Every finding on record at Mount Olive Center

Based on record review, and resident, and staff interviews, the facility failed to protect a resident's right to be free from misappropriation of $300.00 after Resident #1 mistakenly transferred funds to Nurse Aide #1 on a money transfer application. This was for 1 of 3 residents reviewed for misappropriation of property (Resident #1).Findings included:Resident #1 was admitted to the facility on [DATE].The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #1 was assessed as cognitively intact.During an interview on 1/22/2026 at 3:05 PM, Resident #1 reported that around Christmas he asked Nurse Aide (NA) #1 to obtain groceries for him from a local store. The resident stated he transferred $120.00 to NA #1 through a money transfer application on his phone to pay for the groceries. Resident #1 confirmed NA #1 did bring him his groceries and provided a reciept. The resident further stated that on the following day, 12/27/2025, he accidentally transferred an additional $300.00 to NA #1 while attempting to send money to a relative for rent. Resident #1 reported that when NA #1 returned to work, he asked her to return the $300.00. According to the resident, NA #1 told him her account had a negative balance, and the money had already been withdrawn. The resident stated NA #1 told him she would repay him when she received her paycheck in two weeks. Resident #1 stated he repeatedly asked NA #1 for the money, but she avoided him and continued to tell him she did not have the funds. The resident reported he attempted to negotiate partial repayment, first requesting $200.00 and later $150.00, but NA #1 still did not return any money. Resident #1 stated he informed the Social Worker on 1/12/2026 that NA #1 was not returning the money, but no action was taken. The resident stated he eventually reported the matter to the Administrator on 1/16/2026, who returned the $300.00 to him. Resident #1 also stated law enforcement interviewed him on 1/16/2026, but he declined to press charges and was satisfied to have his money returned.Review of the transactions on the money transfer application on Resident #1's phone revealed the following information. On 12/26/2025 Resident #1 paid $120.00 to NA #1 for My groceries. On 12/27/2025 Resident #1 transferred $300.00 to NA #1 for Rent. On 1/3/2026 Resident #1 requested $200.00 from NA #1, but the request expired. On 1/4/2026, 1/5/2026, and 1/12/2026 Resident #1 requested $150.00 from NA #1, but the requests expired. All requests were made through the money transfer application.During an interview on 1/22/2026 at 5:06 PM conducted on the telephone, NA #1 stated Resident #1 frequently ordered food deliveries. NA #1 reported that on 12/26/2025 Resident #1 became upset when a grocery delivery was not brought into the facility because it was after 5:00 PM and there was no one at the front desk to let the delivery person into the locked building. NA #1 stated she offered to go to the store to deescalate the situation. NA #1 explained Resident #1 did not have cash, so he sent her funds through the money transfer application for the groceries. Did she bring him the $120 worth of groceries? NA #1 stated she was off work the next day (12/27/2025) and noticed Resident #1 had transferred $300.00 to her account, but she did not know why. NA #1 stated that when she next worked (12/28/2025), she asked the resident about the transfer, and he told her it was a mistake and requested the money back. NA #1 stated the explanation given by Resident #1 was that he did not have a lot of hand coordination and his shaky hands accidentally sent money to her instead of a family member. NA #1 stated she had over drafted her account and the $300.00 had already been withdrawn automatically by the money transfer application. She stated she told the resident she would repay him when she received her paycheck on 1/16/2026. NA #1 acknowledged the resident continued to ask for the money, but she did not have it to return. NA #1 stated on 1/16/2026 the Administrator called her regarding the matter of the funds, and she came to the facility on her day off to provide $300.00 in cash to the Administrator, who accompanied her to return the money to Resident #1. NA #1 stated she did not intend to take money from Resident #1 and believed the issue would be resolved once she was paid. NA #1 confirmed she had been suspended from her job because she did not come forward to let the Administrator know about the mistaken transfer of money to her by Resident #1 and was suspended until the conclusion of the investigation. NA #1 confirmed she was educated about not taking any money from the residents for any reason.During an interview on 1/22/2026 at 10:49 AM conducted on the telephone, the Social Worker stated Resident #1 informed her on 1/12/2026 that he inadvertently sent $300.00 to NA #1 at Christmas time. Resident #1 told the Social Worker that NA #1's account balance on the money transfer application was negative and she would repay him after receiving her paycheck on 1/16/2026. The Social Worker stated she doubted the truthfulness of the resident's account and decided to wait to see if NA #1 would return the money. On 1/16/2026, NA #1 was not answering phone calls from the Social Worker and was not scheduled to work. At 4:00 PM on 1/16/2026, the Social Worker notified the Administrator of Resident #1's concern that NA #1 was not going to return his funds.The facility Administrator and the Director of Nursing were simultaneously interviewed on 1/22/2026 at 4:46 PM. The Administrator revealed she was notified on 1/16/2026 by the Social Worker that NA #1 owed Resident #1 $300.00. The Administrator stated she interviewed both Resