she would evaluate the resident. 2. Resident 79 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included end stage renal disease with dialysis, gastroparesis, and type 2 diabetes mellitus. On 6/9/25 at 10:18 AM, an interview was conducted with resident 79. Resident 79 stated the facility did not provide a renal diet. Resident 79 stated the facility served him beans, high potassium foods, like lots of bananas. Resident 79 stated the food was not good, there was no seasoning and it was usually cold. Resident 79 stated he had talked to the head cook but nothing had changed. Resident 79's medical record was reviewed 6/9/25 through 6/19/25. A physician's order dated 4/20/25 revealed a renal/diabetic diet with regular texture, thin liquids, double protein portions and low potassium diet. A form titled Nutritional Data Collection and assessment dated [DATE] revealed a renal/diabetic diet. The facility provided a form titled Production Sheet for the meals. According to the form on Tuesday Day 10 for lunch residents with renal diets were served a #12 scoop of mashed potatoes. On 6/19/25 at 12:01 PM, an interview was conducted with the DM. The DM stated if a resident wanted a more strict diet, then the RD would evaluate them. On 6/19/25 at 12:24 PM, an interview was conducted with the RD. The RD stated if a resident was on a renal diet, then the computer system would take out the foods the resident should not be eating. The RD stated she was not aware of concerns with the renal diets. The RD stated she had not visited resident 79 and asked about dietary needs.

Based on interview and record review, for 2 of 61 sampled residents, the facility did not arrange services with an outside agency in a timely manner. Specifically, a resident that needed dental services did not have those services scheduled, and a resident did not have an endocrinology appointment scheduled after a referral from the physician. Resident identifiers: 36 and 64. Findings included: 1. Resident 64 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, schizoaffective disorder, adult failure to thrive, dysphagia, dementia, and morbid obesity. On 6/9/25 at 11:00 AM, an interview was conducted with resident 64 who stated she had seen a dentist in 2024 and was told she needed to see an outside dentist for further treatment. Resident 64 stated she had not yet seen an outside dentist. Resident 64's medical records were reviewed between 6/9/25 and 6/19/25. A physician order dated 8/24/24 revealed, May have dental, vision & eye health, hearing, wound and podiatry consults as needed. A review of resident 64's documents revealed a dental visit note dated 9/25/24 with dental provider notes that stated the following, Facility visit in room for exam. Oral cancer screening complete IO/EO-WNL [Intraoral/Extraoral-Within Normal Limits]. Patient will need to be referred for fillings on teeth #4-6, 9-11. Decay is causing her to cut her lip.-[Dentist initials]. Resident 64's care plan dated 9/4/24 revealed a focus area, [resident 64] has oral/dental health r/t [related to] poor oral hygiene. The goal was, The resident will be free of infection, pain or bleeding in the oral cavity by review date. Interventions included, Coordinate arrangements for dental care, transportation as needed/as ordered. On 6/17/25 at 10:00 AM, an interview was conducted with Registered Nurse (RN) 1 who stated the Unit Manager (UM) or the Nurse were responsible to review the resident's notes after a provider visit. RN 1 stated if a follow-up was recommended, the nurse would submit a request transportation and enter an order for the scheduled appointment. RN 1 stated the entered order would alert nursing staff the day before the follow-up. RN 1 stated evening nurse reminded the resident the night before the appointment and put a reminder on the resident's door. RN 1 stated the process had recently changed and recommended the previous UM be interviewed. On 6/17/25 at 10:30 AM, an interview was conducted with the Respiratory Lead (RL) who stated she used to be the UM on the resident's hallway. The RL stated if a resident returned from an appointment with a follow-up appointment, she would put a physician's order for the appointment in the resident's orders, and would put in a request slip for transportation. The RL stated they would then coordinate with transportation and the schedule to ensure they did not have double rides on that day. The RL stated if a referral was needed, she would complete the referral and write down the information so the resident would know the referral had been completed and the appointment had been made. The RL stated if resident 64 did not want to go to an appointment she would call and cancel. The RL stated she did not remember what happened with resident 64 and her dental appointments. The RL stated another staff member was setting up resident 64's dental appointments. The RL stated she was unsure if resident 64's insurance covered visits with an outside dental provider. The RL stated that normally, a progress note was entered into the resident's medical record when an appointment was made or canceled. The RL stated she put notes in resident 64's progress notes for appointments she was responsible for scheduling. The RL stated she switched to a new position a few months ago. The RL stated she no longer knew what the process was for scheduling transportation or getting documents to medical records to be put into a resident's medical record. On 6/19/25 at 7:22 AM, an interview was conducted with the Regional Nurse Consultant (RNC) who stated she looked at resident 64's previous medical records and was unable to find any documentation stating that resident 64 had refused dental appointments or canceled them, and there was no information about scheduling or rescheduling the dental appointment. 2. Resident 36 was re-admitted on [DATE] with diagnoses of hemiplegia/hemiparesis, chronic respiratory failure, morbid obesity, major depressive disorder, type 1 diabetes, epilepsy, generalized anxiety disorder. On 6/18/25 at 1:20 PM, an interview was conducted with resident 36's medical doctor (MD). The MD stated that he did not know if resident 36 had a PRN (as needed) insulin order for when glucose levels were high but stated a PRN order would help when resident 36's level was high. The MD stated that resident 36's family member requested a specific endocrinologist and a referral was made but there was some back and forth on scheduling with the endocrinologist. The MD stated resident 36's last A1C (glycated hemoglobin) was at 12. On 6/18/25 at 1:59 PM, an interview was conducted with UM 1. UM 1 stated the physician's assistant (PA) referred resident 36 to a preferred endocrinologist about 2 weeks ago. The referral was made on 5/27/25. UM 1 stated he was the unit manager for a couple months and was unaware of previous endocrinology referrals. UM 1 stated a nurse for the endocrinologist assessed resident 36 on 6/9/25 and resident 36 had an endocrinology appointment 7/1/25. Resident 36's medical record was reviewed 6/12/25 through 6/19/25. Resident 36's laboratory Hemoglobin A1c results were as follows: a. On 2/18/25 was 8.9, reference rate <5.7 b. On 5/23/25 was 9.8, reference rate <5.7Endocrinologist referrals a. On 12/26/24, a follow up PA report stated resident 36 may benefit from an outpatient endocrinology referral. b. On 2/12/25, a follow up MD report documented an endocrinology referral in resident 36's assessment and plan. This was signed by the MD on 2/21/25. c. On 3/17/25, a follow up PA report documented an endocrinology referral in resident 36's assessment and plan. d. On 3/19/2025 at 2:17 PM, the interdisciplinary team (IDT) care plan conference, attended by the social services worker (SSW), unit manager (UM 2) who was the 500 hall unit manager at this time, stated they discussed resident 36's diabetes and making adjustments to his insulin and diet and that the PA and the family member wanted him to see the endocrinologist. e. On 5/27/2025 at 14:56 PM, a progress note stated to notify the provider if low blood sugar occurs, and refer resident 36 to an endocrinologist for diabetes mellitus. f. On 6/11/2025 at 11:43 AM, a progress note stated that resident 36 was referred to an endocrinologist. On 6/9/25, resident 36 had his first assessment in the facility by a nurse for the endocrinologist. On 6/19/25, an interview with the SSW was conducted. The SSW was present at the IDT meeting on 3/19/25 and stated that resident 36's family member wanted him to see the endocrinologist. The SSW did not know if an endocrinology referral or attempt to set up an appointment was made after the IDT meeting. The SSW confirmed that UM 2 was present in the IDT meeting and was the person responsible to set up appointments with outside providers. UM 2 was not available for an interview during the survey.

Based on observation, interview and record review, for 1 of 61 sampled residents, the facility did not provide care and services to maintain or improve a resident's ability to carry out the activities of daily living. Specifically, a resident's bed was positioned against a wall so that his inoperable hand was facing his environment, diminishing his abilities in activities of daily living. Resident identifier: 67.Findings included:Resident 67 was admitted on [DATE] with diagnoses which included hemiplegia, cerebral infarction, contracture left elbow, memory deficit, major depressive disorder, contracture left knee, and mood disorder.On 6/9/25 at 1:08 PM, an observation was made of resident 67 lying slumped down in bed with his head of bed elevated to 90 degrees, shirt pulled up and blankets partially covering his lower extremities. Resident 67's legs were bare, knees were bent and lying sideways in the bed with feet against the footboard and resident 67's upper body positioned approximately at midpoint in his bed so that he was not sitting upright in bed. Resident 67 was lying with the right side of his body against the wall and hemiplegic left side of his body facing his environment. Resident 67's water mug was placed on the bedside table out of reach and an over the bed table with a water cup was placed on the left side of the bed out of reach. Resident 67's food was delivered and resident was observed immediately before and after the lunch tray was delivered. Resident 67 was found to be in the same slumped down position after his tray was delivered as he was before his tray was delivered. Resident 67 was not repositioned in bed when his meal was delivered but the bedside table was placed half over resident 67's bed on his left side. Resident 67 was able to reach his water cup and tray with his right hand, reaching cross body.On 6/9/25 at 1:53 PM, an interview was conducted with Certified Nursing Assistant (CNA) 5. CNA 5 stated that resident 67 was able to feed himself if he was sitting up in bed. CNA 5 stated that resident 67 refused to go to the dining room for meals and sometimes received help from a CNA to eat because he was able to feed himself.On 6/9/25 at 2:11 PM, an additional observation was made of resident 67. Resident 67 was observed to have his head of bed upright at 90 degrees and was slid down in bed in the same position as during lunch. Resident 67 stated he could not straighten his left leg but did prefer to sit up in bed.On 6/11/25 at 01:19 PM, an observation and interview were conducted with resident 67. Resident 67 was observed with lunch and was able to eat ice cream with his right hand with a spoon, reaching cross body to his tray placed on his left side halfway over the bed. Resident 67 was upright at an approximately 60 degree angle and was sitting in the middle of the bed and not against the wall. Resident 67 stated he would like to have his bed position changed so his active arm was not against the wall and he was able to access his environment. Resident 67 stated the staff put his head of bed up when he ate and sometimes repositioned him in bed to sit up.On 6/12/25 at 8:45 AM, an observation was made of resident 67 lying in the center of the bed, at a 60 degree angle during breakfast and was able to reach his food and water to eat with his right hand. Resident 67 was able to demonstrate he was able to pull his body and roll to the left side somewhat but was not able to reposition himself in bed. Resident 67's medical record was reviewed 6/9/25 though 6/19/25.On 06/17/25 at 11:15 AM, resident 67's minimum data set (MDS) for 4/30/25 was reviewed and stated that Resident 67 was able to roll left and right with substantial or maximal assist. Resident 67 was dependent with moving from sitting to lying and lying to sitting in bed. Resident 67's care plan dated 7/15/21, revealed resident 67 required up to extensive assistance by staff for turning and repositioning.On 6/18/25 at 9:15 AM, an interview and observation was made of resident 67. Resident 67 was observed to be positioned at the lower portion of his bed with the head of bed at approximately a 75 degree angle. Resident 67 stated he was not uncomfortable and did not mind the position he was in. Resident 67 was not positioned against the wall and he had eaten all of his breakfast but stated he had to reach across his bed to eat or drink and felt it would be easier if his good arm was not positioned next to the wall.On 6/18/25 at 9:23 AM, an interview was conducted with Unit Manager (UM) 1 and Certified Medication Aide (CMA) 1. UM 1 stated resident 67 was previously on the 300 hall with the right side of his body positioned against the wall. UM 1 stated he believed resident 67 preferred his current positioning. CMA 1 stated the protocol for tray delivery was to reposition resident 67 for meals, sitting him up in bed with the head of bed elevated and the over bed table placed in front of resident 67 on his left side. CMA 1 stated resident 67 moved around in bed and slid down on his own.On 6/18/25 at 9:28 AM, an interview was conducted with the Certified Occupational Therapy Assistant (COTA) who stated she treated resident 67 in April 2025 but had not considered the positioning of resident 67's dominant side against the wall and whether the dominant side should be available to the environment. The COTA stated resident 67 did not reposition himself independently and required assistance for bed mobility to sit upright in bed but may be able to scoot himself down in bed if he wanted.On 6/18/25 at 11:54 AM, an interview was conducted with UM 1. UM 1 stated he talked with the Social Service Worker (SSW) about whether resident 67 wanted his right arm against the wall when he was moved into his room on the 500 hall and was told the bed positioning was not discussed at the time of the room move. UM 1 stated he and the SSW talked with resident 67 about whether he wanted to have his bed positioning changed so resident 67's dominant side could access his environment more freely. UM 1 stated resident 67 stated he did want that change.

Based on interview and record review, it was determined for 2 of 61 sampled residents, that the facility failed to maintain medical records on each resident that was complete, accurately documented, readily accessible, and systematically organized; and failed to ensure the medical record contained the results of any preadmission screening and resident review evaluations and determinations conducted by the State; and physician, nurse, and other licensed professionals progress notes. Specifically, one resident had an updated Pre-admission Screening/Resident Review (PASRR) that was not located in the medical record and one resident had no documentation regarding an elopement. Resident identifiers: 82 and 103.Findings included:1. Resident 82 was admitted to the facility on [DATE] with diagnoses which included severe vascular dementia, hypertension, attention and concentration deficit following cerebral infarction, depression, and cognitive communication deficit.Resident 82's medical record was reviewed 6/9/25 through 6/19/25.A PASRR dated 1/3/24 did not indicate resident 82 had a diagnosis of depression.A Psych (Psychiatric) Follow Up note dated 10/4/24 at 6:00 AM indicated, .suggest Lexapro 5mg [milligrams] daily for depression and anxiety A Nursing note dated 10/12/24 at 1:13 PM indicated, New orders received from [mental health services] to start Lexapro [antidepressant medication] 5 mg QD [every day]. [Physician name redacted] agreed with recommendation.A Psych (psychiatric) Follow Up note dated 10/18/24 at 6:30 AM indicated, .Endorses depression, poor appetite, no interest in ADL's [activities of daily living]. She is tolerating the lexapro 5mg well.A Psych GDR (Gradual Dose Reduction) note dated 11/15/24 at 8:15 AM indicated, .Escitalopram Oxalate [antidepressant medication] Tablet 5 MG Give 1 tablet by mouth one time a day for Depression .On 6/18/25 at 1:19 PM, an interview was conducted with the Social Service Worker (SSW). The SSW stated a new PASRR would be completed if a resident had a new diagnoses added. The SSW stated that she probably had an old email that indicated she notified the PASRR evaluator when resident 82 was diagnosed with depression.On 6/18/25 at 3:10 PM, an interview was conducted with the Director of Nursing (DON) 2. DON 2 stated resident 82 was diagnosed with depression in February of 2025 but it did not get updated in the medical chart. DON 2 stated the PASRR should be updated with the new depression diagnosis.On 6/18/25 at 3:26 PM, an email was received from the SSW that indicated resident 82 was screened out on 1/9/25 for Depression due to Dementia.On 6/19/25 at 9:44 AM, a follow-up interview was conducted with the SSW. The SSW stated she updated resident 82's PASRR and uploaded the document to the medical record. 2. Resident 103 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, atherosclerotic heart disease, essential hypertension, type 2 diabetes, bipolar disorder, muscle weakness, and difficulty in walking.Resident 103's medical record was reviewed on 6/9/25 through 6/19/25. The facility reported that resident 103 eloped from the facility on 4/22/25. No documentation of this elopement was located in resident 103's medical record.On 6/19/25 at 11:10 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that any change of condition would require documentation in the progress notes.

Based on interviews and record review, the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable. Specifically, for 1 out of 26 sampled residents, a resident did not have interventions in place to prevent a deep tissue ulcer/injury to the left inner buttocks from developing and treatments to prevent it from getting worse were not completed. Resident identifier: 143. Findings included: Resident 143 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included benign neoplasm of meninges, pressure ulcer of left buttock stage 4, and cognitive communication deficit. Resident 143's medical record was reviewed on 1/23/24. On 4/28/23 at 1:54 PM, a Nursing Note documented Note Text: . alert and oriented x3-4 [person, place, time, and event] but slow at times to respond to commands, . is incontinent of bowel and bladder most times, will at times ask to use the restroom. Uses a walker for locomotion and is a standby transfer with 1-2 staff members. Known skin issues on scalp from surgical incision (closed with sutures) and 2 skin grafts areas on left thigh that are open to air, and an additional skin graft site on his right thigh that is covered with dressing. Trace generalized edema noted, no pitting edema noted. On 4/28/23 at 4:24 PM, a Skilled Evaluation documented . Resident is bedfast all or most of the time. Completed Clinical Suggestions: Advise Resident to frequently shift weight and raise buttocks while sitting in chair. Assist residentwhen [sic] ambulating. Turn and reposition at least every 2 hours while in bed. [Note: The task of turn and reposition at least every two hours while in bed was not initiated on the Treatment Administration Record (TAR) until 5/9/23, 11 days after admission.] A Braden Scale for Predicting Pressure Sore Risk dated 5/1/23, documented that resident 143 was at Moderate Risk for pressure sores with a score of 13. A score of 13 to 14 would indicate a Moderate Risk. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 143 had a Brief Interview for Mental Status (BIMS) score of 14. A BIMS score of 13 to 15 would suggest intact cognition. The Care Area Assessment Summary of the MDS assessment triggered a care plan for Pressure Ulcer/Injury. [Note: A care plan addressing pressure ulcers was not developed until 5/8/23, after resident 143 developed a pressure ulcer.] A care plan Focus initiated on 5/2/23, documented [Resident 143] has skin graft donor sites to bilateral thighs on admission to the facility. The interventions included, Wound care per orders. A care plan Focus initiated on 5/2/23, documented [Resident 143] has an ADL [activities of daily living] self-care performance deficit. The interventions initiated on 5/2/23, included: a. Bathing/Showering: The resident is up to totally dependent on (1) staff to provide bath/shower and as necessary. b. Bed Mobility: The resident requires extensive assistance by up to (2) staff to turn and reposition in bed. c. Dressing: The resident requires extensive assistance by up to (1) staff to dress. d. Eating: The resident requires set up assist of (1) staff for eating. e. Personal Hygiene/Oral Care: The resident requires up to extensive assist of (1) staff for personal hygiene and oral care. f. Toilet use: The resident requires extensive assist of up to (2) staff for toilet use. g. Transfer: The resident requires extensive assistance of up to (2) staff for transferring. A physician's order dated 5/2/23, documented Barrier cream to buttocks with each brief change and PRN [as needed] every shift. On 5/6/23 at 10:22 AM, a Skilled Evaluation documented . Skin Issue: #007: New. Issue type: Redness. Location: Left buttock, medial area. Wound exudate: None. Peri wound: Erythema. Wound odor: No. Pressure ulcer staging: Deep tissue pressure ulcer /injury - persistent nonblanchable deep red, maroon or purple discoloration. Painful: Yes - episodic pain. Resident is bedfast all or most of the time. [Note: No new interventions were implemented upon the discovery of a new deep tissue pressure ulcer/injury.] On 5/6/23 at 10:24 PM, a Skilled Evaluation documented . Pain: Indicators of pain: Vocal complaints of pain. Pain Issue: #001: Needs Review. Location: Left thigh - generalized. Painscore: 3. Aching. Frequency: Multiple times a day. Distraction techniques utilized. Resident position changed. Relaxation techniques encouraged. Non-medication interventions provided relief. Scheduled medication provided. [Note: Resident 143's position change was implemented for pain relief and not provided every two hours for pressure ulcer prevention.] On 5/7/23 at 1:39 PM, a Skilled Evaluation documented . Pain: Indicators of pain: Non-verbal sounds. Pain Issue: #001: No Change. Location: Left thigh - generalized. Painscore: 3. Aching. Frequency: Multiple times a day. Relaxation techniques encouraged. Resident position changed. Distraction techniques utilized. Non-medication interventions provided relief. Scheduled medication provided. [Note: Resident 143's position change was implemented for pain relief and not provided every two hours for pressure ulcer prevention.] On 5/8/23 at 4:35 PM, a Nursing Note documented Note Text: [Resident 143's] wounds to his R/L [right/left] anterior thighs appear to be stable. Both are graft sites on admit to facility. No signs or symptoms of infection. Graft site to scalp appears to be in great condition. Well approximated with sutures. No drainage or signs or symptoms of infection. Area to L [left] inner upper buttock, approximately 1.0cm [centimeter] x [by] 1.5cm x NMD [non-measurable depth]. Dark in color, intact skin but also draining from one area of it. Indurated surrounding the area, drainage is moderate dark serosanguinous. Surrounding redness noted, blanchable. New order to cleanse with Vashe wound cleanser, apply medihoney to area and cover with a bordered foam. Change QD [daily] and PRN. [Resident 143] reports it's slightly painful, at a 3/10 on a pain scale. Low air loss mattress with pump in place atthis [sic] time. Turning/repositioning as much as he will allow/tolerate. Will continue to follow wound and drainage. MD [Medical Director] aware. [Note: The wound orders were not initiated until 5/10/23.] A care plan Focus initiated on 5/8/23, [Resident 143] has a wound to his L inner upper buttock. The interventions included: a. Low air loss mattress with pump to bed. Date Initiated: 5/8/23. b. Wound care as ordered by Nurse Practitioner (NP) and MD. Date Initiated: 5/8/23. c. Encourage and assist resident 143 with turning, repositioning, and offloading every two hours or as much as he will allow or tolerate. Date Initiated: 5/11/23. d. Float resident 143's heels off the bed or apply foam heel protectors when he was in bed. Date Initiated: 5/25/23. e. Wound healing supplements as ordered by Registered Dietician (RD), NP, and MD. Date Initiated: 5/25/23. On 5/9/23 at 12:10 PM, an Interdisciplinary Team Note documented Note Text: Weekly skilled patient review meeting this AM: Therapy reports that resident's functional level is highly variable from day to day, with resident requiring max assist some days and min [minimum] assist others. Nursing reports that he has a rehab [rehabilitation] appt [appointment] on 5/15 [23] and plastics appt on 5/16 [23]. He was noted with a new skin abnormality to left buttock. Wound nurse to follow. Skin graft donor sites to thighs and recipient site to head are healing well with no s/s [signs or symptoms] of complication. A physician's order dated 5/9/23, documented Encourage and assist [resident 143] with turning/repositioning/offloading Q2H [every two hours] or as much as he will allow/tolerate. every day and night shift for offloading. [Note: The order was initiated the three days after the wound was discovered on 5/6/23.] A physician's order dated 5/9/23, documented Low Air Loss Mattress with pump to bed. Ensure functioning appropriately Q [every] shift. every day and night shift for offloading. [Note: The order was initiated three days after the wound was discovered on 5/6/23.] The Task List Report was reviewed. The following tasks were initiated on 5/9/23, for the Certified Nursing Assistants (CNAs) to perform. [Note: The tasks were initiated 11 days after resident 143 was admitted to the facility and three days after the wound was discovered.] a. Monitor - bed - Pressure relieving surface (Low Air Loss Mattress with Pump to bed). Task schedule: Everyday every shift. b. Monitor - Turn and Reposition. Encourage and assist resident 143 with turning, repositioning, and offloading every two hours or as much as he will allow or tolerate. The May 2023 TAR was reviewed. A physician's order dated 5/10/23 at 6:00 AM, documented Wound Care: L inner upper buttock Cleanse wound with wound cleanser or NS [normal saline]. Dry with gauze. Apply small amount of medihoney to the wound bed. Cover with a bordered foam. Change QD and PRN. every day shift for wound care. According to the TAR wound care was not provided on 5/10/23 and 5/11/23. On 5/11/23 at 3:40 PM, a Nursing Note documented Note Text: Wound to [resident 143's] L inner/upper buttock was treated and assessed today by this RN [Registered Nurse]. Wound has broken open it appears and now has measurements of 3.0cm x 3.5cm x 2.5cm. Odor noted with slough to the open edges of wound bed. Moderate serosanguinous drainage. Probed with Qtip and no tunneling or undermining noted. Wound cleansed well with Vashe wound cleanser, and packed with silver alginate. Covered with bordered foam dressing QD and PRN. Continues on low air loss mattress with pump, currently functioning appropriately. Offloading schedule in place for as much as [resident 143] will allow/tolerate to help him with repositioning and keeping him off that L buttock wound. RD notified. New orders for MVI [multi vitamin] with minerals QD, Vitamin C 500mg [milligrams] PO [by mouth] BID [twice daily], Zinc 220mg PO QD x 14days, and Juven packet QD. [Name of doctor removed] notified and is aware of wound, size and current dressing order in place. A Braden Scale for Predicting Pressure Sore Risk dated 5/12/23, documented that resident 143 was at High Risk for pressure sores with a score of 12. A score of 10 to 12 indicated a High Risk. On 5/15/23 at 3:27 PM, a Nursing Note documented Note Text: [Resident 143] returning from f/u [follow up] with [name removed] Rehab, APRN [Advanced Practice Registered Nurse] [name removed] evaluating [resident 143], specifically seeing his L buttock wound. [Name removed] spoke with DON [Director of Nursing], several new orders, including orders for oral Doxycycline and Omnicef, as well as a f/u [follow up] with Oncology, Plastics and Infectious Disease to begin following. New order for wound care to be wet to dry dressings BID and PRN with saline dampened gauze, cover with silver alginate and ABD [abdominal pads], secure in place with mefix tape. [Name removed] expressing concern over the wound and it's rapid progression, odor and tunneling, with the concerns being r/t possible osteomyelitis or cancer recurrence. New orders for labs as well, including CBC [complete blood count] w/ [with] diff [differential], CMP [comprehensive metabolic panel], CRP [c-reactive protein], PSA [prostate-specific antigen], and several others. New order for MRI [magnetic resonance imaging] as well. Wound DNP [Doctor of Nursing Practice] [name removed] to begin rounding on [resident 143's] wound on 5/17 [23] with wound rounds. The May 2023 TAR was reviewed. A physician's order dated 5/15/23 at 6:00 PM, documented Wound care: Wet to dry dressing with NS dampened gauze to L buttock wound. Cover with silver alginate and ABD pad. Secure in place with tape. Change BID and PRN. every day and night shift for wound care. According to the TAR wound care was not provided on 5/16/23 in the evening. On 5/16/23 at 8:27 PM, an Orders - Administration Note documented Note Text: Doxycycline Hyclate Oral Tablet 100 MG Give 1 tablet by mouth two times a day for infection for 15 Days pending delivery. [Note: The antibiotic was not available for administration. Resident 143 missed a dose of the doxycycline.] On 5/17/23 at 2:57 PM, a Nursing Note documented Note Text: Wound Note: [Resident 143's] wound to his L inner upper buttock was treated and evaluated today by this RN along with [name removed] DNP from [name of clinic removed] Wounds. Wound to L buttock, an open pressure wound. Odor noted but is slightly improved from earlier this week. Drainage is moderate serosanguinous. Depth noted at 3.0cm today with a tunnel at 7:00 that is 7.5cm deep and undermining at 6:00 that is 5cm deep. Wound opening measures 2.5cm x 2.5cm approximately. Granulation tissue noted within the wound bed. Slightly painful per [resident 143] when treating his wound. [Resident 143] continues on oral Doxycycline and Omnicef and has several appointments scheduled in regards to this wound, specifically to see Oncology, Infectious Disease and Plastics. Wound care to continue to [NAME] [sic] wet to dry dressing BID at this time. Continue the low air loss mattress with pump and the repositioning/offloading schedule. [Resident 143] aware of his wound, current status and treatment in place. He is aware he is on antibiotics and has several appointments in the future r/t this wound. [Note: The depth of the wound has increased per measurements.] On 5/18/23, the medical records from the local hospital documented. new pressure injury to right buttock. Wound: BID Dressing changes, to be performed by floor RN. Pack with Kerlix Danskins Wet-to-Dry. Secure with 4x4s and tape or mepilex. Continue augmentin. Would consider 10 day course of abx [antibiotic]. Images reviewed and discussed with attending who saw wound over the weekend. Ok for dc [discharge] to nursing facility . No plans for debridement during this hospitalization . Ideally he would go to different nursing facility, as this pressure injury occurred while in the care of the transferring nursing home. Skin: Right sided sacral/coccygeal stage 4-5 decubitus ulcer. Due to concern for ongoing infection from sacral decubitus ulcer, lumbar drainage and/or puncture will be deferred for now so as to avoid seeding infection to the CSF [cerebrospinal fluid] space causing meningitis. [Note: Resident 143 was admitted to the hospital on 5/18/23 and readmitted to the facility on [DATE].] On 5/24/23 at 6:04 PM, a Nursing Note documented Note Text: The resident . admitted from the [name of hospital removed] with a primary diagnosis of normal pressure hydrocephalus. The resident is . , alert and oriented x3-4, maintains oxygen status on RA [room air], and reports no pain. The resident takes their medications whole, is incontinent of bowel and bladder. Uses a wheelchair for locomotion, and is a standby x1-2 assist for transfers. Skin issues: scalp incision r/t craniotomy, skin grafts areas on left and right thighs that are open to air, and a pressure wound on coccyx. A physician's order dated 5/24/23, documented Ciprofloxacin HCl [hydrochloride] Tablet 500 MG Give 1 tablet by mouth two times a day for Infection for 5 Administrations. On 5/25/23 at 4:15 PM, a Nursing Note documented Note Text: Wound Note: [Resident 143's] wound to his L buttock area was treated and evaluated today by this RN. Wound is a Stage IV pressure wound. Measurements are: 2.5cm x 2.5cm x 2.1cm with undermining from 4:00 to 7:00 with the deepest part at about 7:00 being 6.5cm. No odor noted. Moderate serosanguinous drainage noted. Beefy red granulation tissue visible to the wound bed and inner sides. Wound treated as ordered. [Resident 143] tolerated well. Some pain noted with the packing of the wound into the depth of the undermining. He continues on a low air loss mattress with pump, currently functioning appropriately. Heels floated. Currently on an offloading schedule as well. [Note: Measurements were after resident 143 returned from the hospital.] On 5/26/23 at 6:49 PM, an Orders - Administration Note documented Note Text: Ciprofloxacin HCl Tablet 500 MG Give 1 tablet by mouth two times a day for Infection for 5 Administrations on order. [Note: The antibiotic was not available for administration. Resident 143 received four administrations of the antibiotic.] On 5/31/23 at 3:12 PM, a Nursing Note documented Note Text: Wound Note: . L buttock wound, a pressure wound. Wound appears slightly improved from last evaluation. Wound bed granular with depth decreased to between 0.5cm and 1.0cm. Tunnel noted at 6:00 at 5.6cm with some undermining at 7:00 noted at 1.8cm. No odor. Moderate serosanguinous drainage noted. Decreased pain per [resident 143's] when treatment was being completed. Induration surrounding theopen [sic] wound has disappeared. Continue current order in place for treatment. Continue low air loss mattress with pump and floating heels. Continue turning/offloading schedule as much as he will allow tolerate. On 6/7/23 at 1:27 PM, a Nursing Note documented Note Text: Wound Note: . L buttock wound, a healing Stage IV pressure ulcer. Wound has improved. Currently 2.0cm x 2.0cm x 0.5cm with red granulating tissue to wound bed. Tunnel still present at 6:00 but is noted at 2.0cm which is quite improved from 5.6cm last week. Area of undermining at 7:00 remains the same 1.8cm. No odor or signs or symptoms of infection. New order for wound care, cleanse wound with Vashe wound cleanser, apply collagen to wound bed and cover with a bordered foam. Change Q MWF [Monday, Wednesday, and Friday] and PRN. [Resident 143] aware and agreeable. He was reeducated about his wound and current measurements as well. He continues on low air loss mattress with pump and offloading schedule. On 6/14/23 at 1:23 PM, a Nursing Note documented Note Text: Wound Note: .L buttock wound, a healing Stage IV pressure ulcer. Wound has improved greatly, aeb [as evidenced by]: wound bed measures approximately 1.5cm x 1.7cm x 0.5cm. No tunnel or undermining noted. No signs or symptoms of infection. Granulating red wound bed noted. Light serous drainage. Continue current order in place for treatment. On 1/24/24 at 9:08 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the Wound Nurse (WN) would do the Braden scores when they did wound care rounds. LPN 1 stated that initially an RN would perform the Braden scores. LPN 1 stated that an RN and Unit Manager (UM) were responsible for the baseline care plans. On 1/24/24 at 11:30 AM, an interview was conducted with RN 3. RN 3 stated the UM would keep the resident care plans up to date and the UM would take suggestions from the floor staff regarding interventions. RN 3 stated that the floor nurse would conduct the initial head to toe assessment, skin assessment, and sign all the admission paperwork. RN 3 stated the UM would input the resident admission medications, treatments, and make sure the staff had all the paper work. RN 3 stated the Braden scores were completed by the WN. On 1/24/24 at 12:16 PM, an interview was conducted with the WN. The WN stated that Braden scores were done on admission, weekly for four weeks, and quarterly. The WN stated that he would be responsible for completing the Braden scores. On 1/24/24 at 1:20 PM, an interview was conducted with UM 1. UM 1 stated that she did the initial base line care plans for new residents. UM 1 stated the initial care plan included ADLs, falls, pain, etc. and the initial care plan needed to be completed within three days of admission to the facility. On 1/25/24 at 10:22 AM, a follow up interview was conducted with the WN. The WN stated that resident 143 moved around a lot in bed on his own. The WN stated if the resident was at moderate risk for pressure ulcers and moved well he probably would not have developed a care plan for pressure ulcer prevention. The WN stated the baseline care plan addressed skin. On 1/25/24 at 11:24 AM, an interview was conducted with the DON. The DON stated the task to turn the resident every two hours would have pulled to the kardex for the CNAs to reposition as the resident allowed. The DON stated interventions for the CNAs were on the care plan. The DON stated that once staff were aware of skin issues they should care plan so they can relay shift to shift. The DON stated a resident with a moderate Braden score should have a care plan to prevent pressure ulcers. The DON stated if the resident upon admission were a moderate or at risk for pressure ulcers, the resident would get an air mattress or therapy would be involved more. The DON stated that antibiotics should be in the emergency medication system. The DON stated that within the resident electronic medical record there was a reorder button for medications that communicated with the pharmacy. The DON stated the pharmacy got orders through the electronic medical record and when the pharmacy received the orders they should deliver the medications. The DON stated the nurses should call the pharmacy if the medication was urgent. The DON stated that once the staff got an antibiotic order they had four hours to administer the medication. The DON stated there had been talks with the pharmacy regarding the delivery of medications. The DON stated the UM would do the baseline care plans and they should be completed within 48 hours. The facility policy Skin Integrity was reviewed. PURPOSE: To promote the prevention of avoidable pressure ulcers/injuries (PU/PI) and provide care and services consistent with professional standards of practice which will promote the healing of existing PU/PI. POLICY: The facility, based on a resident's comprehensive assessment, will provide care, consistent with professional standards of practice, to prevent pressure ulcers and promote healing, prevent infection and prevent new ulcers from developing unless the resident's clinical condition demonstrates that they were unavoidable. GUIDELINES: 1. Pressure ulcers will be staged according to professional standards of practice. 2. The facility will assess residents upon admission, and thereafter, to identify if the resident is at risk for developing or has a PU/PI, or has pre-existing signs suggesting that tissue damage has already occurred. 3. The facility will evaluate resident specific risk factors and changes in the resident's condition that may impact the development and/or healing of a PU/PI. 4. The facility will implement, monitor and modify interventions to attempt to stabilize, reduce or remove underlying risk factors. 5. If a PU/PI is present, the facility will provide treatment to heal it and will provide treatment in an effort to prevent the development of additional PU/PIs. 6. A resident identified as at risk of developing PU/PIs will have individualized interventions implemented to attempt to prevent PU/PI from developing. Interventions will be monitored for effectiveness. The resident's care plan will reflect the interventions. 7. The comprehensive assessment will address factors having an impact on the development, treatment and/or healing of PU/PIs. These factors will include, but not limited to: a. Risk factors; b. Pressure points; c. Under-nutrition and hydration deficits; d. Moisture and the impact of moisture on skin. 8. The facility recognizes that not all risk factors can be modified. These include, but are not limited to: a. Impaired/decreased mobility and decreased functional ability; b. Co-morbid conditions, such as end stage renal disease, thyroid disease or diabetes; c. Certain drugs, such as steroids, that may affect healing; d. Impaired diffuse or localized blood flow, such as, generalized atherosclerosis or lower extremity arterial insufficiency; e. Resident refusal of some aspects of care and treatment; f. Cognitive impairment' g. Exposure of skin to urinary and fecal incontinence; h. Under nutrition, malnutrition and hydration deficits; i. Presence of previously healed PU/PI. 9. A standardized PU/PI risk assessment tool will be utilized. A clinician may assess the resident to be at a higher risk level than the overall score determined on the assessment tool. The medical record will reflect the clinician's assessment. 10. The resident's care plan will reflect the preventive strategies for residents identified as at risk for developing PU/PI. 11. The resident's care plan will reflect the treatment strategies for residents identified as having a PU/PI. 12. Nutritional assessment and hydration evaluation and possible interventions will be considered when a resident has a non-healing PU/PI and/or continuing weight loss. Nutritional goals will reflect the resident's wishes and goals, consider the whole person and be reflected in the care plan. 13. The facility will strive to keep feces and urine off the skin to reduce the risk of PU/PI and moisture-related skin damage. 14. The comprehensive assessment will provide the basis for defining approaches to address residents at risk of developing or those who already have a PU/PI. 15. Prevention and treatment plans will be individualized and consistently provided. 16. Based on the comprehensive assessment and the resident's clinical condition, choices and identified needs, interventions may include, but not be limited to: a. Pressure redistribution; b. Minimizing exposure to moisture and keeping the skin clean, especially of fecal contamination; c. Provision of pressure-redistributing support surfaces; d. Maintenance or improvement of nutritional and hydration status, when possible; e. Identification and treatment of adverse drug reactions. 17. Efforts to stabilize or improve co-morbidities to minimize the potential impact on PU/PI development or healing will align with the resident ' s preferences. 18. If a resident is refusing care and treatment, the facility will attempt to identify the basis for the refusal and identify potential alternatives, as indicated. 19. 20. 22. Repositioning or relieving constant pressure is an effective intervention for treatment or prevention of PU/PIs. Repositioning plans will be addressed in the resident's comprehensive care plan. 23. Positioning a resident on an existing PU/PI will be avoided if possible. 24. Considerations in repositioning frequency include: a. Level of activity and mobility; b. General medical condition; c. Overall treatment objectives; d. Skin condition e. Comfort. 25. Repositioning needs to maintain the resident's skin integrity will be considered for residents who are reclining, are seated in bed, seated in a chair or wheelchair, as well as for residents who are lying in bed. Repositioning needs/plans will be reflected in the care plan. 26. Pressure redistribution involves both pressure reduction and pressure relief. Pressure redistribution devices (support surfaces/devices) will be used according to manufacturer's recommendations. Their effectiveness will be evaluated on an ongoing basis. 27. Some considerations related to pressure redistribution issues include, but are not limited to: a. Static pressure redistribution devices (i.e. gel mattress or cushion) may be indicated for a resident at risk for developing a PU/PI or for delayed healing; b. Dynamic pressure reduction surfaces may be helpful when: i. Resident cannot assume a variety of positions without bearing weight on a PU/PI; ii. The resident completely compresses static devices; iii. PU/PI is not healing as expected and pressure may be contributing to the delay in healing. 28. Donut-type cushion devices are not recommended. 29. Facility staff will monitor residents skin condition and be alert to potential changes in the residents' skin condition. Identified changes will be reported. 30. The IDT [interdisciplinary team] will develop a relevant care plan that includes measurable goals and interventions for prevention and management of PU/PIs. Identified interventions will be implemented. 31. Existing PU/PIs will be identified and causative factors recognized, assessed and addressed. Preventive measures will be re-evaluated when a resident develops a new PU/PI or an existing PU/PI shows delayed healing. 32. 33. 34. 35. 36. 37. 38. Treatment plans will be re-evaluated, taking into consideration the resident's condition, if the PU/PI does not have evidence of healing within 2-4 weeks. If the clinician determines to continue all, or part, of the current treatment, the rationale will be documented in the resident's record. 39. Whenever significant changes in the nature of the wound or overall resident condition are identified, physician involvement will be sought. 40. PU/PI infection may be acute or chronic. Pain may be the only symptom of infection. 41. The first sign of infection in a PU/PI may be delay in healing and an increase in exudate. In a chronic wound, signs of infection may include: a. Increase in amount or change in characteristics of exudate; b. Decolorization and friability of granulation tissue; c. Undermining; d. Abnormal odor; e. Epithelial bridging at the base of the wound; f. Sudden pain. 42. The facility will assess and treat pain related to PU/PIs. 43. Dressings and treatments will be determined based upon the PU/PI characteristics, treatment goals, professional standards and manufacturer's recommendations for use. 44. PU/PIs will be assessed throughout the healing process and treatments and dressings modified as necessary.

Based on observation, interview, and record review it was determined, for 1 of 51 sample residents, that the facility did not ensure that pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a resident was observed to cry out in uncontrolled pain for over 4 hours and the licensed nurse would not notify the physician of the resident's condition to request any new orders for pain medication. Resident identifier 194. Findings included: Resident 194 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 11:21 AM, an interview was conducted with resident 194. Resident 194 stated that she took [MEDICATION(S)] for muscle spasms and her primary care provider had her on a schedule for her pain management. Resident 194 stated that she had been fighting a battle with the facility to try and get the pain medication schedule back to what it was prior to admission. Resident 194 stated that at home she took two Tylenol 500 milligrams (mg), two [MEDICATION(S)] 50 mg, and a [MEDICATION(S)], every 5 hours. Resident 194 stated that at bedtime she took [MEDICATION(S)]. Resident 194 stated that when she was at home, she did not start taking the daytime medication until 1:00 PM in the afternoon. Resident 194 reported waking in the morning and delaying the medication until 1:00 PM. Resident 194 stated that the facility had her medications scheduled at different times and that they were spaced out and not administered together. Resident 194 stated that they have changed the schedule and that it had been a fight. Resident 194 stated that she spends all her time in pain due to the scheduling of her pain medication. Resident 194 stated that the [MEDICATION(S)] was not a part of the scheduled medication at home, but here at the facility it was a scheduled medication. Resident 194 stated that she had spoken to the facility nurses about not messing with her previous home pain schedule. Resident 194 stated that she had not spoken to the facility doctor about the ordered pain medication schedule yet because she had not seen the doctor. Resident 194 reported that the current pain was a 4 out of 10. Resident 194 stated that she had nerve pain that was located in the left flank. Resident 194 reported that when her pain medication was managed her pain score was a ,d+[DATE]. Resident 194 stated that if the break through pain was bad she also had [MEDICATION(S)] available for the pain. Resident 194 stated that she preferred to use the lesser medication for pain first. Resident 194 stated that while she had been at the facility the pain had been a ,d+[DATE] or down to ,d+[DATE] and had kept her from going to sleep at night. Resident 194 stated that she dealt with the pain every single day. Resident 194 stated that an acceptable level of pain was a ,d+[DATE]. Resident 194 stated that the pain was located in her lower back and hips, down to her feet. Resident 194 stated that the pain was so intense that it caused her toes to spread out. On [DATE] resident 194's medical records were reviewed. On [DATE] at 12:41 PM, resident 194's Brief Interview for Mental Status (BIMS) assessment documented a score of ,d+[DATE] which would indicate that the resident was cognitively intact. Review of resident 15's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] 4 %, Apply to Right Bicep topically every 12 hours as needed for pain. The order was initiated on [DATE]. b. Acetaminophen Tablet, Give 1000 mg by mouth three times a day for pain. The order was initiated on [DATE]. c. [MEDICATION(S)] [MEDICATION(S)] (HCl) Capsule Delayed Release Particles, Give 60 mg by mouth one time a day related to chronic pain. The order was initiated on [DATE]. d. [MEDICATION(S)] Capsule, Give 300 mg by mouth three times a day for [CONDITION(S)]. The order was initiated on [DATE]. e. Hot pack to residents lower back as needed for Back pain. The order was initiated on [DATE]. f. [MEDICATION(S)] HCl Tablet, Give 2 mg by mouth every 8 hours as needed for muscle spasms do not give more than 3 doses within 24 hours. The order was initiated on [DATE]. g. Question resident about presence of pain or burning including pressure points every shift. Monitor for pain using ,d+[DATE] scale. 0 for no pain, 10 for worst pain possible. If resident was not able to answer, use PAINAD scale. The order was initiated on [DATE]. h. Record non-pharmacological interventions to pain every shift: 1=repositioning/limb, elevation 2=reassurance/emotional support 3=distraction/diversionary activities 4=ROM/ambulation/stretching 5=rest period/quiet environment 6=deep breathing/relaxation exercises 7=massage/therapeutic touch 8=application of ice/heat pack 9=laughter/socialization; 10=Aroma therapy 11=NO PAIN PRESENT. The order was initiated on [DATE]. i. [MEDICATION(S)] Tablet, Give 15 mg by mouth at bedtime for hip/back pain take with food and plenty of water. The order was initiated on [DATE]. Review of resident 194's [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was initiated on [DATE] and expired on [DATE]. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The following [MEDICATION(S)] administrations were documented as not affective: a. On [DATE] at 1:23 PM, resident 194 requested the [MEDICATION(S)] for a pain score of ,d+[DATE], and the medication was marked as not effective. b. On [DATE] at 6:52 PM, resident 194 requested the [MEDICATION(S)] for a pain score of ,d+[DATE], and the medication was marked as not effective. c. On [DATE] at 1:27 PM, resident 194 requested the [MEDICATION(S)] for a pain score of ,d+[DATE], and the medication was marked as not effective. d. On [DATE] at 5:28 AM, resident 194 requested the [MEDICATION(S)] for a pain score of ,d+[DATE], and the medication was marked as not effective. e. On [DATE] at 2:10 PM, resident 194 requested the [MEDICATION(S)] for a pain score of ,d+[DATE], and the medication was marked as not effective. f. On [DATE] at 10:11 PM, resident 194 requested the [MEDICATION(S)] for a pain score of ,d+[DATE], and the medication was marked as not effective. g. On [DATE] at 8:29 AM, resident 194 requested the [MEDICATION(S)] for a pain score of ,d+[DATE], and the medication was marked as not effective. h. On [DATE] at 9:41 PM, resident 194 requested the [MEDICATION(S)] for a pain score of ,d+[DATE], and the medication was marked as not effective. It should be noted that no documentation could be found to indicate that the ineffective [MEDICATION(S)] medication administration was addressed by the licensed nurse or the provider. The non-pharmacological pain interventions that were documented on [DATE] through [DATE] for day and night shift included repositioning limb, elevation, reassurance/emotional support, and rest period/quiet environment. Review of resident 194's MAR for [MEDICATION(S)] 4%, apply to right bicep topically every 12 hours as needed documented that it was administered on [DATE] at 2:39 PM, and the medication was marked as effective. The [MEDICATION(S)] 2 mg every 8 hours as needed for muscle spasms, was documented as administered on [DATE] at 12:19 AM, and the medication was marked as effective. It should be noted that resident 194 cried in pain from 1:15 AM to 5:57 AM on [DATE]. The [MEDICATION(S)] was not documented as administered on [DATE]. Review of resident 194's MAR for [MEDICATION(S)] 2 mg every 8 hours as needed for muscle spasms documented the following administrations as not effective: a. On [DATE] at 9:35 PM, resident 194 requested the [MEDICATION(S)], and the medication was marked as not effective. b. On [DATE] at 8:49 PM, resident 194 requested the [MEDICATION(S)], and the medication was marked as not effective. Nursing progress note on [DATE] at 9:00 PM documented that the Nurse Practitioner (NP) was notified of the resident complaints. No documentation could be found of the NP follow-up. c. On [DATE] at 5:28 AM, resident 194 requested the [MEDICATION(S)], and the medication was marked as not effective. d. On [DATE] at 2:10 PM, resident 194 requested the [MEDICATION(S)], and the medication was marked as not effective. e. On [DATE] at 10:11 PM, resident 194 requested the [MEDICATION(S)], and the medication was marked as not effective. f. On [DATE] at 9:41 PM, resident 194 requested the [MEDICATION(S)], and the medication was marked as not effective. It should be noted that no documentation could be found to indicate that the ineffective [MEDICATION(S)] medication administration on [DATE], [DATE], and [DATE] were addressed by the licensed nurse or the provider. The non-pharmacological pain interventions that were documented on [DATE] through [DATE] for day and night shift included repositioning limb, elevation, reassurance/emotional support, distraction/diversionary activities, and rest period/quiet environment. Review of the pain scores from admission on [DATE] to current [DATE] revealed an average pain score of 6 with the lowest pain score recorded as ,d+[DATE] and the highest recorded as ,d+[DATE]. Review of resident 194's progress notes revealed the following: a. On [DATE] at 5:44 AM, the note documented a new order from the NP of [MEDICATION(S)] 3 mg at bedtime. b. On [DATE] at 11:36 PM, the note documented, .Res has displayed some anxiety and fits of crying throughout shift. Reassured/redirected multiple times, and was able to calm her down; .Pain Mgmt [management]: Chronic pain. C/o [complained of] pain multiple times this shift with little relief. Offered heat pack for back pain, but resident refused. Gave PRN [as needed] [MEDICATION(S)] x [times] 1 this shift for muscle spasms c. On [DATE] at 11:40 AM, the note documented that the resident reported right bicep pain. The NP ordered [MEDICATION(S)] 4 % to be applied to the right bicep every 12 hours as needed for pain. d. On [DATE] at 8:48 AM, the note documented, Patient has displayed some anxiety and fits of crying. Reassured patient, was able to calm her down and gave pain medications.; .Scheduled APAP [Tylenol], PRN [MEDICATION(S)] and [MEDICATION(S)] positioning and heat used as interventions for patients pain; Pain Mgmt: Patient reports chronic pain. Fits of crying and grimacing observed. Repositioned, reassured, given prntramadol (sic) and [MEDICATION(S)] as well as scheduled tylenol for pain e. On [DATE] at 3:50 AM, the note documented, Tearful episode again tonight. Gave patient hot packs with marginal effect. Patient continued to complain of pain. f. On [DATE] at 9:10 AM, the note documented, Upon arrival to shift patient relaxing comfortably in bed. Morning medications provided at 0619 [6:19 AM] and pain assessed. Patient denies pain at present time and states she wishes to wait on PRN [MEDICATION(S)] until later into the morning. Patient instructed to use call light for outbreaks of pain, patient verbalized understanding. at CNA [name omitted] reports patient complaining of extreme pain and c/o [complaining of] of wanting 'it to be over.' Immediate follow up with patient who states she is frustrated over current medication schedule,as (sic) she had been taking [MEDICATION(S)] 4x [times] daily while at home. Patient states she would like her medication reassessed. Patient provided PRN [MEDICATION(S)] and [MEDICATION(S)] per orders and patient assisted in repositioning for comfort. Patient asked if she had any thoughts of hurting herself. Patient verbalized that she had no thoughts of hurting herself. She states she wants her stay at the facility to be 'over' but has no suicidal ideation. She states she would never 'go there', indicating suicidal ideation. Patient provided emotional support and comfort measures and was smiling and engaging at end of visit. Follow up with [name omitted] NP r/t [related to] patients (sic) current pain medications, and continued hourly rounding to ensure patient comfort. g. On [DATE] at 1:15 AM, the note documented, Spoke with patient, patient reports history of spinal stenosis and lower back pain with spasms. Describing the pain as electric feeling in nature. Also reports what she described as 'hot spots' within the joint of her hips indicating towards the acetabulum (hip socket) with a bilateral inference. Reports [AGE] year history of the [NAME]. Frequently observe patient sitting up in bed in room rocking back and forth. Fits of crying is observed. h. On [DATE] at 4:05 PM, the note documented, NP notified 'PRN [MEDICATION(S)] / [MEDICATION(S)] 100mg and scheduled [MEDICATION(S)], Tylenol given at 1400 [2:00 PM]. Resident still reports a pain of ,d+[DATE]'. i. On [DATE] at 9:00 PM, the note documented, patient anxious over her current medication orders. She states pain medication is different from what she had while living at home. NP [name omitted] notified of patients concerns with follow up to be provided. Patient provided emotional support and active listening; .patient states current prescribed pain medication regiment is ineffective for adequate pain relief. Patient provided comfort measures, repositioning, and PRN heat to assist in pain relief. NP [name omitted] notified of patient complaints j. On [DATE] at 4:32 PM, the note documented, This resident is still having complaints about her pain management / orders. Resident upset that her [MEDICATION(S)] is q8 [every 8 hours]. NP [initials omitted] notified. k. On [DATE] at 1:00 PM, the note documented, Resident has been anxious r/t pain medication administration. Reassured. Explained to pt. [patient] scheduled and PRN medication orders. Wrote down a list of available medications and scheduled times. Resident pleasant et. [and] cooperative.; .Pt. reported a generalized pain of ,d+[DATE]. PRN [MEDICATION(S)] HCl Tablet 50 MG [milligram] administered c [with] request from resident. Pain medication management discussed c pt l. On [DATE] at 11:00 AM, the note documented, Resident given hot pack for lower back pain. Barrier between skin et. pack m. On [DATE] at 6:34 PM, the NP note documented, Chronic stable problems include: 1) Spinal stenosis 2) chronic back pain 3) constipation . Patient seen for acute visit. When seen she was sitting on the toilet and crying. She says she is 'frustrated because of where I'm at'. She reports ,d+[DATE] pain in hips. She likes [MEDICATION(S)], says 'it's a wonder drug' . Spinal Stenosis/Chronic pain polypharmacy -avoid increasing or prescribing sedating meds - [MEDICATION(S)] 300 mg BID - [MEDICATION(S)] HCl Tablet 2 MG q8h [every 8 hours] - [MEDICATION(S)] HCl Tablet 100 MG q8h PRN x 7 days - [MEDICATION(S)] 15 mg Anxiety/Depression - [MEDICATION(S)] 60 mg Review of resident 194's Care plan revealed a focus area for had pain r/t contractures of muscles. The care plan was initiated on [DATE]. The goal was resident 194 will not have an interruption in normal activities due to pain through the review date. Interventions identified were: Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; Residents tolerable level of pain is ,d+[DATE]; Resident frequently requests PRN pain medications when asked if any non-pharmacological pain interventions help resident stated no and that she would refuse them. On [DATE] at approximately 1:15 AM, the ADM and RN 8 were speaking at the nurse's station about resident 194. RN 8 stated that resident 194 needs Something done because she had been up all night. The ADM was observed to walk away. RN 8 stated that the resident 194 was attention seeking. RN 8 stated that they will go into resident 194's room and help her, and then as soon as they leave the resident will cry out again. RN 8 stated that they were going to talk to the NP again tomorrow about resident 194 because she had been constantly calling staff into her room. RN 8 stated that resident 194 had been at the facility before so staff were familiar with her behaviors. On [DATE] at 1:56 AM, resident 194 was heard crying. At 2:01 AM, CNA 16 was observed to walk past resident 194's room. At 2:02 AM, resident 194 was heard crying and the walker was heard moving around in the room. At 2:05 AM, resident 194 was heard crying and saying mumbled words help me. Resident 194 placed the call light on at 2:05 AM. Resident 194 was heard saying I can't and crying from the hallway. On [DATE] at 2:07 AM, CNA 16 entered resident 194's room to answer the call light. CNA 16 was heard asking resident 194 if she wanted any medication or anything. Upon exit of the room, CNA 16 stated that resident 194 wanted to talk to the nurse about some issues she had. Resident 194 continued to cry out, and was heard stating from the hallway just please come in. Somebody. On [DATE] at 2:09 AM, CNA 16 informed RN 8 that resident 194 wanted to talk to her about some concerns she has. CNA 16 stated that he had asked if he could do anything for her, but that resident 194 had asked for RN 8. RN 8 stated that it has been like this all night. RN 8 stated that resident 194 had been asking for more pain medication due to chronic pain, and that there have been several conversations with the NP over the past several days specifically about this. RN 8 stated that resident 194 had reported that the medication was not effective, but that the NP said there was a history of narcotic abuse so they would not increase the medication at this time. RN 8 stated that resident 194 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 2:14 AM, RN 8 entered resident 194's room. Resident 194 stated that she needed a certain medication. RN 8 was stated they could not do anything until morning. Resident 194 stated that she just felt like she needed to run down the hallway. Resident 194 asked if the [MEDICATION(S)] was administered with the medication. RN 8 stated they gave the [MEDICATION(S)]. Resident 194 stated that the medication gets all messed up when she goes into a care facility. Resident 194 stated that her back was killing her, and RN 8 stated they could get her a hot pack. Resident 194 stated that would be wonderful, but the hot pack did not last very long like a heating pad. I know that you think I'm in a panic, but when I talk no one listens. RN 8 stated that she gave her all the medication she could and had done everything she could tonight for her. Resident 194 stated that this was not normal, and her body did not feel right. RN 8 stated that the doctor would come in tomorrow. Resident 194 stated that she was scared and if she moved her neck a certain way then it hurt the rest of her body. Resident 194 stated that she just needed some help. Resident 194 stated Can't stand and can't sit because of the pressure. RN 8 stated It's the middle of the night so I'm not calling her [provider] right now. RN 8 exited the room at 2:19 AM. On [DATE] at 2:20 AM, CNA 16 entered resident 194's room with a hot pack. Resident 194 thanked CNA 16 for trying to help. Resident 194 stated, There's a bunch of[OBSCENITY]going on in by body. Resident 194 was heard crying and moving the walker around. CNA 16 exited the room. Resident 194 was heard crying out at 2:42 AM. On [DATE] at 2:21 AM, RN 8 spoke to resident 194. RN 8 stated that it was the middle of the night and she had given her everything she could. RN 8 stated that she could not do anything until morning and refused to contact the MD because it was the middle of the night. On [DATE] at 2:47 AM, resident 194 placed the call light on and CNA 16 answered. Resident 194 requested another hot pack and stated that they did not last long. CNA 16 asked if there was anything else that the resident needed. CNA 16 exited the resident room and returned with a new hot pack. Resident 194 continued to cry out and was heard from the hallway. On [DATE] at 3:00 AM, resident 194 placed the call light on and CNA 16 answered. Resident 194 stated I don't know what's going on. Resident 194 stated she could not wait until tomorrow. Resident 194 stated that she did not have much faith in this place. Resident 194 stated she had a really dumb back and when she sat in the chair her back hurts. Resident 194 stated she could not do this, and she needed to see a doctor. CNA 16 stated that the doctor would be here during the day. Resident 194 stated What am I supposed to do? On [DATE] at 3:03 AM, CNA 16 stated that resident 194 was like this every night. CNA 16 stated that resident 194 was at the facility for medication abuse at home. CNA 16 stated that resident 16 was taking a lot of medication at home, and her body was asking for more and more. CNA 16 stated that they to give her everything she asked for and try to comfort her. On [DATE] at 3:07 AM, resident 194 was heard calling out down by the main nurse's station. An interview was conducted with RN 8. RN 8 stated that CNA 16 was just in resident 194's room. RN 8 then showed documented messages from the licensed nursing staff to the NP that had not been responded to. The message content was all about pain medication. RN 8 showed documentation 4 days ago where the nurse said that resident 194 was upset that her [MEDICATION(S)] was only every 8 hours and it was ineffective. RN 8 stated that the NP has not responded. RN 8 stated that We've told [name of NP omitted] every day that there's an issue. RN 8 stated that she thinks the NP had talked to resident 194 about it. It should be noted that there was no NP documentation since [DATE]. RN 8 stated she asked resident 194 if she would take something for anxiety because maybe it was not about the pain, and resident 194 replied I will take anything! It should be noted that per resident 194's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 3:08 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated he had no issues with notifying a provider at any time there was a need. LPN 1 stated that he could call the MD or NP and if they were not available the facility had a on-call MD 24 hours a day 7 days a week. LPN 1 stated that he would attempt to contact the MD first with a resident change in condition and then the NP as they were familiar with the residents, but the on-call physician also had access to the resident's electronic medical records. LPN 1 stated that he would not hesitate to call the provider if the resident was experiencing severe pain even if it should have been addressed on the day shift. On [DATE] at 3:16 AM, CNA 16 reported to RN 8 that resident 194 wanted to talk to her because she was ready to call 911, she's in so much pain. RN 8 stated that she did not know what else to do. She did not have any orders and the NP was not responding so she was between a rock and a hard place. RN 8 was observed to enter resident 194's room. Resident 194 stated, It's my whole body. Resident 194 stated she just could not wait, and she just hurts, It sure does hurt while crying. RN 8 stated I'm sure it does. Resident 194 stated, I don't know what to do with these muscle spasms. RN 8 stated it was almost time for the [MEDICATION(S)]. Resident 194 stated she would try anything. RN 8 exited the resident's room. At 3:24 AM, resident 194 could be heard crying from the hallway and stated, I can't do it. On [DATE] at 3:23 AM, a follow-up interview was conducted with RN 8. RN 8 stated that a lot of it was attention seeking, and this happened a lot. RN 8 stated that resident 194 had [MEDICATION(S)] for muscle spasms a couple hours ago. RN 8 stated I'm sure she's hurting. RN 8 stated that resident 194 was on [MEDICATION(S)], [MEDICATION(S)], and all medications were for pain. RN 8 stated that resident 194's [MEDICATION(S)] was scheduled now and that resident 194 did have it but that it was not coming up now. RN 8 stated that she had contacted the physician. RN 8 stated that a week ago resident 194 did not have the [MEDICATION(S)] order, and the [MEDICATION(S)] was a new medication. RN 8 stated that the [MEDICATION(S)] was every 12 hours as needed, so she was going to check to see if it could be administered. RN 8 stated that resident 194 knew that the state surveyors were in the building, so she was crying even more. RN 8 stated that she did not administer the [MEDICATION(S)] to resident 194 because it was not on the MAR. RN 8 stated that she had no idea why it dropped off the MAR. So that could be a factor of why she is hurting. RN 8 stated that she had not given resident 194 any [MEDICATION(S)] during her shift. And her light is back on again, I just left! On [DATE] at 3:27 AM, RN 8 answered resident 194's call light. RN 8 stated that she knew what the physician was going to say, and that the physician would be there in the morning. Resident 194 stated she did not know what to do and was crying and she felt like a complete maniac. Resident 194 stated she has had chronic pain for 8 years and finally got it under control and other people's interruption did not help her. What did I do wrong? Resident 194 was heard crying and speech was indiscernible. Resident 194 asked RN 8 for a shot of muscle relaxer. RN 8 stated she was unable to do that. Resident 194 stated Every single night this happens. RN 8 stated I'll take care of it tonight, I promise. Resident 194 was heard crying from the hallway. RN 8 asked resident 194 to sit in chair for a while, and the resident stated she just tried that, and it did not work. RN 8 stated that she had to give the patch time to work because it was not magic. RN 8 stated it was not fun for anyone, and It's hard to see you this way. Resident 194 was heard sobbing. On [DATE] at 3:32 AM, an interview with conducted with LPN 2. LPN 2 stated that she was with an agency, and this was her first night in the facility. LPN 2 stated that she was being trained by facility LPN 1. LPN 2 stated the first thing she asked LPN 1 was who to call if there was a problem, and she knew to call the MD first, the NP second, and the on-call service next. LPN 2 was able to locate the contact numbers for all the facility providers. LPN 2 stated that she would not hesitate to call a provider if a resident was injured, in severe pain, or needed anything that was serious and could not wait until morning. On [DATE] at 3:35 AM, resident 194 was heard screaming and crying from the hallway Please. Resident 194 was heard exclaiming, I can't get up, please, Get me out of here, help me, I can't sobbing, I can't get up, and Someone please come and help me. On [DATE] at 3:36 AM, RN 8 was interviewed. RN 8 stated that she could call the MD but that she did not think they would do anything. RN 8 stated that if she called the MD, he would just tell her that the NP was coming in the morning. RN 8 stated that if she called the NP, she would just tell her that she was coming in the morning. RN 8 stated that according to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 8 stated that she would message the NP about restarting the medication. On [DATE] at 3:48 AM, CNA 16 responded to resident 194's call light alarming. Resident 194 was heard exclaiming, I can't do this, and I don't think I ever want too again. Resident 194 was heard sobbing and hitting herself. On [DATE] at 3:40 AM, RN 8 was interviewed. RN 8 stated, Where's the line with her regarding medication seeking and the resident being in pain. RN 8 stated that she could call the on-call providers if things get really bad, and they will answer. RN 8 stated she could call and ask for [MEDICATION(S)] [for anxiety] and possibly get a order for [MEDICATION(S)]. RN 8 was asked how she knew resident 194 was med seeking and RN 8 replied that the nurses that have worked with resident 194 have seen it and will tell each other on the shift-to-shift report. RN 8 stated that if you give in to what resident 194 wanted she just wants more. RN 8 stated that she just tried to stay positive with the resident. RN 8 was asked if the MD or NP had given any direction to the licensed nurses regarding resident 194's medication seeking behaviors and RN 8 replied no. On [DATE] at 3:48 AM, RN 8 informed CNA 16 that If she really threatens to go to the hospital, I'll call the on call and see what they say. On [DATE] at 3:57 AM, CNA 18 entered resident 194's room. Resident 194 was heard telling CNA 17 that she wanted to go home. CNA 17 stated okay, but let me help you. Resident 194 stated she could not locate her shoe. CNA 16 entered the room and CNA 17 exited. Resident 194 stated that it hurts to stand, it hurts to sit, it hurts. Resident 194 was sobbing. I can't control anything; I can't even get this slipper on. Sobbing. I can't get my whole body to shut up. I know the medication, but they won't give it to me. Resident 194 continued to cry. On [DATE] at 4:04 AM, resident 194 was heard from the hallway exclaiming, Please, I can't, Please, and I want to see a doctor. On [DATE] at 4:16 AM, resident 194 was observed ambulating out of her room with a walker. Resident 194 was sobbing and stated, I can't do this. RN 10 was observed to enter resident 194's room. Resident 194 stated that her hips and legs hurt and that she was having spasms with a whole lot of pain. Resident 194 stated that this happened last night and the night before. Resident 194 stated she could not live that way. Resident 194 stated she was not sure when her last pain pill was given. CNA 16 entered and stated that resident 194 had been like this all night, and they did not have anything to give the resident. On [DATE] at 4:20 AM, resident 194 was observed inside her room and was heard stating everyone says they are going to get someone, and I never see them again. Resident 194 then walked out of her room breathing heavily and stated, It hurts. I can't sleep or anything. On [DATE] at 4:22 AM, an interview was conducted with RN 10. RN 10 stated she informed RN 8 and RN 8 told her that resident 194's [MEDICATION(S)] had run out yesterday and they were going to get her more when the doctor come in today. On [DATE] at 4:28 AM, resident 194 stated that her knee and hip hurt and everything hurt. CNA 16 told resident 194 to sit down so she did not fall. CNA 16 stated that she needed her shoes on and resident 194 replied, I can't they keep coming off. Resident 194 asked Where are they and what are they doing? Are they going to ignore me all night? CNA 16 stated again to sit down so she did not fall. Resident 194 stated I can't it's not comfortable. CNA 16 exited the resident's room and closed the door behind him. Resident 194 could be heard making banging and slapping sounds from inside the room. Resident 194 was talking but the words were indiscernible. At 4:35 AM resident 194's call light was turned on. CNA 17 was observed to walk past resident 194's room without answering the call light. On [DATE] at 4:42 AM, resident 194 was heard stating please give me anything to relax. Please don't ignore me. Resident 194 was sobbing. I can't see straight. Would someone come in and talk to me please? It's killing me. On [DATE] at 4:59 AM, resident 194 was observed walking in the hallway with a walker. Resident 194 returned to her room and stated, I need some help. CNA 17 informed CNA 15 and CNA 16 that resident 194 was reporting that her arm hurt. CNA 16 stated that resident 194, Has arthritis like crazy. CNA 16 stated he would i [TRUNCATED]

Based on observation, interview, and record review it was determined, for 4 out of 51 sample residents, that the facility did not ensure that the residents were free from abuse and neglect. Specifically, two residents were engaged in sexual activity without the consent of one resident and neither resident had been assessed for the capacity to consent to the sexual activity. Additionally, a resident was heard crying out in pain for over 4 hours and the nurse did not notify the physician to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The above examples were found to have occurred at a harm level. Lastly, a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident identifiers: 15, 19, 194, and 196. Findings included: HARM 1. Resident 19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility final investigation report for sexual abuse on 3/11/22 documented that on 3/5/22 at 2:00 PM resident 19 reported to Registered Nurse (RN) 5 that she had asked resident 196 to stop kissing her breasts and that he did not immediately stop. RN 5 reported the incident to the facility Administrator (ADM) and an investigation was initiated. Resident 19 reported that she asked resident 196 to stop kissing her breast as it caused her discomfort, and that he did not stop after the first time she asked him to. However resident 19 reported that he did stop after she told him a second time. Resident 19 also reported that resident 196 tried to get her to stick her hand down his pants. Resident 19 stated that initially she had been okay with the encounter and then changed her mind. Resident 19 stated that she did not wish to press charges against resident 196. The final report documented that both resident 19 and resident 196 were alert and oriented times 3 (person, place and situation) and had the ability to make decisions. Neither resident had a guardian. The final report documented that the investigation did not support the finding of abuse. On 3/5/22 at 3:00 PM, resident 19's witness statement documented, resident states she had a consentual (sic) encounter with [resident 196]. Resident states that she and [resident 196] were kissing, and that [resident 196] was 'sucking on her titty' in the hallway. [Resident 19] stated that [resident 196] was kissing her breast and it hurt, she says she told him to stop, [resident 19] states that [resident 196] did not stop immediately but that she said stop again a second time and that he then stopped. Resident states that [resident 196] also took her hand and tried to put it down his pants and she said no. Resident stated that initially that she was ok with the encounter, but that she told [resident 196] to stop when she felt discomfort. The witness statement was initialed by the facility ADM and documented verbal with resident. On 3/5/22 at 3:00 PM, Certified Nurse Assistant (CNA) 13's witness statement documented, Approx. [approximately] 0600 on 3/5 observed [resident 19] and [resident 196] to be kissing, touching [resident 19] breasts on 500 hall [CNA 13] reports that she intervened and redirected the residents. [CNA 13] reports that she reported this to the nurse ASAP [as soon as possible] - [RN 7]. [CNA 13] observed [resident 19's] hand down [resident 196] pants or in that area. -[Resident 19] stated 'its ok I let him' -We reported immediately to nurse, the residents did not stop kissing when we told them too. [RN 7] was immediately onsite and intervened and separated them. The witness statement was initialed by the facility ADM and another undistinguishable initial. On 3/10/22 at 12:00 PM, RN 7's witness statement documented, 0600 [6:00 AM] shift change; observed Res's [residents] holding hands zero distress, walked by, [CNA 13] approached '[resident 196] is touching [resident 19]' -Found Res's sitting by each other on 500 hall -Redirected Res to separate rooms/areas. -Did not observe any contact other than previous hand holding. -[Resident 19] denied abuse The witness statement was initialed by the facility ADM. On 3/6/22 at 12:00 PM, CNA 12's witness statement documented, states Res was anxious, talking about how her life 'sucked'. Reported to [RN 5]. On 3/11/22 at 10:32 AM, RN 5's witness statement documented, On 3/5/22 at 6:00 AM I overheard two aides reporting that [resident 19] and [resident 196] were found in the hall having sexual contact. Aides reported when they asked them to separate [resident 19] told them she wanted [resident 196] to touch her. RN 7 gave instruction to separate [resident 19] and [resident 196] and to keep them separate (sic). At 1400 [2:00 PM] [CNA 12] reported to me that [resident 19] was anxious at which time I interviewed [resident 19] and asked her how she felt about the sexual contact. [Resident 19] reported she had asked [resident 196] to stop and told him he was hurting her. [Resident 19] also said she was worried about getting [resident 196] in trouble. The witness statement was signed by RN 5. On 3/7/22, (time not documented) the Master of Social Work (MSW) witness statement documented, On 3/7/22 I spoke to [resident 19] about what transpired between her and [resident 196]. [Resident 19] told me that [resident 196] had kissed her on the mouth and then went down her shirt with his mouth and bit her on the nipple. [Resident 19] stated that it hurt and she told [resident 196] to stop. I spoke to [resident 196]. He stated he had put his hand down her shirt but not his mouth. [Resident 196] stated he was never going to do it again because he was scared. Both residents stated they feel safe here. The witness statement was signed by the MSW. On 3/16/22 resident 19's medical records were reviewed. On 12/22/21, resident 19's Quarterly Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated an intact cognitive response. The assessment documented a resident mood interview (PHQ-9) score of 00 which would indicate none to minimal depression severity. The assessment also documented no hallucinations or delusions with the behavior marked as not exhibited. On 3/8/22 at 11:33 AM, resident 19 was assessed for a BIMS and scored 15 which would indicate an intact cognitive response. It should be noted that the assessment was completed 3 days post incident. Review of resident 19's Pre-Admission Screening Applicant/Resident Review (PASRR) Level I Assessment on 11/10/2020 documented that resident 19 had a Moderate Intellectual Disability. The comment section documented Difficulty interacting with others d/t [due to] developmental delay. On 11/20/21 at 9:46 AM, an email was sent by the PASRR evaluator to the facility that stated that they would be screening resident 19 for the need of a Level II Intellectual Disability/Related Condition (IDRC) PASRR. The email stated that the referral was made based on the Moderate Intellectual Disability diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The email further stated that resident 19 suffered a TBI after being thrown from a balcony at age 22 which resulted in troubles with behaviors and cognition. Review of resident 19's PASRR Level II Assessment on 3/24/21 documented a hospitalization from [DATE] through 3/17/21 for Altered Mental Status and was subsequently diagnosed with [CONDITION(S)]. The assessment documented a cognitive decline due to the TBI and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . However, when she admitted to the facility in December she scored a 3/15 [Resident 19] will likely require ongoing skilled nursing care throughout the remainder of her life, as her cognition is likely to continue to decline where it may become primary at some point. The assessment's evaluation of cognitive functioning documented that the resident was alert and oriented to person and place and partially oriented to situation and time. The evaluation further documented that resident 19's judgment was severely impaired with poor insight and recent and remote memory was fair. The assessment obtained resident 19's history of psychiatric symptoms from previous PASRRs completed and the following was a compilation of that history. The PASRR completed in June 2012 documented that resident 19 appeared her stated age but seemed to function at a much younger developmental stage. She repeatedly asked about what time her lunch was and if she could get a smoke break. She seemed to need significant reassurance; almost seeming child-like in her worry about if she was doing things 'right.' When asked routine questions for the evaluation, she was at times unable to answer and at times would answer and then ask, 'Is that ok?' with a very worried expression. Her short term memory seemed significantly impaired. The PASRR completed in May 2015 documented, She has history of some self-harming behaviors when she does not get her way following the [CONDITION(S)] that seemed indicative of personality changes related to the injury. Self-injurious behaviors were banging her head on the floor when she did not get a cigarette. The current psychiatric functioning documented that resident 19 talked in a childlike manner and appeared to seek reassurance and acceptance. She is aware of her cognitive decline and this is reportedly 'hard'. The assessment recommended continued skilled nursing services with cognitive stimulation, socialization and participation in group activities where allowed. On 9/20/21, resident 19's Notice of Involuntary Commitment by the 3rd District Court scheduled a hearing date for 10/1/2021. The notice also provided a Sealed Civil Commitment Proceeding Notice of Request by Respondent for Continued Mental Health Court Order. The notice documented that the respondent was required to abide by the provider's plan for continued treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The notice documented the respondent's right to a hearing to determine if the Order stayed in place. The notice stated that by signing said agreement the respondent agreed to keep the Civil Mental Health Court Order and abide by the treatment plan that their case manager or care provider had set out for them. The Notice of Request by Respondent was not filled out or signed by resident 19. On 3/29/2021, resident 19's notice of a Sealed Civil Commitment Proceeding Notice of Request by Respondent for Continued Mental Health Court Order was signed. The form did not document a timeframe that the order would be in effect. On 3/5/22 at 2:00 PM, the facility incident report documented that resident 19 stated that she was having an inappropriate relationship with a male resident and stated that she had told him no and that she didn't like what he was doing. She stated that it was consensual and that she allowed it to happen but then stated that she didn't like what was happening now. [Resident 19] and the male resident were separated and both pace (sic) on 15 min. checks to monitor for safety to each resident. The immediate action taken documented that resident 19 was placed on 15-minute checks or safety and behavior tracking for emotional distress and a full skin check was completed with no injuries noted. Resident 19 would smoke with the group but resident 196 would smoke with a CNA. Resident 196 was moved away from resident 19. Review of the 15-minute check sheet revealed that resident 19 was placed on 15 minute safety checks beginning on 3/5/22 at 6:00 AM and those checks continued until 3/6/22 at 2:00 PM. It should be noted that the 15 minutes check sheet was contained within 3 separate forms with duplicate forms dated 3/5/22. Discrepancies were noted on the duplicate forms dated on 3/5/22 with the location of the resident for the following times (all times were listed in military time): a. 1900 room verses hallway b. 1915 room verses hallway c. 2130 room verses hallway d. 0015 room verses hallway e. 0030 room verses nurse's station f. 0045 room verses nurse's station g. 0430 room verses nurse's station h. 0445 room verses nurse's station No documentation could be found for an evaluation of resident 19's capacity to consent to sexual activity. Review of resident 19's progress notes revealed the following: a. On 3/5/22 at 6:13 PM, the nursing note documented, Resident has been placed on 15 min checks to ensure safety due to incident. Resident had a complete skin check done. Resident is still behaving with anxious behaviors. Resident went to the ER (emergency room ) last night in a manic state. ER sent her home. Medications review was done today and new orders for medication given to nurse. no other orders at this time. Resident will be placed on daily social service visits to make sure she is having her needs met. b. On 3/6/22 at 8:45 AM, the nursing note documented, Pt (patient) demonstrated anxious episodes during shift change. Pt was re-directed several times, and provided strategies for relaxation i.e. snacks, wipes, and therapeutic talk. Staff set clear expectations of when pt would expect medications, and additional items requested. At some point on hour about 1 hour of interaction, fire department had arrived to facility, and then local police. Fire department evaluated pt, as well as police. Fire department reported having visited facility with same pt for the fourth time within the day. Fire department/ police spoke with pt and then left. Facility admin notified of findings will monitor pt. c. On 3/6/22 at 9:02 PM, the nurse practitioner (NP) documented, 3/5/22 Patient called 911 last night/sister called fire department due to complaints of nausea and vomiting. No reports of nausea or vomiting to staff. She underwent abd [abdominal] CT [computerized tomography] which was normal and she was returned to facility. This morning she again called 911 and reported shortness of breath. She was ordered meds and refused yesterday and this morning. I arrived to facility after ambulance had left and she was seen sitting on her bed and appeared very angry. She agreed to take meds. Phone was removed and it was explained that she can't call 911 for non-emergencies and she need to talk to nurse. Calling 911 is a behavior for attention. Behaviors discussed with [name of psychiatrist], he did not think she was appropriate for admission. [Name of psychiatrist] agreed with plan to start [MEDICATION(S)]. 3/6/22 It was reported that [resident 19] and another resident were found in a sexually inappropriate in her room. Both residents were interviewed as well as staff. It is unclear if consent was given due to conflicting stories and because both residents are poor historians. There will be continuing investigations. Residents have been separated for now. [Resident 19] appeared at baseline when seen and was asking for bananas. The physicians exam documented under Psychiatric: judgement and insight: bizarre, impulsive. mood and affect: anxious, nervous, sad, stressed. The physicians assessment and plan documented Hypersexuality (?) - she does like to show breasts to staff members - thinks she has rashes that need to be seen - continuing investigation with recent sexual behavior with another resident . Cognitive impairment - may be genetic (reports sister has a learning disability) vs. [verses] TBI vs. hx (history) of SUD (substance use disorders) -reports fall from 3rd story building - moca [Montreal Cognitive Assessment] 13/30 .panic attacks - encourage exercise -redirect -plan to start [MEDICATION(S)] -[MEDICATION(S)] 600 mg (milligram) BID (two times a day) -[MEDICATION(S)] 1 mg TID (three times a day) - [MEDICATION(S)] 225 mg It should be noted that no documentation could be found of a Montreal Cognitive Assessment (MOCA) assessment for resident 19. However, a score of 13/30 as indicated in the NP note would indicate mild Alzheimer's disease. d. On 3/7/22 at 12:05 PM, the nursing note documented a new order from the NP of [MEDICATION(S)] tablet, give 25 mg by mouth one time a day for 3 days then give 50 mg by mouth one time a day related to [CONDITION(S)] disorder. e. On 3/8/22 at 3:02 PM, the social services note documented, Met with resident to make sure all needs are being met. She was engaging during conversation. She was allowed to vent. No further inventions (sic) needed. No concerns or questions reported. resident was educated on the importance of having appropriate boundaries with residents and staff. No questions or concerns were reported at this time. f. On 3/8/22 at 3:53 PM, the nursing note documented that resident 19 was worried about a cut on her hand. Resident 19 had asked for briefs numerous times and the aides found the new briefs in the garbage. Resident 19 worried excessively about money, toilet paper, and mouthwash. g. On 3/10/22 at 2:01 AM, the nursing note documented that resident 19 was anxious, asking many questions and restless. Resident 19 asked to call her family member from the nurse's station. Resident 19 told her family member she wanted to go to the ER. The nurse spoke to the family member and informed them that the resident was not presenting with any signs and symptoms of sickness to be sent to the ER. Resident 19 was redirectable and calmed down. h. On 3/14/22 at 4:25 PM, the nursing note documented that the psychiatrist was at the facility to evaluate resident 19 related to recent incident. i. On 3/15/22 at 3:24 PM, the nursing note documented that resident 19 approached the nursing station stating she was having a panic attack. Clearly states she is not wanting to harm herself but that she needs a pill for anxiety. Social services met with resident and provided multiple interventions including a safe quiet place to discuss feelings. Res (resident) calmed. Scheduled [MEDICATION(S)] administered at 1400 (2:00 PM) as ordered with effective results. On 3/14/22, the psychiatrist note documented that he met with resident 19 after an alleged sexual assault. I've met with her before and am familiar with her case. When I met with her, she was pleasant, smiling, talkative and excited to see me. She denied experiencing any sexual assault and seemed perplexed when I spoke to her about it. She described herself as feeling happy and looking forward to dinnertime when she can be with her friends. MSE (mental status examination): talkative, redirectable, coherent; no SI (suicidal ideation)/HI (homicidal ideation); she denies any AH (auditory hallucinations)/VH (visual hallucinations); I am unable to elicit any delusions; affect is happy, expansive, but overall stable; Insight and judgement are limited. No e/o (evidence of) [CONDITION(S)]. I am not seeing any post-acute stress or trauma following a supposed sexual assault. [Resident 19] seems at her baseline. I discussed this with her treatment team at [name of facility]. I do not recommend any interventions at this time. Review of resident 19's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] 5 mg tablet was given by mouth one time only on 3/15/22 at 4:57 PM for [CONDITION(S)] disorder, and [MEDICATION(S)] 2 mg tablet was given by mouth one time only on 3/16/22 at 4:57 PM for anxiety. Review of resident 19's monitoring for behavior tracking for anxiety on 3/5/22 documented 6 episodes during the day shift. Interventions that were documented as implemented were redirection with the outcome documented as the same. No episodes were documented during the night shift on 3/5/22. No episodes were documented on 3/6/22 or 3/7/22 for either day or night shift. Review of resident 19's care plan revealed the following focus areas: a. Resident 19 exhibits alteration in thought process manifested by moderate cognitive impairment related to dementia; needs reminders/prompts/cues to choose activities; mood problem; [CONDITION(S)]/depression/anxiety/[CONDITION(S)]; has little interest/pleasure in doing things. The care plan was initiated on 4/6/2021. Interventions identified included: Invite, encourage, and involve in activities; Support and engage in social/reminisce/discussion activities in accordance to past occupation/life role at hotel doing reservations; Support independent leisure and check for satisfaction with leisure choices; Supply leisure materials as needed and post calendar in room; Encourage positive coping strategies/social interactions and help uplift mood during activities; Encourage involvement in activities and provide positive praise to increase interest/pleasure during activities; Provide with opportunities to recall long/short term memories during activities; Use validation to help express feelings appropriately; and Provide adaptations to activities as needed. b. Behavior: Resident 19 has attention seeking behaviors and will ask all male nurses to look at her breast. She had been educated to ask her nurse on her hallway and to do this in her room not at the nurse's station. The care plan was initiated on 2/3/21 and revised on 3/13/22. Interventions identified included: Anticipate and meet the resident's needs; Caregivers provide opportunity for positive interaction, attention; Discuss the resident's behavior and explain/reinforce why behavior was inappropriate and/or unacceptable to the resident/ Intervene as necessary to protect the rights and safety of others; Approach/Speak in a calm manner; Divert Attention; Remove from situation and take to alternate location as needed; Resident can have manic behaviors; Take to a quiet spot and let the resident vent and calm down with positive interactions; Resident is redirectable; Residents phone was taken so that we could help the resident process between emergent and non-emergent phone calls; and Resident educated on phone use availability at the nurse's station or in the social services office. c. Resident 19 has impaired cognitive function, impaired thought processes related to dementia and [CONDITION(S)] drug use for [CONDITION(S)] disorder. The care plan was initiated on 1/13/21. Interventions identified included: Administer medications as ordered and monitor/document for side effects and effectiveness; Ask yes/no questions in order to determine the resident's needs; Communicate with the resident/family/caregivers regarding the residents capabilities and needs; Cue, reorient the resident to person, place, time and supervise as needed; Engage the resident in simple, structured activities that avoid overly demanding tasks; and Present just one thought, idea, question, or command at a time. On 3/16/22 at 8:38 AM, an interview was conducted with the ADM. The ADM stated that there was a reportable incident between resident 19 and resident 196. The ADM stated that resident 196 was observed kissing resident 19's breast, and they were separated. The ADM stated that resident 19 had indicated that she told resident 196 to stop and he did not. The ADM stated that resident 19 indicated initially that the interaction was consensual and then later it was reported that she did not feel right about it. The ADM stated that they notified the police and adult protective services immediately. The ADM stated that he conducted a thorough review and investigation. The ADM stated that they had video surveillance and still photos of the residents walking down the hallway holding hands, but that the camera was not able to view the area of the hallway where the incident took place. On 3/16/22 at 9:34 AM, a follow-up interview was conducted with the ADM. The ADM stated that resident 19 had a relationship with another resident previously that consisted of hand holding only, and that relationship was not sexual in nature. The ADM stated that originally the incident was a concern, but that resident 19 had denied abuse. The ADM stated that resident 19 was not displaying any signs or symptoms of trauma. The ADM stated that both residents were able to consent, and this was based off a BIMS score of 15. The ADM stated that both residents had a significant cognitive impairment, and were alert and oriented times 3 to person, place and situation. The ADM stated that resident 19 went and grabbed resident 196 and they were making out, resident 196 did not seek resident 19 out. The ADM did not state how he came to this determination. The ADM stated that resident 19 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . It should be noted that no documentation could be found in resident 19's medical record to substantiate this assertion of prior sexual abuse. The ADM stated that they were exploring different facility options for resident 19, such as a facility that was all female. The ADM stated that they had conducted an assessment for the capacity to consent to sexual activity on both residents and determined that even though they were cognitively impaired they did have the ability to consent. The ADM stated that both residents were their own representatives and did not have legal guardians. The ADM stated that they involved the NP, social worker, and interdisciplinary team try to respect the resident's rights but also protect the residents from abuse. On 3/21/22 at 9:21 AM, an interview was conducted with resident 19 in the hallway at the end of the 500 hall. Resident 19 requested the interview be conducted in the hallway as she was waiting to go outside for a smoke break. The resident stated on the day of the incident she had her breakfast, bought a soda, and was waiting for a smoke break. Resident 19 stated that resident 196 had started kissing her on the mouth and she told him no. Resident 19 stated that resident 196 then started kissing her on the breast and pinched her nipple. Resident 19 stated that it really hurt, and she told him to stop. Resident 19 stated that the incident made her feel uncomfortable. Resident 19 stated that this happened by the smoking patio and also by the store on the 500 hall. Resident 19 stated she did not want to get into trouble or get resident 196 into trouble. Resident 19 stated that resident 196 kept on doing it (kissing) and she did not know what to do. Resident 19 stated that she felt like she could not push resident 196 away, the staff were around, and they did not help me, so I did not know what to do. Resident 19 stated that RN 7 was there. Resident 19 stated that she remembered that it happened before the 10 AM smoke break, but that she did not recall the day, month, or year. Resident 19 stated that RN 7 witnessed it happen and told them to go to their rooms. Resident 19 stated that she did not know what happened to resident 196. Resident 19 stated that after the incident she went back to her room. Resident 19 stated that it made her feel uncomfortable, sad, depressed, and used. Resident 19 stated that she did not talk to anyone after the incident because she was too scared to. Resident 19 stated that it had not happened since then, but that it occurred a couple of times with resident 196 in the past. Resident 19 stated she wanted to say something but did not know who to tell. Resident 19 stated she had low self-esteem. Resident 19 stated that she did not talk to anyone at the facility about the incident and how it made her feel. Resident 19 stated that she did not want to get resident 196 into trouble. Resident 19 stated that she would see resident 196 outside smoking and she kept her distance. Resident 19 stated that she did not know what room resident 196 was residing in now, but that she would see him periodically in the building. Resident 19 again stated that she did not want to get into trouble. Resident 19 stated that she did not feel safe at the facility, not really. Resident 19 stated that she felt scared and thought that other people were trying to steal her belongings, stuff. Resident 19 stated that she was [CONDITION(S)] and [CONDITION(S)] and that those were just thoughts that she had in her head. Resident 19 stated that she was taking antipsychotic medications and was compliant with taking all the medication. Resident 19 stated that the thoughts were still present, and she was not sure if her medication was working. On 3/21/22 at 1:32 PM, a telephone interview was conducted with RN 7. RN 7 stated that his participation in the incident was very little. RN 7 reported that the incident happened at end of his night shift at approximately 6:00 AM on 3/5/22. RN 7 stated that he did not document the events of the incident. RN 7 stated that he was conducting a narcotic count with the oncoming day shift nurse when CNA 13 reported that the residents were kissing and touching. RN 7 stated that he could not recall the exact retelling of the events. RN 7 stated that the residents had just walked by the medication cart holding hands, and approximately 2-3 minutes later the CNA 13 reported the incident. RN 7 stated that he left the other nurse during the narcotic count and went to investigate. RN 7 stated that he located resident 19 and resident 196 on the 500 hallway at the west end by the exit to the smoking patio. RN 7 stated that the residents were seated on the floor next to each other. RN 7 stated that he asked if everything was okay, and they replied yes. They seemed fine. RN 7 stated that he asked the residents to return to their rooms. RN 7 stated that resident 19 requested to stay in the hallway to wait to smoke. RN 7 stated that he reminded resident 19 that it was not time for the scheduled smoke break and that would not be until 9:00 AM. RN 7 stated that at this point he went back and finished the narcotic count with the day shift nurse, RN 5. RN 7 stated that when he approached resident 19 and resident 196, he did not witness any sexual contact. RN 7 stated that he did not recall what was reported to him but that in that hallway things happened so fast with residents, and that was why he responded immediately. RN 7 stated that the ADM interviewed him by phone and took his statement. RN 7 stated that he did not sign the statement and did not review the statement for accuracy. RN 7 was read the statement and he stated that sounded about right. RN 7 stated that he did not report the incident to anyone because RN 5 also heard the aide report the incident. RN 7 stated that when he did not witness anything inappropriate, he did not report the incident. RN 7 stated that the facility abuse coordinator was the ADM. RN 7 stated that any allegations or incidents of abuse were to be reported to the ADM. RN 7 stated that any incidents that they suspected were abuse should be reported as well. RN 7 stated that the process was to document the incident and then inform the Director of Nursing (DON) and ADM. RN 7 confirmed that if the aide reported inappropriate contact between two residents, even though he did not witness the contact, that incident should be reported as a possible allegation of abuse. RN 7 stated that because it was during shift change, and it was reported to both the nurses at the same time, he assumed that the day shift nurse would report the incident to the facility ADM. RN 7 stated that if he was working that shift, he would have separated the residents and made sure they were safe, then notified the ADM, DON, NP, and completed a incident report. RN 7 stated that he would also initiate a 15-minute check for safety. It should be noted that 15 minutes safety checks we [TRUNCATED]

Based on interview and record review, the facility did not ensure that 3 of 51 sample residents received treatment and care in accordance with professional standards of practice and the residents' choices. Specifically, a resident with a recent history of hospitalization for strokes was not assessed and was discharged against medical advice when a family member requested the resident be taken to a local hospital. The findings for this resident were determined to have occurred at a harm level. In addition, a resident did not receive treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: HARM: 1. Resident 201 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/21/22 at 5:10 PM, an interview was conducted with resident 201's girlfriend (GF). The GF stated that on 3/14/22, she noticed that resident 201 wasn't breathing right, and his arm was gushy and swollen. Resident 201's GF stated that she was concerned because it was resident 201's left arm that was swollen, and he had experienced multiple heart issues. Resident 201's GF stated that when she expressed her concerns to Registered Nurse (RN) 8, RN 8 said we will just wait to take care of him until tomorrow, to which the GF stated well if you're not going to do anything, I'm going to call an ambulance. Resident 201's GF stated that she called an ambulance. Resident 201's GF stated that RN 8 came in with a paper that said he's leaving AMA (Against Medical Advice) because the physician said they would take care of it in the morning because they had already done a chest x-ray. Resident 201's GF stated that RN 8 told us to take all of his stuff and he can never come back. Resident 201's GF stated that when emergency personnel were onsite to take resident 201 to the hospital, they were angry and stated to RN 8 that he's not signing any paper. He needs to go to the hospital. Resident 201's GF stated that the resident was admitted to the hospital on 3/14/22 and had been there ever since due to ongoing health issues. Resident 201's medical record was reviewed on 3/15/22. Nurse notes for resident 201 indicated the following entry on 3/14/22 at 8:50 PM by RN 8: Resident left AMA with EMS (Emergency Medical Services) at 2047 (8:47 PM). Resident was told that he was leaving against all medical advice this evening, and that he would be responsible for all the bills that were to be charged to him, including ambulance and all hospital bills that insurance would not cover. He was also told that he was not allowed back to this facility this evening if he was to go with EMS per [name of physician] and [name of Director of Nursing (DON)]. Both physician and DON were notified that his family was wanting to send him out, and was told by both of them that if he left, it would be AMA. Resident would not sign the AMA paper, so this nurse and another nurse signed as a witness. All belongings were taken out of the room with family. Review of vital signs documentation revealed that the last time vital signs were performed was at approximately 7:00 AM on 3/14/22, prior to resident 201 experiencing a suspected change in condition. No nurses notes could be located to indicate if RN 8 or any other facility staff had assessed the resident prior to discharging the resident to the hospital, and what their findings were, if any. A document entitled AMA Release Form dated 3/14/22 was reviewed. The AMA form indicated that resident 201 had been issued an AMA form on 3/14/22. On 3/16/22 at 5:01 AM, an interview was conducted with RN 8. RN 8 was asked about resident 201 and the night he left the facility to go to the hospital. RN 8 stated that she did not think resident 201 wanted to go to the hospital, but his family was being very demanding. I had a crazy night, and a readmit, and then the family of this man kept coming out every 5 minutes saying something was wrong with him. RN 8 stated that she had not met resident 201 prior to 3/14/21. RN 8 stated that she and another nurse assessed resident 201 due to his history of multiple strokes and pulmonary embolism. RN 8 could not indicate what she had done to assess resident 201. RN 8 stated that resident 201's left arm was swollen, and the family member was worried about it. RN 8 stated that she called the facility's nurse practitioner, but the nurse practitioner had not seen the resident and referred her to the physician. RN 8 stated that she called the physician, who told her that he had seen resident 201 that morning and he's fine but if they want to send him out it would be against our wishes. RN 8 stated that she spoke with her Director of Nursing (DON), who also stated that if the resident left the facility, it would be considered AMA, and the resident would not be allowed back to the facility because you're discharging yourself. RN 8 stated that facility staff was awaiting the results of a chest x-ray and she felt like I was the pawn between the facility and the family. On 3/17/22 at 10:20 AM, an interview was conducted with the facility Administrator (ADM). The ADM stated that if a resident wanted to go to the hospital, they have that right. The ADM stated that residents who request to go to the hospital can be readmitted to the facility, and that we wouldn't improperly discharge people from the facility. The ADM stated he did not know why RN 8 had told resident 201 that he could not return to the facility. On 3/17/22 at 10:42 AM, an interview was conducted with the DON. The DON stated that even if someone left the facility AMA, it did not mean that they could not return to the facility. The DON stated that on 3/14/22, resident 201's family approached staff and told them that the resident was not at his baseline, but he was at his baseline for us. The DON stated that the physician had ordered multiple diagnostic tests to be performed on the resident. The DON stated that even if the physician was frustrated with a family member wanting to seek care outside of the facility, that did not mean the resident could not come back. The DON stated that RN 8 had contacted her on 3/14/22 because the family wanted to call 911, and so she told RN 8 to call the physician. The DON denied telling RN 8 that resident 201 could not return to the facility. The DON confirmed that resident 201's family called 911, and the resident went to the hospital that evening, where he was subsequently admitted . Resident 201's hospital notes dated 3/14/22 were reviewed. The hospital notes indicated that resident 201's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The notes indicated that resident 201 had experienced a prior left frontal stroke in January 2022 . and right frontal stroke in February 2022.After complicated hospitalization between 2/14/2022 - 3/11/2022 involving multiple ICU (intensive care unit) admissions, he was discharged from the [name of hospital] to [name of the facility]. The notes also indicated that the resident had initially presented to [name of hospital emergency room ] for hypoxic respiratory failure and later found to have small punctate infarcts on MRI (magnetic resonance imaging) brain. Etiology of new strokes possibly due to small vessel disease [and/or] cardioembolism . Overall prognosis remains guarded given patient has now had multiple stokes (sic) with severe dysphagia, [CONDITION(S)], and L (left) [CONDITION(S)]. The hospital notes indicated that the resident has had complex areas of evolving multifocal ischemic CVAs (Cardiovascular accidents) within the last 3 months who is admitted with acute hypoxemia respiratory failure, [CONDITION(S)] injury, and acute lacunar infarct of the inferolateral right cerebellar hemisphere. His acute hypoxemia respiratory failure (initially 6 L (liters) 02 (oxygen) requirement from baseline of 1.5-2 [liters] is now resolved and was most likely due to recurrent aspiration/mucous plugging. The notes confirmed that the resident was admitted to the hospital. POTENTIAL FOR HARM 2. Resident 4 was admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/15/22 at 1:06 PM, an interview was conducted with resident 4. The resident stated she had episodes of [CONDITION(S)] at night, even though the physician had been adjusting her insulin dose. Resident 4 stated that she kept candy bars in the bottom drawer of her nightstand to eat when she had a hypoglycemic episode. Resident 4 stated that sometime last week she was having an episode of [CONDITION(S)] and called a staff member to assist her. Resident 4 stated that she asked the staff member to bring her a candy bar while she was in the bathroom. Resident 4 stated that the staff member gave her the candy bar but then left the room to help other residents. Resident 4 stated that she was shaking so hard from the [CONDITION(S)] that she dropped the candy bar on the bathroom floor. Resident 4 stated that she was able to pick it up, but dropped it a second time. The resident stated, Lord help me she was so sick she had to eat the candy bar off the floor. The resident stated that she was disgusted with the fact that she had to eat the candy bar off of the dirty bathroom floor. Resident 4's medical record was reviewed on 3/15/22. Resident 4's February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/1/22, resident 4's blood glucose level was 52. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurses progress notes for that date did not indicate the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/2/22, resident 4's blood glucose was 52. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurses progress notes for that date did not indicate the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . c. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The order did not indicate parameters for when the physician should be contacted. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurses progress notes for that date did not indicate that the physician had been notified. The nurses notes indicated that a Boost supplement was provided, but did not indicate if a follow up blood glucose level was performed. Resident 4's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The order did not indicate parameters for when the physician should be contacted. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurses progress notes for that date did not indicate the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/21/22 at 3:25 PM, an interview was conducted with the DON. The DON stated that the procedure for low blood sugars was to notify the physician or nurse practitioner so they could determine treatment. The DON stated they used a secure messaging system or a phone call, and so the notification might not show up on the residents medical record. 3. Resident 198 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/14/22 at 1:18 PM, an interview was conducted with resident 198. Resident 198 stated that he had open wounds on the bottom of both feet, and that he had [CONDITION(S)]. Resident 198 stated that he did not have any wound care for his feet, no dressing changes, no creams or ointments. Resident 198 stated that the wounds were located on the heels and big toes, and would bleed a little bit. Resident 198 stated that he did not think that the facility staff knew about the wounds. On 3/15/22 resident 198's medical records were reviewed. On 3/12/22 at 1:50 PM, resident 198's Brief Interview for Mental Status (BIMS) assessment documented a score of 12 which would indicate that the resident had a moderate cognitive impairment. Resident 198's skin assessments were reviewed and revealed the following: a. On 3/9/22 at 1:50 PM, the Admission Evaluation documented [CONDITION(S)] on right and left lower extremity. Skin issues were documented as present with skin breaks documented on the right toe, sacrum and sores on left and right heel. b. On 3/9/22 at 2:50 PM, the Braden scale for Predicting Pressure Sore Risk documented a score of 21, which would indicate that the resident was at risk. c. On 3/16/22 at 1:50 PM, the skin and wound assessment document no wounds, the condition was normal, the elasticity was good, skin color was normal for ethnic group, temperature warm (normal), and moisture was normal. Review of resident 198's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident 198's progress notes revealed the following: a. On 3/9/2022 at 5:19 PM, the note documented, .has wounds on both feet and bruising on his R [right] arm. b. On 3/10/2022 at 10:35 AM, the physician/provider note documented, Skin: inspection: no rashes, [CONDITION(S)], normal coloring and complexion, warm and dry. Skin is clean, dry and intact. c. On 3/14/2022 at 6:28 AM, the physician/provider note documented, Skin: inspection: no rashes, [CONDITION(S)], normal coloring and complexion. Review of resident 198's task for skin observation revealed daily documentation since admission that checked None of the above observed. The above were documented as scratched, red area, discoloration, skin tear, and open area. No resident refusals were documented. It should be noted that this task for skin observation was completed daily by the Certified Nurse Assistants (CNA) in their Point of Care (POC) charting. Review of resident 198's care plan revealed a focus area of had the potential for impairment to skin integrity. The care plan was initiated on 3/10/22. The goal identified was that the resident will maintain or develop clean and intact skin by the review date. Interventions identified were to encourage good nutrition and hydration in order to promote healthier skin. On 3/17/22 at 9:03 AM, an interview was conducted with CNA 12. CNA 12 stated that resident 198 was alert and oriented times four to person, place, time, and situation. CNA 12 stated that resident 198 was able to independently ambulate, and toilet himself. CNA 12 stated that he was not sure about resident 12's bathing assistance needs as he had not provided him a shower yet. CNA 12 stated that the showers were documented in the tasks under POC charting. CNA 12 stated that they completed a skin assessment with showers and reported any skin issues or concerns to the nurse. CNA 12 stated that they did not fill out a shower sheets with the resident skin condition, but gave the nurse a verbal report of the skin condition. CNA 12 stated that they then charted the skin condition in skin observation in tasks. CNA 12 stated that if what they observed was not one of the options in the task to document then they just notified the nurse. CNA 12 stated that resident 198 had a bandage on his left upper shoulder where the sling rested on the skin. CNA 12 stated he was not aware of any other skin conditions. On 3/17/22 at 9:14 AM, an interview was conducted with CNA 19. CNA 19 stated resident 198 was able to ambulate independently. CNA 19 stated that she had not assisted resident 198 with bathing. CNA 19 stated that resident 198 had been in pain and refusing showers. CNA 19 stated that they assessed the residents skin condition during showers and toileting. CNA 19 stated that resident 198 had redness on the left shoulder due to the shoulder strap from the sling. CNA 19 stated that resident 198 did not have any other skin conditions. CNA 19 stated that she would report any identified skin conditions to the nurse, and the nurse would provide the aides with creams to apply if needed. CNA 19 stated that the nurse would inform the aides of what interventions were implemented to help improve the skin. CNA 19 stated that the aides documented the skin condition in the task section of POC. On 3/17/22 at 9:23 AM, an interview was conducted with RN 11. RN 11 stated that resident 198 was independent with mobility, and required a 1 person assist for toileting and showers. RN 11 stated that the aides supervised more with showers and helped with the areas he could not reach. RN 11 stated that resident 198 had a head to toe skin check ordered, and she looked at them every day. RN 11 then stated that resident 198 had a head to toe skin assessment completed once a week. RN 11 stated that resident 198 had a skin assessment on admission and it was viewed in evaluations. RN 11 stated we definitely look at them on our shift. RN 11 stated that the aides would report any identified skin issues. RN 11 stated that resident 198 had bruising on his arms, and that she had identified it on the skin assessment she completed yesterday. RN 11 stated that he had sores identified on his feet when he was admitted , but he did not have any treatments ordered for them. RN 11 stated that the wound nurse probably looked at them. RN 11 stated that resident 198 did not want to take off his socks yesterday so she did not look at his feet. RN 11 stated that resident 198's shoulder had padding for the sling so it did not dig into the skin. RN 11 stated that after admission the wound nurse would come and evaluate the residents, and sometimes it was the same day or the next day. RN 11 stated that the staff nurse should also do a skin assessment. On 3/17/22 at 11:08 AM, an interview was conducted with the wound nurse (WN). The WN stated that when a resident required wound care the staff alerted him to new skin issues verbally or by a secure message in the electronic medical records (EMR). The WN stated he was informed of resident 198's issues with his feet today. The WN stated that resident 198 had eschar to both great toes and cracking to the right heel. The WN stated that he assessed the feet today, updated the care plan, notified the provider and obtained wound care orders. The WN stated that he took measurements and pictures today as well. The WN stated that he was not sure where the breakdown was in communicating the skin issues with his feet, but that he had not been informed of resident 198's feet prior to today. The WN stated that the nurse's do a head to toe assessment on admission, and the nurse would typically relay that information to him. The WN stated that all the residents were scheduled weekly for skin assessments afterwards, and they were full body assessments. The WN stated that the skin checks that populated after the new admission assessment asked for new wounds and maybe the staff nurses thought it was not a new wound. The WN stated that the nurse should be documenting the skin condition in a nurse's progress note also. The WN stated that he did not see any other documentation of the feet condition in the nurse's notes or assessments. The WN stated that resident 198's feet were not assessed or address prior to him assessing and treating them today. The WN stated that the treatment orders were to apply [MEDICATION(S)] on the eschar and leave them open to air, and the heel will be cleaned and moisturized with vitamin A & D ointment and a bordered foam dressing will be applied daily and as needed (PRN). On 3/17/22 at 4:38 PM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that they had a lot of agency CNAs in the building and they may not know how to fill out the shower sheets. UM 1 stated that they had lead CNAs that were required to educate the agency CNAs on routines and facility protocols. UM 1 stated that they had binders located at each nurse's station with instructions for the agency staff, but that she would have to see if it had instruction on skin assessments and shower sheets. UM 1 stated that the staff nurse conducted weekly skin checks for elasticity, color, temperature, and wounds. UM 1 stated that the staff nurse should document in the evaluation and write a progress note of any identified skin issues, and notify the provider. UM 1 stated that the process of notifying the WN of residents with new or worsening wounds was that the floor nurse completed a weekly head to toe skin assessment and notified the Medical Doctor (MD) and then the WN of any identified concerns. UM 1 stated that there should be a documentation trail either in evaluations or progress notes of the wound identification and progression of treatment. On 3/21/22 at 12:07 PM, an interview was conducted with Regional Nurse Consultant (RNC) 1. RNC 1 stated that the CNA skin observation in tasks did not trigger or notify the nurse in the EMR if the identified concern/area was not a new issue. RNC 1 stated that they were providing education to the CNAs on how to properly chart so the nurse would be notified. RNC 1 stated that the aides could also verbally inform the nurse of any newly identified skin issues, and that was part of the education given over the weekend too. RNC 1 stated that the aides should notify their supervisor immediately of any skin condition, either new or old, or suspicious bruising should be reported to the nurse.

Based on observation, interview, and record review it was determined, for 3 of 51 sample residents, that the facility did not provide a resident with pressure ulcers the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. Specifically, staff did not notify the provider or wound care nurse of a resident's worsening pressure ulcer in a timely manner, resulting in the delay of necessary and appropriate treatment and services. In addition, the resident continued to receive treatment inappropriate for the worsening pressure ulcer due to staff not notifying the provider or wound care nurse in a timely manner. The deficient practice identified was found to have occurred at a harm level. Resident identifier: 36, 76 and 82. Findings included: HARM 1. Resident 76 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/15/22 at 10:11 AM, an interview was conducted with resident 76. Resident 76 stated she had to go the hospital and have surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 76's medical record was reviewed on 3/14/22. A review of resident 1's records showed that resident 76 had a stage IV facility acquired (FA) pressure ulcer (PU) on her right buttock. A record review of resident 76's progress notes indicated the following: resident 76's right thigh wound was initially discovered on 11/4/21. The nurse practitioner (NP) and wound nurse (WN) were notified, and the wound was identified as excoriation. An initial order for wound care was written. On 11/11/21 it was documented that the right inner thigh wound continued to be open, but no documentation was found indicating when the wound changed from excoriation to an open wound. On 11/11/21 at 1:33 AM, the WN was notified of resident 76's worsening wound. No documentation was found indicating the NP or WN were notified of the worsening wound prior to this date. On 11/12/21 at 3:23 PM, the WN assessed resident 76's wound and identified it as a deep tissue injury (DTI)-like wound. The WN obtained new wound care orders at that time. See nursing notes below. [Note: A review of resident 76's records indicated the WN was notified of the initial right thigh wound on 11/4/21 but was not notified of worsening condition of right thigh wound until 11/12/21. The worsening right thigh wound was not assessed for 8 days.] [Note: A record review of resident 76's treatment administration record (TAR) indicated nursing staff followed initial wound care orders for excoriation from 11/4/21 until 11/12/21 when new orders were written. The treatment ordered for excoriation was provided to the worsening (open) right thigh wound for 8 days.] Nurses notes for resident 76 were reviewed and revealed the following: a. 11/4/21: Excoriation to right upper thigh. NP and Wound nurse notified. New order to apply Venelex and [MEDICATION(S)] ointment to area BID [twice daily] and prn [as needed] until healed. Resident denies pain to area. Will continue to monitor. b. 11/11/21: Open skin area to her R [right] inner thigh continues to be open. Treatment applied as directed. Wound is not improving. Resident continues spending long hours sitting on her powered WC [wheelchair]. Refuses to lay down in bed when asked Currently resting in bed. No distress noted during RN [registered nurse] rounds. Fluids and call light within reach. Will continue to monitor. c. 11/12/21: Resident has a open skin area to her right inner thigh. Ointment applied as directed after brief being changed and hygiene/peri care provided. Open skin area has been worsening. Wound nurse notified. Resident continue to be non compliant with her cares and spending more time in her bed to take pressure from buttocks areas Currently resting in bed. Fluids and call light within reach. Will continue to monitor. d. 11/12/21: Wound to R [right] posterior upper thigh, appears to be a DTI [deep tissue injury] like wound. No signs or symptoms of infection. No odor. New order to cleanse with wound cleanser or NS [normal saline]. Dry with gauze. Apply medi honey to wound bed. Cover with superabsorbent dressing, fix in place with [MEDICATION(S)] tape to ensure it stays in place d/t [due to] where the wound is located. Encourage and assist [resident 76] to offload from this area to help with wound healing. Wound NP aware of wound and new order for treatment. Author: [wound nurse]. A review of resident 76's records indicated resident was sent to the hospital for debridements of a stage IV necrotic ulcer on right buttock on 12/15/21 and 12/22/21. See hospital history and physical (H&P) below. [Resident 76] is a [AGE] year old female with hx [history] of relapsing-remitting MS [[CONDITION(S)]] complicated by [CONDITION(S)], mood disorder, [CONDITION(S)] [CONDITION(S)], and RLS [restless leg syndrome] who presented with R [right] buttock stage IV necrotic ulcer on s/p [status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Currently medically stable and awaiting placement. e. 1/12/22: Resident arrived back to facility via stretcher. Resident is calm laying on side, wound vac is in place on R buttock. Will continue with offloading off site. Resident is on 2liters nasal cannula. No SOB [shortness of breath] or unlabored breathing noted. Will continue to monitor. No further needs verbalized at this time. On 3/17/22 at 11:09 AM, interview was conducted with the wound nurse (WN). The WN stated that initially resident 76's buttock wound started as a minor excoriation and the wound care being done was for excoriation. The WN stated he was not notified of the worsening condition of the right buttock wound until 11/12/21 at 1:23 AM. He stated he assessed the wound on 11/12/21 where he noted the wound had opened up, appearing to be a deep tissue injury (DTI)-like wound. The WN stated he obtained new orders for wound care for the now open, deteriorating wound. The WN stated the nurse practitioner (NP) was following and adjusting treatments. The WN stated he and NP were educating resident 76 about spending more time in bed and offloading pressure on the wound, and a urinary catheter was placed. The WN stated that despite doing everything they could, the right buttock wound continued to deteriorate to the point where it was necessary for resident 76 to be sent to the hospital for surgery (wound debridement). The WN stated when resident 76 returned to the facility she was on a wound VAC. The WN stated there were not enough staff to manage all the wound care needs within the facility. 2. Resident 82 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/14/22 at 10:05 AM, an interview was conducted with resident 82. Resident 82 stated he had a pressure wound on left heel. Resident 82 stated that he had it for months and thought it was going away but I guess it's been coming back. Resident 82 stated the staff looked at it yesterday and it was not bandage. On 3/17/22 at 9:30 AM, an observation was made of resident 82. Resident 82 was observed in bed on a mattress. Resident 82 had his ankles turned outward with both heels against the mattress with socks on. On 3/17/22 at 3:01 PM, a follow up interview was conducted with resident 82. Resident 82 stated that he got the wound on his foot from the mattress. Resident 82 stated that he had pressure sore there prior. Resident 82 stated that he wore a bootie at night but wore shoes and socks during the day. Resident 82 stated staff encouraged him to wear only socks but he needed shoes to feel complete. Resident 82 sated he noticed his shoes rubbed on his heel. Resident 82 stated those were the only shoes he had and no one had looked at where his shoes rubbed. Resident 82 stated the shoes he was wearing, he had since he was admitted in August of 2020. Resident 82's medical record was reviewed on 3/17/22. A quarterly MDS dated [DATE] revealed that resident 82 had 1 unstageable pressure ulcer. The MDS further revealed that resident 82 had a Brief Interview of Mental Status score of 15 which revealed resident was cognitively intact. A care plan dated 7/10/21 and updated on 2/28/22 revealed [Resident 82] has pressure wound to L (left) heel. The goal developed was [Resident 82's] wound to L heel will show signs of healing without complication by the next review. Interventions included Encourage [resident 82] to wear a gripper sock without shoe instead of normal tight tube sock and shoe; Float heels while in bed. - Offloading boot to L foot/heel; Wound care as ordered by NP/MD; Wound healing supplements . and Wound NP to evaluate and treat as indicated. According to the wound evaluation section of the medical record resident 82 had an unstageable on his left heel. The pressure ulcer was acquired in house. The initial measurements on 7/9/21 revealed the area size was 4.45 cm² (centimeter squared), length was 3.41 cm (centimeter) and width was 1.92 cm. The measurements on 3/9/22 were Area was 1.01 cm², length was 1.41 cm, and width was 0.99 cm. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 12/18/21, Offloading boot to LLE [left lower extremity]. Ensure [resident 82] is wearing offloading boot whenever in bed. Every day and night shift for wound. b. On 3/10/22, Wound care to L heel Apply [MEDICATION(S)] to area Q [every day] day and leave open to air. Encourage [NAME] to wear a gripper sock to that L foot instead of a tube sock and tight shoe. Every day shift for wound care. Progress notes revealed the following entries: a. On 8/18/2020 at 4:57 AM, Resident admitted from [local behavioral health hospital].Dry feet, . There are no other skin issues. b. On 7/14/2021, Wound Note: Wound APRN [name removed] seeing [resident 82] today in regards to wound to L heel. Wound to L heel is DTI. Continue current order for treatment and order to offload. Wound healing supplements .No signs or symptoms of infection. [Resident 82] aware of wound, wound status and current order in place for treatment. There were no other progress notes regarding resident 82's heel prior to 7/14/21. On 3/17/22 at 11:00 AM, an interview was conducted with CNA 14. CNA 14 stated she was not aware of any wounds on resident 82. On 3/17/22 at 9:33 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 82 had a wound on one of his heels. CNA 1 stated that he had a cushion and a bootie that he wore while in bed. CNA 1 observed resident 82 while in bed without his bootie on. CNA 1 stated that he had just taken it off. CNA 1 stated resident 82 wore the bootie when he was in bed. CNA 1 stated he was not aware of further interventions for resident 82's heel. On 3/17/22 at 4:51 PM, an interview was conducted with UM 1. UM 1 stated that resident 82 had an off loading boot while in bed. UM 1 stated she did not know how the wound developed. UM 1 stated she had not looked into resident 82's shoes that he wore during the day. On 3/17/22 at 11:50 AM, an interview was conducted with the WN. The WN stated resident 82 had an unstageable wound on his left heel. The WN stated that the eschar came off and then upon seeing it again, some of the eschar came back. The WN stated a podiatrist saw resident 82 last week. The WN stated with resident 82's circulation and his comorbidities made it difficult to heal the wound. The WN stated that he started following resident 82's wound in October or November of 2021. The WN stated that according to the wound evaluations the wound developed 7/9/21 and was facility acquired. The WN stated his best educated nursing guess as to why the wound developed would be circulation because it started as a DTI and then moved to pressure. The WN stated that currently the order for treatment was [MEDICATION(S)] and leaving it open, wearing socks and shoes for less time, and off loading boot at night when in bed. The WN stated that the wound was currently stable. On 3/17/22 at 3:47 PM, an interview was conducted with the DON. The DON stated that resident 82 had a personality disorder so he told people what they wanted to hear. The DON stated she was not sure if resident 82's shoes had been looked at since he had a wound on his heel. On 3/21/22 at 12:07 PM, an interview was conducted what Regional Nurse Consultant (RNC) 1. RNC 1 stated that resident 82 had to wear his shoes and staff had asked him to leave the shoe off the left foot because of the wound. RNC 1 stated staff did not do specialized shoes because he was not diabetic. RNC 1 stated the WN explained the treatments and the shoes on 3/18/22 and documented it in resident 82's medical record. POTENTIAL FOR HARM 3. Resident 36 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/14/22 at 1:49 PM, an interview was conducted with resident 36. Resident 36 stated that she had a wound on her left heel. Resident 36's roommate stated that resident 36 cried and stated her heel hurt at night. Resident 36's medical record was reviewed on 3/17/22. A quarterly MDS dated [DATE] revealed resident 36 had unhealed pressure ulcers/injuries. The MDS revealed resident had 1 stage 2 pressure ulcer, 1 stage 3 pressure ulcer, and 2 DTIs. There were no unstageable pressure injuries upon admission or reentry. A care plan dated 2/1/22 and revised on 3/9/22 revealed [Resident 36] has an (sic) pressure wound to her R [right] heel. The goal was [Resident 36's] pressure wound to her R heel will show signs of improvement without complications by the next review. The interventions were low air loss mattress, offloading boots initiated on 3/3/22, wound care as ordered, and wound healing supplements. Progress notes revealed the following entries: a. On 12/30/21 at 3:53 PM, Wound care for [resident 36] completed today by this nurse. Wound to R shin, .L hip wound, nearly healed.Wound to R buttock, pressure wound. Wound is stable.wound L posterior thigh, appears to have improved some.[Resident 36] continues on low air loss mattress with pump. Repositioned with staff assist throughout the shift. [Resident 36] aware of her wounds, wound statuses and current orders in place for treatment. APRN evaluating wounds, aware of current wounds and treatments in place. It should be noted that there was no information regarding a right heel wound. b. On 1/3/22 at 4:22 PM, Dressings to buttocks and right shin changed this shift.Right leg dressed .Foam boot to right foot in place. c. On 1/3/22 at 11:22 PM, Dressings to buttocks and right shin changed previous shift. Foam boot to right foot in place. No pads used on this resident. Catheter is in site, resident not laying on it. Encouraged offloading, but res (resident) refused. A total body skin assessment dated [DATE] revealed no new wounds. A skin and Nutrition review dated 12/30/21 and signed on 1/7/22 revealed abrasion to left heel on admit, right rear thigh, abrasion left calf, right calf which were improving. [Note: There was not information regarding the right heel.] According to the Wound Evaluation regarding an unstageable to the right heel revealed on 1/6/22 the measurements of the wound were 2.2 centimeter (cm) in length, 1.37 cm in width with 0.0 deep. On 3/16/22 the right heel was 1.63 cm in length and 1.44 cm width. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Ensure offloading boot is in place. every day shift for skin/offloading. Another physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Ensure in place at all times. every day and night shift for offloading. On 3/17/22 at 12:11 PM, an interview was conducted with the Wound Nurse (WN). The WN stated resident 36 right heel was a DTI and unstageable. The WN stated the wound had eschar on it and it developed a few months ago. The WN stated that he had not followed anything regarding resident 36's right heel until 1/6/22 when it was a large wound. The WN stated it looked like resident 36 had a low air loss mattress and offloading on 1/6/22 and on 1/3/22 foam boots were applied to the right foot. The WN stated he did not think he was notified regarding the wound until 1/6/22 when the would was open. On 3/17/22 at 4:47 PM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that if something was noticed on the skin assessment then a progress note should be completed and the wound nurse notified. On 3/17/22 at 11:06 AM, an interview was conducted with CNA 1. CNA 1 stated that he was not aware of wound or skin issues with resident 36. On 3/17/22 at 11:04 AM, an interview was conducted with CNA 14. CNA 14 stated that resident 36 had a pressure sore on her hip but she was unable to remember if she had any other skin issues. CNA 14 stated that the nurse informed the CNAs if a resident had a pressure sore and nurses educated CNAs on interventions. On 3/17/22 at 3:39 PM, an interview was conducted with the DON. The DON stated skin checks for residents were scheduled weekly. The DON stated that a head to toe skin check to ensure no open areas, redness, bruising was to be completed. The DON stated nurses sent secure messages to the doctor, UM, DON and NP when a skin issue was observed. The DON stated if the wound was open, then the nurses contacted the WN. The DON stated the WN contacted the wound NP to look at the wound on Wednesday. The DON stated the doctor gave the orders and consulted with the WN.

Based on observation, interview and record review, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of correction to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance at a harm level with F684, F679, F686 and F600. In addition, several deficiencies were cited during the 2019 recertification survey, and again during the 2022 survey. Resident identifiers: 4, 198 and 201 Findings include: 1. Based on interview and record review, the facility did not ensure that 3 of 51 sample residents received treatment and care in accordance with professional standards of practice and the residents' choices. Specifically, a resident with a recent history of hospitalization for strokes was not assessed and was discharged against medical advice when a family member requested the resident be taken to a local hospital. The findings for this resident were determined to have occurred at a harm level. In addition, a resident did not receive treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . [Cross refer to F684] 2. Based on observation, interview, and record review it was determined, for 1 of 51 sample residents, that the facility did not ensure that pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a resident was observed to cry out in uncontrolled pain for over 4 hours and the licensed nurse would not notify the physician of the resident's condition to request any new orders for pain medication. Resident identifier 194. [Cross refer to F697] 3. Based on observation, interview, and record review it was determined, for 3 of 51 sample residents, that the facility did not provide a resident with pressure ulcers the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. Specifically, staff did not notify the provider or wound care nurse of a resident's worsening pressure ulcer in a timely manner, resulting in the delay of necessary and appropriate treatment and services. In addition, the resident continued to receive treatment inappropriate for the worsening pressure ulcer due to staff not notifying the provider or wound care nurse in a timely manner. The deficient practice identified was found to have occurred at a harm level. Resident identifier: 36, 76 and 82. [Cross refer to F686] 4. Based on observation, interview, and record review it was determined, for 4 out of 51 sample residents, that the facility did not ensure that the residents were free from abuse and neglect. Specifically, two residents were engaged in sexual activity without the consent of one resident and neither resident had been assessed for the capacity to consent to the sexual activity. Additionally, a resident was heard crying out in pain for over 4 hours and the nurse did not notify the physician to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The above examples were found to have occurred at a harm level. Lastly, a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident identifiers: 15, 19, 194, and 196. [Cross refer to F600] 5. During a recertification survey with an end date of 11/21/19, the facility was cited for non-compliance with regulations F550, F561, F584, F600, F607, F609, F655, F676, F677, F684, F689, F812, F838, F880, and F881. These same tags were cited on the survey completed on 3/21/21. This demonstrated the inability to maintain compliance.

Based on interview and record review it was determined, for 3 of 51 sampled residents, that the facility failed to ensure that the residents were free from abuse and neglect. Specifically, the facility did not provide services to address a resident's emotional distress and mental anguish caused by continued exposure to an alleged perpetrator of sexual abuse. The deficient practice identified was found to have occurred at a harm level. Additionally, the facility did not provide protection to ensure that residents were free from verbal and physical abuse from other residents. Resident identifiers: 51, 55, and 68. Findings include: HARM 1. Resident 51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/18/19 at 10:10 AM, an interview was conducted with the resident 51. Resident 51 reported an incident of alleged sexual abuse by a facility licensed nurse. Resident 51 stated that Registered Nurse (RN) 1 kissed her on her lips, and then unzipped his pants and took her hand and wrapped it around his penis. Resident 51 stated that the contact occurred on bare skin and not on top of clothing. Resident 51 stated that the contact lasted approximately 10-15 seconds. The resident stated that this occurred when she was in another room on a different hallway, and it was approximately 2 months ago. The resident stated that the incident occurred around 9 PM when RN 1 was administering her bedtime medications. Resident 51 stated she informed the facility Administrator and Social Service Worker (SSW) about the incident a little bit later after the incident occurred. The resident stated that the facility decided that she was making things bigger than they were. Resident 51 stated that the they made her feel like she was exaggerating the situation, and because she has [MEDICAL CONDITION] that she had made it bigger than it was. The resident identified they as the facility Administrator and SSW. Resident 51 stated that the facility Administrator's response to the allegation was, we've handled it, we've worked on it and it's getting taken care of. Resident 51 stated that she felt like she was told not to worry about it anymore that they were handling it. The resident stated she felt like she had not received any support from the facility Administrator and SSW. Resident 51 stated that the SSW had said he believed her reporting of the incident. The resident stated she sees a psychologist outside of the facility and also reported the incident to him. Resident 51 reported that she had been going to the psychologist every three weeks, and that the sessions helped her to deal with the situation of abuse. The resident stated she saw RN 1 shortly after the incident and confronted him in the hallway, saying you know what you did. The resident stated she has not worked with him since the incident but has seen him in the hallway. Resident 51 stated that seeing RN 1 in the hallway frightened me. The resident stated she feels safer in her current room in the back hallway. The resident stated she did not say anything to RN 1 at the time of the incident because she was terrified, and she thought she would get into trouble or he would not give her the medication. When asked if she felt safe, the resident replied not really. The resident stated she would feel safer if the facility fired RN 1. The resident stated she was raped when she was a child and that had contributed to her [MEDICAL CONDITION]. The resident stated that her [MEDICAL CONDITION] did not interfere with her ability to recall the current incident with RN 1. Resident 51 stated she had a roommate at the time of the incident. The resident stated the roommate was in the room when this happened, but the privacy curtain was pulled. The resident stated she was not upset with her (the roommate) for not noticing because the nurse was quiet. I don't even know if she was aware of what was going on. Resident 51 stated she does not feel supported by the staff, they don't think anything is wrong. Review of resident 51's Preadmission Screening Resident Review (PASRR) conducted on 8/28/17 revealed [DIAGNOSES REDACTED]. Recommendations included to monitor for increased mood symptoms or any thoughts of suicide, and to provide reassurance, support and encouragement. The assessment further documented that specialized services (mental health treatment) was needed in the nursing facility. Review of resident 51's care plan revealed the following psychosocial focus areas with interventions: a. Resident 51 uses [MEDICAL CONDITION] medications for MDD, dependent personality disorder, and [MEDICAL CONDITION]. The interventions were to administer medications as ordered and monitor for side effects and effectiveness, a quiet environment as needed, consult with pharmacy for dose reduction of medications, monitor [MEDICATION NAME] level, monitor for [MEDICATION NAME] toxicity, and reassurance. The care plan was initiated on 4/8/19. b. Resident 51 has behaviors related to her [DIAGNOSES REDACTED]. and visit as needed. It should be noted that the care plan was initiated on 11/20/19 during the recertification survey period. No other documentation could be found for care plans for psychosocial well-being or mood. Review of resident 51's progress notes revealed the following: a. On 4/25/19 at 1:55 PM, the Social Service Psychosocial Note stated, Social Services has assessed the resident's psychosocial needs and has created the initial care plan. b. On 6/14/19 at 1:30 PM, the Physician/Practitioner Note stated, Staff requested visit - increased depression making suicidal statements, wanting to eat despite NPO (nothing by mouth) status Staff reports she has been suicidal and requests assessment. She has a long standing hx (history) of recurrent MDD, anxiety, and [MEDICAL CONDITION] and requires ongoing management. States she has been hospitalized approximately 4x (times) in past and reports it stems from being raped as a child and witnessing a kid hit by a car, hilling (sic) him. Has had marked limitation of function over the years due to this. She is adherent to her current tx (treatment) but has a variable response. Symptoms of depression and anxiety worsens with stress and the inability to eat exacerbates it lately Today she verbalizes to both staff and myself 'wishing she were dead' with feelings of hopelessness, increased sadness, social isolation and lack of interest in in activities due to her inability to eat and denial of food and drink other than water. Currently on [MEDICATION NAME], and [MEDICATION NAME] for recurrent MDD, anxiety, and [MEDICAL CONDITION]. Reports monotherapy and psychotherapy alone have been ineffective in managing symptoms in past and for the most part combination therapy has been effective in managing her MDD, anxiety, and [MEDICAL CONDITION]. Denies sleep disturbance ([MEDICAL CONDITION]), cognitive impairment, and lack of interest in activities, social isolation, suicidal thoughts, thoughts of harming self, hallucinations, or that she has a plan in place PSYCH: Appears depressed, anxious, irritable, and visibly upset with some difficulty concentrating. Appears coherent, patient appears alert, patient is oriented to time, place, self, examiner, situation, and knows current President. Insight and judgement fair acknowledging problems but not directly attributing to illness, but able to verbalize the consequences Recurrent MDD, Anxiety, [MEDICAL CONDITION]. Continue going to therapy learning to acquire assertion skills in reducing anxiety and depression symptoms. GDR (gradual dose reduction) is clinically contraindicated at this time as pt's anxiety and depression are not controlled at this time. Tapering of this medication at this time would not achieve the desired therapeutic effect and current dose is necessary to maintain resident's function, well-being, safety, and quality of life. Continue [MEDICATION NAME], and [MEDICATION NAME]. Monitor for ASE's (adverse side effects). c. On 7/25/19 at 8:55 AM, the Social Service Quarterly & Annual Note stated, Resident's BIMS (Brief Interview for Mental Status) score indicates she is cognitively intact. Resident's PHQ9 score indicates no depressive mood. Resident has no behavioral problems. PASRR recommendations are in resident's care plan. Resident participates in her care plan. d. On 7/26/19 at 3:40 PM, the Social Services Note stated, Resident and Social Services met and discussed some personal interpersonal issues resident wanted to talk about. Resident reported no problems with any other residents or with staff. Resident reported feeling better after talking about her personal issues. e. On 8/27/19 at 4:34 PM, the Social Services Note stated, Resident reported an allegation to social services. Social services held meeting with administrator and resident and filled out a report for adult protective services. f. On 9/11/19 at 7:23 PM, the Nursing Note stated that the resident had an appointment with her psychologist scheduled for 10/9/19. g. On 9/24/19 at 4:16 PM, the Social Services Note stated, Resident stopped by Social Services office and discussed her favorite country singer[NAME]Cash and how much she likes him. f. On 10/2/19 at 8:42 AM, the Social Services Note stated, Social Services met with resident and discussed interpersonal issues that the resident wanted to talk about. g. On 10/9/19 at 1:49 PM, the Nursing Note stated, Resident went to follow up with (name of clinic) with her psychologist (name of psychologist). no new order. follow up with him on [DATE] at 12:00pm. Review of the facility investigation documentation for the allegation of sexual abuse revealed a final investigation summary. The summary stated that the resident alleged that a male staff member kissed her. Resident alleges that this happened on or about 8/24/19. The summary stated that staff interviews did not support the resident allegation, and that the investigation did not support the allegation of sexual abuse. The employee was returned to work on 8/31/19. It should be noted that RN 1 was returned to duty and was assigned to the the 300 hallway where resident 51 resided. According to the facility census report resident 51 resided on the 300 hallway until 9/28/19 when a room transfer was initiated. Review of the daily nursing schedule for (MONTH) 2019 revealed that RN 1 worked night shift, 6 PM to 6 AM on the 300 hallway on 9/2/19, 9/4/19, 9/7/19, 9/9/19, 9/11/19, 9/14/19, 9/16/19, 9/18/19, 9/21/19, 9/23/19, and 9/25/19. This provided 11 opportunities for RN 1 to be in close proximity to resident 51 and to be assigned as resident 51's nurse. On 11/20/19 at 8:53 AM, an interview was conducted with the SSW. The SSW stated that he was working with resident 51's family to move her to another facility. The SSW stated that resident 51 had problems with RN 1 and that the resident had alleged sexual abuse by this staff member. The SSW stated that he was involved in the initial reporting of the incident, and that he participated in follow-up interviews with resident 51 and the facility Administrator, Director of Nursing (DON) and the Certified Social Worker (CSW). The SSW stated that the allegation was not substantiated by the facility, we didn't find any evidence. Only her word against his word, and her word changed. It didn't match up with the facts, such as the dates of allegations. The SSW stated that when resident 51 saw RN 1 she became shaky and had symptoms of [MEDICAL CONDITION]. The SSW stated that resident 51 was moved from the 300 hallway to the 500 hallway for her protection. The SSW stated that every time resident 51 saw the nurse she relived her experience. The SSW stated that the move also protected RN 1 because resident 51 had reported confronting the nurse. On 11/20/19 at 11:55 AM, an interview was conducted with the facility Administrator. The Administrator stated that the resident was moved from the 300 hallway to the 500 hallway on 9/28/19. The Administrator stated that the RN 1 only worked the 300 hallway and was a nighttime nurse. The Administrator stated that they offered to move resident 51 several times but she refused. The Administrator stated that the resident finally agreed to be moved to another hallway, and that it was for the RN's protection. The Administrator stated this was to avoid any further allegations of abuse. The Administrator was asked why RN 1 was not moved to another hallway. The Administrator did not respond to the question. On 11/20/19 at 12:03 PM, resident 51's psychologist was interviewed. The psychologist stated that resident 51 had reported sexual molestation to him by a facility nurse, and that he had tried to kiss her and forced her to touch his genitals. The psychologist stated that he had worked with resident 51 for a long time. The psychologist stated that resident 51 was not dramatic, did not exaggerate, and he had no reason to think she was making this up. The psychologist stated that the facility administration had tried to discount this allegation and that was what prompted him to call the police. On 11/21/19 at 12:20 PM, a follow-up interview was conducted with resident 51's psychologist. The psychologist stated that he had been providing treatment to resident 51 for the past 5 years, and that for the last 6 months he had been seeing her every couple of weeks for depression. The psychologist stated that resident 51 had MDD with an anxiety disorder that was more prominent since the incident with RN 1. The psychologist stated that resident 51 had no history of reporting allegations of abuse. She was depressed from periods of moderate depression to not really depressed at all. The psychologist stated that he had never seen any psychoses with resident 51; no manifestations of hallucinations or delusions. The psychologist stated that prior to the incident with the nurse her behavior was fine. Over the last year she had been struggling with living in a care center and finding a place to live. It had been an adjustment for her and her physical health had deteriorated. The psychologist stated that resident 51's mood had gone down with mostly being in a care center. The psychologist stated that since the incident with the nurse it had caused resident 51 to be more anxious and hypervigilant. The psychologist stated that resident 51 was really angry that this happened to her, and that she had a sense of resignation that no one wanted to do anything or take her seriously. It has made her feel unsafe, not trusting that she will be safe where she is at. It's contributed to more anxiety. She's pretty upset about this. The psychologist stated that he thought it would be good that she go to another facility, and he was encouraging resident 51 to find another place to live where she would feel safe and validate her concerns. The psychologist stated, I don't think that there is anything in her history or interaction with her that there is any reason to believe that her mental health would affect her ability to retell events from an incident. I've never had any concerns with any other reports of abuse. I've never had an experience where I thought she was stretching the truth or delusional. The psychologist stated that he had never communicated with the facility about resident 51's treatment. On 11/20/19 at 1:50 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that resident 51 had alleged that a male nurse on night shift had been inappropriate with her. The resident reported that he had kissed her on the mouth and unzipped his pants and placed his penis in her hands. The ADON stated that resident 51 did not change her recollection of the allegation that had occurred. The ADON stated that he recalled asking resident 51 if she wanted to change rooms and she said no she enjoyed her roommate and wanted to stay with her. The ADON stated that the allegation was not substantiated by the facility due to inconsistencies with the date of incident, description of perpetrator, and reports that the roommate did not see anything. The ADON stated that resident 51 was residing in the 300 hallway, and RN 1 was the night nurse on that hallway. On 11/20/19 at 2:17 PM, an interview was conducted with the Certified Social Worker. The CSW stated that resident 51 had reported to the SSW that the nurse had been inappropriate with her. The CSW stated that normally the SSW would be involved with this facility investigation but that there was a conflict of interest as the SSW and resident 51 were related, distant cousins. The CSW stated she was informed of the incident on Wednesday 8/28/19. The CSW stated she conducted 2-3 interviews with resident 51. The CSW stated that during the interviews no trauma responses were displayed. Trauma responses would be not making eye contact or fidgeting. The CSW stated that resident 51 was able to talk about the incident in a very detached manner, which could or could not be indicative of abuse. The CSW stated that with her history of sexual abuse she would have expected the resident to be more emotional about it. The CSW stated that a lot of what she knows of resident 51 was through reading through her medical records and staff reports. The CSW stated that she had started at the facility at the end of (MONTH) 2019, and did not have a lot of experience with resident 51. The CSW stated that RN 1 was a trigger for resident 51 since the allegation of abuse, and that he should not be around her. The CSW stated that she had mentioned in a meeting with the Administrator, Director of Nursing (DON), ADON, and SSW that the nurse should be moved to another hallway away from resident 51. The CSW stated that the Administrator point blank said, I'm not going to move him because of her. The CSW stated that resident 51's family member found out that RN 1 continued to work with resident 51 and did not want him to be the nurse on resident 51's hallway. The CSW stated, even if this didn't happen he shouldn't be around the resident. The CSW stated that having RN 1 continue as her nurse had a negative impact on her psychosocial well-being. The CSW stated that resident 51 started talking about the incident again, when RN 1 returned from suspension. She started discussing it again and it became a trigger for her. The CSW stated that the SSW had reported that resident 51's tremors had increased since the incident. The CSW stated that resident 51 began to perseverate more on the account of the abuse with RN 1 and presented more lethargic from her baseline. The CSW stated she was very much a proponent of getting RN 1 moved to another hall. The CSW stated that when she resigned from the facility at the end of (MONTH) 2109, the resident was still residing in the 300 hallway and RN 1 was still working in that hallway. On 11/20/19 at 3:05 PM, a follow-up interview was conducted with the SSW. The SSW stated that resident 51 was still in the same room when the RN 1 was reinstated to work. The SSW stated that RN 1 was instructed not to go into the resident's room, and that the other nurses working the nightshift were to provide care for resident 51's room. Her family contacted him and said that she had been having some anxiety over seeing RN 1 in the hallways, and that resident 51 was having panic attacks. The SSW stated that this was reported on a weekend, could not recall which one; and that on the following Monday he spoke to resident 51 again. The SSW stated he encouraged resident 51 to move to another hallway. The SSW stated he told the resident, we will get you away from him and you won't see him. The SSW stated that seeing RN 1 had caused resident 51 some distress, but was not aware of this until the family informed him. The SSW stated that resident 51 would come into his office and talk to him about the RN 1. The SSW stated that he did not document the conversations with resident 51. The SSW stated that moving RN 1's work area assignment was discussed in a morning management meeting. The SSW stated that it was decided not to move RN 1 because the other residents on the hallway had good a relationship with him and they did not want to tell the other residents that they could not see RN 1 anymore. On 11/20/19 at 4:05 PM, a follow up interview was conducted with the facility Administrator. The Administrator stated that while resident 51 was residing on the 300 hallway, after the report of alleged abuse, she was monitored by the facility staff. The Administrator stated that he was not sure if he had documentation that was specific to monitoring for changes in mood and behavior. The Administrator stated that resident 51 had been seen by a doctor in the community and discussed the allegation of abuse with them. The Administrator stated that RN 1 was instructed to have another employee go into the resident 51's room with him when care was provided. I asked him to not go in alone. The Administrator stated that the medication pass nurse on the evening shift was asked to assist RN 1 with medication administration. The Administrator stated that they were trying to get resident 51 to move to another part of the building or to coordinate a discharge from the facility. The Administrator stated that they wanted to move resident 51 and not RN 1 because they felt it would be more appropriate. The Administrator stated that he could not substantiate the allegation and did not think the nurse should be moved. The Administrator stated that the other residents on that hallway liked RN 1. On 11/21/19 at 8:12 AM, a follow-up telephone interview was conducted with the CSW. The CSW stated she was contacted by the facility Administrator and asked if her recollection was the same as his in regards to asking resident 51 to move rooms and she refused. The CSW stated that it was possible that this happened, but I know that in the conference room he said he was not going to move him. He said I'm not going to move him because of her. The CSW stated, Lets say this didn't happen. The fact that this is a trigger for her is enough in my opinion to be moved to a different hallway. The CSW stated that the family member had filled out a grievance form and it stated that the nurse should not be resident 51's nurse anymore. The CSW stated that the new company policy was that all grievances were handled by the Administrator. The CSW stated she gave the grievance form to the Administrator. On 11/21/19 at 7:08 AM, an interview was conducted the RN 1. RN 1 stated that when he returned from suspension he was instructed by the ADON to not give medication to resident 51. RN 1 stated that the other floor nurses would administer resident 51's medication, and that resident 51 did not require any other nighttime care. RN 1 stated that if resident 51 required assistance or care that the ADON had instructed him to have another nurse provide it. RN 1 stated that the Administrator had said that he could go into resident 51's room but to have other nurses or CNAs present. RN 1 stated he would prepare medication in the hallway and that resident 51 could see him from inside the room. RN 1 stated he did not enter resident 51's room, that he remained in the hallway after the incident. RN 1 stated that he would document monitoring for behaviors of resident 51 in the medical records. RN 1 stated that he was documenting behaviors from observations made of resident 51 from the hallway. RN 1 stated that he was able to see resident 51 in her room from the hallway. On 11/21/19 at 9:02 AM, a telephone interview was conducted with resident 51's family member. The family member stated that they were first informed of the allegation of sexual abuse by resident 51 on 8/27/19. The family member stated that resident 51 was not sure of the exact date the incident had occurred on, and that the facility was trying to discredit the allegation because of this. The family member stated she had spoken to facility staff many times regarding the allegation of abuse, and that she had text conversations with the SSW. The family member stated that all the facility was willing to do was move resident 51 out of the hallway that RN 1 was on. The family member stated that she requested that they move RN 1 out of the hallway, but instead they uprooted (resident 51) from her home and roommate. The family member stated that she requested this from the SSW. The family member stated that she was told that they were not able to move RN 1 but they would move resident 51. The family member stated that she had requested the nurse be moved on (MONTH) 20th or 21st, and the conversation continued until the 27th. The family member stated that the SSW had said that resident 51 was okay with RN 1 being in the hallway. The family member stated that resident 51 would not have said this and that was when she had requested they not talk to the resident without her present anymore. The family member stated that she had filled out a grievance form on (MONTH) 21, 2019 and said that the accusation was not being taken seriously, that they were trying to sweep it under the rug, and protect there nurse. The family member also stated that she had requested that RN 1 be moved on the grievance form. The family member stated that she noticed that resident 51 was quite anxious after the alleged incident of abuse occurred. She was more jumpy and whenever she would take her to a family outing resident 51 would try to delay her return to the facility. The family member stated that resident 51's anxiety had diminished since her transfer to another room away from RN 1. The family member stated that during the time immediately following the incident and up until the date of the room transfer she tried to get resident 51 out of the facility more often. Review of the text communication between resident 51's family member and the facility SSW revealed the following: a. On 7/26/19 at 5:36 PM, the text from resident 51's family member stated, Is this (name of SSW)? b. On 7/26/19 at 6:05 PM, the text reply from the facility SSW stated, Yes. c. On 8/31/19 at 6:23 PM, the text from resident 51's family member stated, I'm wondering if (resident 51's) transfer got sent through? (Name of facility) said they didn't get it yet. (Resident 51) is really scared and stressed being there. d. On 8/31/19 at 6:29 PM, the text from resident 51's family member stated, She is gonna spend the day with us tomorrow so I'm sure that will help her too. e. On 8/31/19 at 6:32 PM, the text reply from the facility SSW stated, That's actually one of the ideas. She can check out for leave of absence overnight, 12 days a year. If family is available she can stay with family a couple days. f. On 9/19/19 at 5:47 PM, the text from resident 51's family member stated, Can you tell me how I would go about filing a grievance about the guy that is still allowed in the same hall where her (sic) perpetrated (resident 51)? g. On 9/19/19 at 6:25 PM, the text reply from the facility SSW stated, Call me about it in the morning tomorrow. Are you available about 8:00? h. On 9/26/19 at 5:51 PM, the text from resident 51's family member stated, I can't believe you guys!!!!! I hope you sleep well knowing that your (sic) allowed this abuse to go on. It's disgusting. i. On 9/26/19 at 5:56 PM, the text reply from the facility SSW stated, Has administration responded to you yet? If not, I'll talk to them more. Remember, this isn't my decision. j. On 9/26/19 at 5:58 PM, the text from resident 51's family member stated, All I have to say to all of you is that your (sic) putting a bad name to. The healthcare fasility (sic). No but your (sic) in charge of the patients to feel safe. k. On 9/26/19 at 6:01 PM, the text from resident 51's family member stated, Just think if it was your parent too terrified to even go to sleep. l. On 9/26/19 at 6:05 PM, the text reply from the facility SSW stated, When I talked to (resident 51) personally yesterday, sure (sic) told me she feels safe as long as he doesn't go into her room. I asked her about the hallway and she said it was okay. If she's still telling you something different, I will talk to her again and then advocate for him to work a different hallway. Honestly, I think he should be working a different hallway too, but I understand some people requested for him to work with them still. I think that was part of why he's still working that hall. m. On 9/26/19 at 6:06 PM, the text from resident 51's family member stated, She would not say that. You must be confusing the question. She says no one asked her if it was ok to work in her hallway. She said the only person that talked to her told her they didn't believe it was important or it didn't happen. I need to request that I be present any time anyone talks to her I guess. Cause she is not Ok. n. On 9/26/19 at 6:13 PM, the text reply from the facility SSW stated, I said 'do you feel safe with him working this hall as long as he does not come into your room.' I asked that yesterday. She said 'yes'. Perhaps she misheard. I'll talk to her again tomorrow. Sometimes she forgets conversations I've had with her. I've seen it happen a few times. o. On 9/26/19 at 6:17 PM, the text reply from the facility SSW stated, That's up to her really. I can't ethically do that unless it's what she wants. Listen, I care about her, and I care about you all, her family. I really do. And I understand why you are upset. I'll be happy to call you tomorrow okay? In the mean time, you mentioned you reported an APS case. If you have an investigator name I'll be happy to talk to them. I worked there before. I may be able to get the investigator to tell administration to have him assigned to another hall. On 11/21/19 at 1:25 PM, a follow-up interview was conducted with the SSW. The SSW stated that resident 51 seemed distressed. When she talked about it she was shaky. The SSW stated that resident 51 talked about it and told him that she was distressed that it happened at all. The SSW stated that when he asked resident 51 about RN 1 working on the hallway she reported feeling safe anyway. The SSW stated that resident 51's family member reported that the resident did not feel safe on 9/27/19. The SSW stated he then spoke with resident 51 and she reported she gets distressed when she sees RN 1. The SSW stated he then encouraged resident 51 to move rooms, and the room transfer was completed on 9/28/19. The SSW confirmed that he communicated with the family member by phone, text, and in person. The SSW again stated that the family member did not report resident 51's distressed or fear prior to 9/27/19. The SSW was then asked about the text messages between him and the family member. Specifically, the text on 8/31/19 that stated (Resident 51) is really scared and stressed being there. The SSW stated, that rings a bell. The SSW stated that at that time we weren't looking at distress of him being there, he was still on suspension. It should be noted that RN 1 was returned to work on 8/31/19. The SSW stated that they waited one month to move resident 51 because she reported feeling safe as long as he did not go into her room. The SSW stated that resident 51's behavioral health services were that he met with the resident and asked how she was doing and I think she's on some medications. The SSW stated that he met with resident 51 whenever she would come to his office or if he saw her in the hallway. The SSW stated that resident 51 did not have a psychosocial care plan for her [DIAGNOSES REDACTED].

Based on observation, interview, and record review it was determined, for 4 of 52 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, consistent with the resident's comprehensive assessment and plan of care. Specifically, facility staff did not reassess a resident's pain level, thus causing the resident to experience unrelieved pain. This finding will be cited at Harm. Additionally, facility staff were not coordinating care with the physician for one resident who requested to be sent to the emergency department related to pain, one resident who had a documented abrasion to her coccyx and did not have orders to treat or a plan of care to follow, and another resident whose leg wraps were not applied per physicians orders. Resident identifiers: 35, 52, 85, and 184. Findings include: 1. Resident 184 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 8/9/17 at 9:05 AM, resident 184 was interviewed. Resident 184 stated that he was concerned that his pain medication was not as effective as it was when he was first admitted to the facility on [DATE]. Resident 184 stated that his pain was not controlled. Resident 184 further stated that the current dose helped, however it did not relieve his pain, and that he continued to have discomfort. Resident 184 stated that his pain was usually at a 7 to 8 on a scale of 1 to 10, with 10 being severe pain. Resident 184 stated that he received his pain medication at 8:00 AM that morning and that it initially helped, however by 9:00 AM he began to feel discomfort. Resident 184 stated that he had reported his pain to the nurses and was told that it was not time for his next ordered dose of pain medication and he had to wait for the next ordered dose. Resident 184 stated the pain medication took 20 to 30 minutes to help and then 30 minutes later he felt discomfort again. Resident 184 also stated that he had [MEDICAL CONDITION] and that his left ankle hurt. Resident 184 also stated that sometimes it felt as if it was burning and it would throb. Resident 184 stated that the pain interfered with his sleep and he was unable to sit for very long. Resident 184 stated that he was only able to sit on the sofa in his room for about ten minutes after his therapy and then he became restless. Resident 184 was asked by the surveyor if he had reported his pain to the physician. Resident 184 stated that the doctor visited him on 8/7/17 and asked him how he was doing; resident 184 stated he told the doctor he was doing fine. Resident 184 stated that the doctor did not ask him specifically about pain, but asked in a general way of how he was doing so resident 184 stated his response to the doctor was in general. Resident 184 stated that he did not like to complain, So I just wait for the staff to come in the room, and then I say something about my pain or if I need to lie down. Resident 184 stated his pain was at a 6 or 7 at the time of the interview with the surveyor. Resident stated that on a scale from 1 to 10, that he could tolerate pain at a 5 (not the acceptable pain level) but was still in discomfort and unable to rest. Resident 184 stated that he received [MEDICATION NAME] 10 milligrams every four hours as needed for pain, and that he had to request the pain medication. When questioned by the surveyor, resident 184 stated that staff did not come in and check on his pain level after he received his pain medication. Resident 184 stated that he would not say anything about his pain because he knew that the staff would tell him he needed to wait for the next time they can give him his pain medication per his physician's orders [REDACTED]. Resident 184 stated that he did not receive his pain medication before therapy once before and the pain was bad, so I have tried to work with the timing of my pain medication and therapy so it doesn't happen again. When the resident was asked if the nurses coordinated his pain medication around his therapy, resident 184 stated that there were a lot of different nurses and they changed so much that some knew him and others did not. Resident 184 stated that there were still times when he would have to wait until after therapy to receive his pain medication. On 8/9/17 resident 184's medical record was reviewed. Review of the physician's orders [REDACTED]. a. Question resident about presence of pain or burning including pressure points. Monitor for pain using 0-10 scale, 0 for no pain, and 10 for worst pain possible. If resident is not able to answer use PAINAD (pain assessment in advanced dementia) scale. b. [MEDICATION NAME] tablet 325 milligrams (mg) - give 2 tablets by mouth every 4 hours as needed for general discomfort. Not to exceed (3 Grams in 24 hrs.) c. [MEDICATION NAME] HCI capsule 5 mg give 10 mg by mouth every 4 hours as needed for pain. d. [MEDICATION NAME] HCI capsule 5 mg, give 5 mg by mouth every 4 hours for needed for pain. The July 2017 Medication Administration Record [REDACTED]. Of the 19 days in July, resident 184 received [MEDICATION NAME] 10 mg as needed (PRN) for pain 37 times. The resident pain level was documented as follows: pain level of 4 twice, pain level of 5 once, pain level of 6 twice, a pain level of 7 on 23 occasions, pain level of 8 on 18 occasions, pain level of 9 twice, and a pain level of 10 once. The July 2017 MAR indicated [REDACTED]. Resident 184's pain level was documented as follows: pain level of 6 once, a pain level of 7 once, and a pain level of 8 once. The August 2017 MAR indicated [REDACTED]. The resident pain level was documented as follows: pain level of 3 twice, pain level of 4 on 3 occasions, pain level of 5 on 3 occasions, pain level of 6 twice, pain level of 7 on six occasions, and a pain level of 8 on 8 occasions. The August 2017 MAR indicated [REDACTED]. Resident 184's pain level was documented as follows: pain level of 5 once, and a pain level of 7 once. (Note: Resident 184's post pain level was not reassessed, and the pain level was below the resident's stated tolerable pain level of (5) 9 of the 67 times it was documented that resident 184 had pain. In addition, the orders for his pain medication remained the same with no changes or reported continued pain to the physician). Review of the admission Minimum Data Set ((MDS) dated [DATE] in section J documented the following: a. J0200 documented that the resident had pain. b. J0300 documented that the resident had pain in the last 5 days. c. J0600 documented that the residents pain was a 7 on a scale of 1 -10. This section was supposed to describe the intensity of the worst pain over the last 5 days, but it was left blank and not answered. Resident 184's pain level summary was reviewed. The summary indicated that resident 184 had pain 113 times of the 28 days that he had been in the facility. On the pain level summary it was documented 80 times that resident 184 had a warning of High of 4 exceeded. Review of resident 184's physician visits revealed that resident 184 was seen on 7/14/17 by the Nurse Practitioner (NP). The NP note revealed that resident 184 had pain due to prosthetic implants/devices/grafts. The NP note did not include a plan for resident 184 going forward, such as what interventions would be implemented regarding pain control. Review of resident 184's physician visits revealed that resident 184 was seen on 8/7/17 by the Medical Director (MD). The MD's notes indicated that resident 184 was status [REDACTED]. Patient was involved in a motor vehicle accident with multiple pelvic fractures 2 months ago. continue pain control with current medications. The MD's notes did not indicate how he had evaluated resident 184's pain control regimen. Review of resident 184's pain care plan with an initial date of 7/13/17 and a revision date of 7/20/17 revealed the following: Problem: the resident has pain related to multiple surgical wounds. Goal: Resident 184 will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through review date. (Revision date 7/20/17). Interventions: Administer [MEDICATION NAME] as per orders. Give one half hour before treatments or care. Identify and record previous pain history and management of that pain and impact on function. Identify previous response to [MEDICATION NAME] including pain relief, side effects and impact on function. Listen to input the resident has about his pain. Report significant finding to medical doctor. (Note: The resident had multiple recent fractures related to a motor vehicle accident. This was not included in the care plan for pain management, nor was the resident care planned to have a goal of pain relief, only adequate relief of pain or the ability to cope with incomplete relief of pain. There were not any non-pharmacological interventions for the resident to cope with incompletely relieved pain.) On 8/10/17 at 9:30 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that she often worked with resident 184. CNA 2 stated that the resident was a pusher and he would not allow pain to stop him. CNA 2 also stated that at first she was worried because when she entered his room resident 184's room, his bed was tilted with his head down and his feet in the air. CNA 2 stated that the reason he was doing this to relieve pain to his hip. On 8/8/17 at 1:30 PM, the Director of Nursing (DON) and Regional Nurse Consultant (RNC) 1 were interviewed regarding pre and post pain assessment. The DON reviewed the resident's charting on the computer and stated the nurse should have completed a pain level rating prior to giving the pain medication. The DON also stated that there should be a note in the nurses note of the post pain level documented in the chart when reassessed for the effectiveness of the pain medication. The DON confirmed that there was not a post pain level documented for a reassessment of the effectiveness of resident 184's pain. The DON was also interviewed regarding the incompleteness of resident 184's pain evaluation dated 7/13/17. RNC 1 also confirmed that the pain evaluation for resident 184 was not complete. On 8/8/17 at 1:15 PM, RN 4 was interviewed regarding pain management and pain assessment when giving a resident a pain medication as needed. RN 4 stated that she would ask the resident what their pain level was and explain the 1 to 10 pain rating scale to the resident. RN 4 stated that she would do a follow up post pain assessment 40 minutes later to see if the pain medication was effective. RN 4 stated that she would also document the post pain level in the nurses notes. On 8/8/17 at 1:30 PM, RN 5 was interviewed regarding pain management and pain assessment when giving a resident a pain medication as needed. RN 5 stated that she would ask the resident where the pain was, and then assess the pain based on a 1 to 10 pain scale and administer the pain medication as ordered. RN 5 stated that she would follow up and see if the pain medication was effective and assess what the new pain level was and document it in the computer. RN 5 then stated, we write the pain level in before and after we give a PRN pain medication in the computer. On 8/8/17 at 2:30 PM, RN 6 was interviewed regarding resident 184's pain. RN 6 stated that resident 184's pain was usually at a 6 on a scale of 1 to 10, and would take [MEDICATION NAME] 2 tablets about every 4 hours. RN 6 stated that he would assess resident 184's pain level and then would follow up by assessing for a post pain level once he had given resident 184's pain medication. RN 6 stated, then I would document the follow up pain level with a number. RN 6 stated that resident 184's normal post medication rating was 3 to 4. RN 6 stated that he had not noted resident 184's pain to get any lower than a 3 or 4. RN 6 stated that he worked three 12 hour shifts a week, and was one of resident 184's consistent RNs. RN 6 stated that he had not followed up with the physician regarding resident 184's frequency in the need for pain medication and his post level of pain being consistent of a 3 to 4. RN 6 was also interviewed regarding pain management and what he did for resident 184 to manage his pain prior to going to therapy. RN 6 stated that if resident 184's PRN pain medication was close enough to be given as ordered then he would give resident 184's pain mediation before therapy, otherwise resident 184 would need to wait until after therapy. RN 6 stated that the pain management for therapy was not a coordinated effort. On 8/8/17 at 3:00 PM, the occupational therapist (OT) was interviewed, the OT stated that resident 184 usually reported his pain level at a 5. On 8/9/17 at 8:00 AM, the physical therapist (PT) was interviewed. The PT stated that resident 184 was motivated and he does have a lot of pain, but he can usually tolerate an hour of therapy. The PT stated that she tried to communicate to the nurses regarding coordinating care. The PT stated that resident 184 was supposed to be treated at 8:30 AM that same morning however she was running behind that day and would not be able to work with resident 184 until 10:15 AM. On 8/9/17 at 9:57 AM, RN 7 was interviewed regarding resident 184's pain. RN 7 stated that the night shift had given resident 184 his pain medication, and when she gave resident 184's pain medication to him at 7:30 AM that morning, his pain was still at a 7. RN 7 stated that she had not gone back to reassess resident 184's pain level, approximately 2 1/2 hours later since she had given resident 184 his pain medication at 7:30 AM. RN 7 stated that resident 184 had been on the same pain medication since his admission. RN 7 stated I try to explain that we cannot totally alleviate pain but can try to get it to where we can manage it. RN 7 stated she had not reported resident 184's continued pain to the physician. RN 7 stated that resident 184 would not be able to have his next dose of pain medication until 11:30 AM, and 'I will not be able to give it before therapy today. On 8/9/17 at 3:15 PM, the DON and Assistant Director of Nursing (ADON) were interviewed regarding pain management. The DON stated that she reviewed a daily report of which residents had experienced pain. The DON also stated that she would send a weekly report to her corporate consultants regarding residents in the facility who had pain. The DON stated that the report did not indicate the levels of residents' pain, so she was not aware of the resident's ongoing intense pain. The DON stated that if a resident experienced pain, it was expected that the nurse would document it and report the continued pain to the physician for necessary changes in the medication. The DON stated that if there was a new order then facility staff would review it in the morning meeting and that the interdisciplinary team (IDT) would reassess the resident as necessary. The DON and the ADON stated that resident 184 had not been reassessed for pain or reviewed in an IDT meeting since his initial admission IDT meeting. On 8/10/17, at 1:00 PM, the facility Medical Director (MD), who was also resident 184's physician, was interviewed. The facility MD stated that he was unaware of resident 184's ongoing pain because the resident had not directly reported it to him. The facility's Pain Assessment and Management policy was reviewed. The policy included the following: . Purpose The purposes of the procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goal as and needed and that address the underlying causes of pain. General Guidelines 1.The pain management program is based on a facility -wide commitment to resident comfort. 2. 'Pain management' is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary process that includes the following: a. Assessing the potential for pain; b. Effectively recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of the pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different level and sources of pain; g. Monitoring the effectiveness of interventions; and h. Modifying approaches as necessary . 4. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Assessing Pain: 1. During the comprehensive pan assessment gather the following information as indicated from the resident (or legal representative): a. History of pain and its treatment, including pharmacological and non-pharmacological interventions; b. Characteristics of pain: 1)Intensity of pain (as measured on a standardized pain scale); 2) Descriptors of pain (e.g., constant or intermittent); 3) Pattern of pain (e.g., constant or intermittent); 4) Location and [MEDICAL CONDITION] of pain on ; and 5) Frequency, timing and duration of pain. c. Impact pain on quality of life; d. Factors that precipitate or exacerbate pain; e. Factors and strategies that reduce pain; and f. Symptoms that accompany pain (e.g., nausea, anxiety). 2. Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. 3. Discuss with the resident (or legal representative) his or her goals pain management and satisfaction with the current level of pain control. Monitoring and Modifying Approaches 1. Re-assess the resident's pain and consequences of pain at least each shift for acute pain significant changes in levels of chronic pain at least weekly in stable chronic pain. 2. Monitor the following factor to determine if the resident's pain is being adequately controlled: a. The resident's response to intervention's and level of comfort over time; b. The status of the underlying cause(s) of pain, if identified previously; and c. The presence of adverse consequence to treatment. 3. Monitor the residents by performing a basic assessment with enough detail and as need, with standardized assessment tools (e.g., approved pain scales, etc.) and relevant criteria for measuring pain management (e.g., target signs and symptoms). 4. If pain has not been adequately controlled the multidisciplinary team, including the physician, shall reconsider approaches to make adjustments as indicate. 5. If pain symptoms have resolve or there is no longer an indication for a pain medication, the multidisciplinary team and physician shall try to discontinue or taper [MEDICATION NAME] medication to the extend possible. Documentation 1. Document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and effectiveness of interventions for pain) as necessary and in accordance with the pain management program. 2. Upon completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's medical record. Reporting Report the following g information to the physician or practitioner: 1. Significant changes in the level of the resident's pain . 2. Prolonged, unrelieved pain despite interventions. 2. Resident 35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 35's medical record was reviewed on 8/7/17. Resident 35's physician's orders [REDACTED]. Wrap from base of toes to bellow (sic) knee. change three times a week on M (Monday) W (Wednesday) F (Friday) and as needed . On 8/7/17 at 7:00 AM, resident 35 was observed to be in the 300 hallway in her wheelchair. Resident 35 was observed to have wraps around her legs, extending from her feet up to halfway up her calves. On 8/7/17 at 2:15 PM, resident 35 was observed to be in her room in her wheelchair. Resident 35 was observed to have wraps around her legs, extending from her feet up to halfway up her calves. On 8/8/17 at 1:30 PM, resident 35 was observed to have wraps around her legs, extending from her feet up 3/4 of the way to her knee. Resident 35 stated that the wraps were supposed to be placed from her feet to her knee to help reduce the [MEDICAL CONDITION] in her legs. On 8/10/17 at 10:00 AM, resident 35 was observed to be in her room in her wheelchair. Resident 35 was observed to have wraps around her legs, extending from her feet up 3/4 of the way to her knee. On 8/7/17 at 2:30 PM, an interview was conducted with Regional Nurse Consultant (RNC) 1. RNC 1 stated that resident 35 was supposed to have the wraps from her feet all the way up to the knee. On 8/10/17 at 10:00 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 35 sometimes requested that facility nurses cut the wraps off of her legs because it was painful. RN 1 also stated that resident 35 refused to let the facility nurses put the wraps on at times. RN 1 stated that resident 35 did not make specific requests as to how far up the leg the nurses wrapped the resident's legs. RN 1 confirmed that resident 35's legs were supposed to be wrapped from the foot all the way up to the knee, but stated that sometimes the wraps rolled down. On 8/10/17, an interview was conducted with the Medical Director (MD). The MD confirmed that resident 35 had an order for [REDACTED]. 3. Resident 85 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/7/17 at approximately 10:00 AM, an interview was conducted with resident 85. Resident 85 stated that she had wounds on her lower extremities. On 8/7/17 at 1:22 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that resident 85 had sores and [MEDICAL CONDITION] on her lower extremities. RN 2 stated that resident 85 did not have pressure sores. Resident 85's medical record was reviewed on 8/8/17. A form titled, Weekly Skin Observation dated 8/2/17 revealed that resident had redness to buttocks and posterior thighs. A form titled Weekly Skin Observation dated 8/6/17 revealed that resident 85 had an abrasion on her coccyx which measured 3 centimeters (cm) by .02 cm. A nurses note dated 8/6/17 revealed, Nurse assessed resident skin this shift during care to resident. Abrasion noted to her coccyx area (3 cm (by) 0.2 cm.) No other open areas noted. Both lower extremities with dressing in place. There were no physicians orders for a treatment for [REDACTED]. There were no care plans regarding resident 85's coccyx wound. On 8/10/17 at 1:10 PM, an interview was conducted with resident 85's medical doctor (MD). The MD stated that resident 85 was followed by a wound physician every Monday. The MD stated that he had not observed the wound because the wound doctor would assess and order treatments. On 8/10/17 at 1:50 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that he was the wound nurse for the facility. The ADON stated that he was not aware that resident 85 had a wound on her coccyx. The ADON stated that the wound physicians did not assess resident 85 on 8/7/17. The ADON confirmed there were no orders for treatments or care plans regarding the coccyx wound on resident 85. On 8/10/17 at approximately 8:30 AM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that when a wound was observed during a skin check then the nurse reported the wound to the UM. UM 1 stated that the UMs were supposed to investigate how resident wounds developed and obtain treatment orders. UM 1 stated that she was unaware that resident 85 had a wound on her coccyx. 4. Resident 52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/9/17 resident 52's medical records was reviewed. Review of the incident reports on 4/23/17 revealed resident 52 complained of pain in her hip and shoulder and requested to be sent to the emergency room (ER) for evaluation. The incident report stated that the resident was informed that the facility must have a good reason to go to the ER for further eval The incident report also indicated that at 9:15 PM resident 52 was identified as not being at the facility and an elopement was announced. At 10:30 PM, RN 10 called 911 to report that resident 52 was missing from the facility. At 10:40 PM, RN 10 received a call from the facility administrator stating that resident 52 was at the hospital ER. Review of resident 52's admission assessment on 11/22/17 revealed a Brief Interview for Mental Status (BIMS) score of 15, cognitively intact. Resident 52's quarterly assessment on 3/21/17 revealed a BIMS of 13, cognitively intact. On 8/10/17 at 12:30 PM an interview was conducted with the MDS coordinator. The MDS coordinator stated that resident 52 is alert and oriented and was able to sign herself out on leave, and that the resident comes and goes as she pleases. The MDS coordinator further stated that resident 52's complaints of pain were from a recent fall on 4/22/17. On 8/10/17 at 12:57 PM, an interview was conducted with the DON. The DON stated that her expectations of staff were to assess the patient first and then to notify the MD of a change in condition or complaints of pain. The DON further stated that if the resident is responsible for themselves then we would send them to the hospital as they requested.

Based on interview and record review, it was determined the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 6 sample residents. A resident received second degree burns from a inappropriate hot compress applied to his back without adequate supervision. Resident identifier 1. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 was interviewed on 6/1/11 by telephone. The resident stated the facility had effectively been using hot packs applied to his back to help relieve his back pain. Resident 1 stated he had requested a hot pack from a nursing assistant on the evening of 5/18/11. The resident stated the nursing assistant applied a heating package to his back that night. The resident stated he first became aware of a problem when he was getting up in the morning and found a 'little bit of blood" on his sheet. He stated he had developed a couple of burn wounds on his back from the heating package. Resident 1 stated he was seen by his physician on 5/19/11. He stated the physician advised him he had two second degree burns on his back. Resident 1 stated he discharged from the facility to his home on 5/19/11. Resident 1 stated a home health nurse began providing daily wound care as ordered by his physician. The resident stated only one wound around his waist was still weeping. Resident 1 stated because of the wounds, he could no longer sleep on his back. The resident stated it had been known for some time that he had decreased sensation in his feet. He stated he had not previously known he had developed decreased sensation on the skin of his back. Resident 1 had been assessed as having pain and his admitting [DIAGNOSES REDACTED]. The resident had a physician's medication order for Percocet to treat his pain. There was no physician's order for hot packs to be applied. Resident 1's care plan was reviewed on 6/1/11. There was no care plan regarding use of hot packs. There was a single notation, on a care plan for assistance with Activities of Daily Living, that resident 1 had received a burn. There was no notation in resident 1's Treatment Administration Record, Medication Administration Record or in the Nurse's Notes that resident 1 had ever received treatment with hot packs. Registered Nurse (RN) 1 was interviewed by telephone on 6/1/11. RN 1 stated that, at the end of her nursing shift on 5/18/11, she had been approached by a nursing assistant regarding use of a hot pack. The RN stated she had explained to the nursing assistant that a hot pack could be made by putting hot tap water on an absorbent incontinence pad and putting the pad in a covered plastic bag. RN 1 stated she then returned to completing her shift change tasks. She stated she had not been aware if the nursing assistant had used the procedure to make a hot pack for any resident. Certified Nursing Assistant (CNA) 1 was interviewed on 6/1/11 at 4:05 PM. CNA 1 stated resident 1 had requested a hot pack for his back at approximately 7:00 PM or 7:30 PM on 5/18/11. She stated she spoke with a nurse (RN 1) who told her resident 1 had used hot packs previously and told her to get one from the supply room. CNA 1 stated she was unable to locate a prepackaged hot pack. She stated RN 1 explained how she could improvise a heating pack. CNA 1 stated the nurse told her to heat water in the microwave but didn't say for how long. CNA 1 stated she heated the water for thirty seconds. CNA 1 stated she had misunderstood the nurse's instructions. The CNA thought she was following instructions when she poured the heated water into a plastic bag. CNA 1 doubled the plastic bag to prevent leaking. She put the water filled bags into a pillowcase and put a towel around the package before she positioned it on resident 1's back. CNA 1 stated she looked in on resident 1 during her last rounds, prior to completing her shift at 10:00 PM. CNA 1 stated the resident said he was comfortable and he had told her she could leave the heated package in place. She had trusted resident 1 to tell her if there was a problem. She had not assessed resident 1's back after the heated package was initially placed on him. The Administrator was interviewed on 6/1/11 at 2:40 PM. The Administrator stated there was no Policy and Procedure for use of hot packs in the facility. The facility's Policy and Procedure for use of warm, moist compresses included to use the material and solution as ordered by the physician and to use a bath thermometer. The procedure included 7) Test the temperature of the solution with the bath thermometer (no parameters were defined), 8) Be sure the temperature of the solution will not scald or burn the resident, 11) Check the skin under the compress every 5 minutes during the treatment. If skin appears excessively red, discontinue treatment to avoid scalding sensitive skin, 15) Record the procedure and any pertinent information in the medical record. The Administrator stated there had been an ad hoc Quality Assurance (QA) meeting, on 5/20/11, to address the circumstances regarding resident 1's injury. The Administrator stated the QA team discussed the issue and made a decision that only nurses and therapists would be allowed to apply hot packs for residents' comfort and that only approved supplies were to be used. The QA action plan included, 5 minute huddles with nurses and CNAs regarding application of hot packs, hot packs would be made available in medication rooms, "not supply room", a physician's order was required for the use of hot packs and only nurses were allowed to use the hot packs as it was within their scope of practice. It was documented information regarding applying and proper procedure for hot packs was presented at the general staff meeting. Hot packs were to be the responsibility of nurses, not CNAs. It was documented the nurse and CNA involved had been educated. For the QA follow-up, it was documented hot packs were stored in the medication room on 5/19/11, huddles had been completed on 5/19/11, and the general staff inservice had been conducted on 5/20/11. On 6/1/11, the medication rooms were checked for the availability of hot packs. The first medication room had no hot packs but they were included on a supply requisition list. A second medication room was observed to have no hot packs available. There were five hot packs in a third medication room. There was a case of twenty-four hot packs in the supply room. LPN 5 stated they could call central supply to get hot packs. The facility provided documentation regarding the subjects discussed in the huddles and inservices, as well as the names of staff who had attended them. By correlating staff signatures with the names on staffing schedules, it was determined approximately 16 nurses and 17 CNAs had not signed as having attended a huddle or an inservice. As the information was not available in the QA minutes, the Administrator was queried regarding monitoring to ensure all nursing and CNA staff had been educated. He stated that inservices were the responsibility of nursing. The Administrator was queried regarding additional follow-ups or monitoring to ensure proper procedures were being followed by the proper staff. There had been no additional monitoring planned. The Assistant Director of Nursing (ADON) was interviewed on 6/1/11 at 5:15 PM. The ADON was also the new staff developer as of April 2011. She stated they were going to start putting inservice information in a binder where all staff could read it and sign that they had read it. There had been no inservice information prepared for the binder regarding the use of hot packs. She stated she had just started lining up the employee inservice records but she had not begun to use the binder. The ADON stated that "as far as I know, only nurses have the rights" to do hot and cold packs. She stated she was never aware that CNAs were applying the hot packs. She stated only therapy used the heated towels as hot packs. The ADON stated hot packs had not been used on the wing she was assigned to monitor for over a year. Interviews were conducted with an additional 5 nurses and 4 CNAs who were working on 6/1/11. All but one CNA understood hot packs were to be applied only by nurses. Nurses were not consistant about obtaining physician's orders or about when to check the hot packs that were in use. At 1:10 PM, CNA 4 was interviewed. CNA 4 stated only nurses can apply hot packs or heating pads. "It is not in my scope of practice." At 1:17 PM, CNA 3 was interviewed. CNA 3 stated CNAs can provide comfort by repositioning a resident or provide them with pillows. The CNA stated they have been instructed to notify the nurse if cold packs or hot packs are needed because they can only be applied by a nurse. At 1:20 PM, Licensed Practical Nurse 2 (LPN 2) was interviewed. LPN 2 stated he/she had received training regarding hot packs for pain control in nursing school and "about 2 or 3 weeks ago" at the facility. LPN 1 stated hot packs should be used after a physician's order is obtained, only use the "pop" kind, should be wrapped in a towel and checked after 15 or 20 minutes. At 1:20 PM, CNA 2 was interviewed. CNA 2 stated, "I use cold packs more than hot packs. I wrap them in a towel so they don't burn the skin." CNA 2 stated he/she used the packs "for pain, like bone pain". CNA 2 had attended the inservice. At 1:25 PM, LPN 3 stated he/she had received inservice a few weeks ago regarding using hot packs. LPN 3 stated the hot packs are helpful for pain relief but must have a protective barrier between the hot pack and a resident's skin. LPN 3 stated the nurse must assess the resident before and after use for breakdown. The nurse must assess after 15 minutes for skin burn. LPN 3 stated a physician's order was needed to use a hot pack. At 1:27 PM, LPN 4 was interviewed. LPN 4 stated he/she had an inservice regarding use of hot packs "last year". LPN 4 stated he/she hadn't used hot packs. LPN 4 knew to use the prepackaged hot packs and to use a protective barrier between the skin and heat source. At 1:28 PM, CNA 5 stated he/she had not received inservice training at the facility regarding use of hot packs. CNA 5 stated the last time he/she put a hot pack on a resident was approximately one month ago, at the request of a nurse. At 1:35 PM, RN 2 was interviewed. RN 2 knew of a recent inservice but had not been able to attend. RN 2 stated coworkers had advised her that only nurses were to apply hot or cold compresses. The RN stated cold packs were not used as frequently as hot packs. The RN stated physicians' orders were not obtained prior to using hot packs for pain as it was a standard nursing intervention. At 2:25 PM, LPN 1 was interviewed. LPN 1 stated that he/she had not used hot packs "for ages". When he/she did use them, it was only the disposable kind and they were always wrapped in a wash cloth. At 1:22 PM, Physical Therapist 1 (PT 1) and Occupational Therapist 1 (OT 1) were interviewed. The therapists stated they used heat therapy to loosen up muscles. The therapists stated they used warm, moist compresses. They stated they would not leave the compresses on longer than 10 to 15 minutes, unless they were monitoring.

Based on observation, interview, and medical record review it was determined that for 1 of 24 sample residents, the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents. Specifically, a 51 inch, 233 lb. (pounds) resident was placed in a shower chair and pushed backwards up a ramp attached to a scale. While pushing the resident backwards up the ramp the shower chair fell over backwards resulting in the resident experiencing a T-9 (Thoracic) vertebral fracture of the back. Resident identifier: 4. Findings included: Resident 4 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of resident 4's medical record on 8/30/10 revealed that resident 4 was 51 inches tall and weighed 233 lbs. according to the Quarterly Minimum Data Set ((MDS) dated [DATE]. Review of resident 4's Quarterly MDS, dated [DATE], revealed that resident 4 required extensive assistance with bed mobility and required 2 people for physical assistance and was totally dependent with transfers requiring 2 people for physical assistance. Observations of resident 4 on 9/1/10 revealed that resident 4 had congenital defects resulting in resident 4 carrying a majority of her weight in her upper body. Resident 4 was observed to have small lower extremities which were disproportionate to her upper body. Review of facility incident reports revealed that on 4/8/10 at 8:10 AM, CNA 2 (Certified Nursing Assistant) "was trying to get her (resident 4's) weight before giving her a shower when the chair fell backwards. From the weighing scale area. Full body assessment done." Review of Nurses Notes for resident 4 revealed an entry dated 4/8/10. RN 1 (Registered Nurse) documented, "... Resident alert and O X 2-3 (oriented to name, place, date and or situation) ... (CNA 2) was trying to get her weight when in the shower chair when the chair fell backwards. Incident happen (sic) in the weighing scale area. ... " On 9/1/10 at 2:00 PM, a telephone interview was conducted with RN 1 regarding the incident that occurred on 4/8/10 when resident 4 fell backwards in the shower chair. RN 1 stated that the nurse aide put resident 4 in the shower chair and then tried to pull resident 4 backwards up onto the scale and the chair went backwards. RN 1 further stated that the chair hit the ground but resident 4 did not hit her head because the nurse aide was holding her head. On 9/8/10 at 11:00 AM, a telephone interview was conducted with CNA 2 regarding the incident that occurred on 4/8/10 with resident 4. CNA 2 stated that she took resident 4 down to the scale while resident 4 was in the shower chair. CNA 2 stated that she was facing the resident and began pushing resident 4 up the ramp, backwards, while holding on to resident 4's shower chair. CNA 2 further stated that the wheel from the shower chair got caught on the lip of the ramp, resulting in the resident falling backwards onto the scale. CNA 2 stated that because resident 4 was facing her, and fell backwards, there was no way to prevent resident 4 from falling. CNA 2 further stated that she tried to hold on to resident 24 to prevent her from falling but that resident 4 was too heavy for her to hold up. CNA 2 stated that resident 4 was short and heavy. CNA 2 stated that resident 4 required 2 people for transfers. CNA 2 stated that after resident 4 fell on her back she began screaming and was very scared. CNA 2 stated that after resident 4 had fallen she was told by the facility nurse to use 2 people when she weighed resident 4. CNA 2 further stated that after the fall the Director of Nursing instructed staff to use 2 people while weighing resident 4. On 9/1/10 at 12:30 PM, resident 4 was interviewed regarding the fall that occurred on 4/8/10. Resident 4 stated that CNA 2 had put her in a shower chair and took her to the scale to get weighed. Resident 4 stated that the wheels of the shower chair got caught on a lip on the scale and resident 4 fell down backwards, landing on her back with her legs up in the air. Resident 4 further stated that the nurse came running from the desk and it took 4 CNAs and the nurse to get her back in the chair. Resident 4 stated that she told the facility nurse that, "my back really hurts" and that she wanted to go to the hospital. Resident 4 then began to cry and stated that since that incident she would not get on the shower chair for fear the chair would tip over. Resident 4 further stated that since the incident, she had received bed baths because of her fear of the shower chair. Review of the facility incident reports revealed, on the Additional follow-ups section, that on 4/8/10, "Staff educated to use 2 people when resident is in the shower chair getting weighted (sic)" and on 4/11/10, "Pain increasing MD (Medical Doctor) notified, resident sent to ER (emergency room ) for evaluation." Review of the Hospital History and Physical report, dated 4/12/10, revealed that resident 4 was admitted to the hospital for delirium, T-9 vertebral fracture and possible pneumonia. It was documented on the History and Physical report from the hospital that the care center nurses reported that resident 4 had experienced a fall three days ago when she fell on her back.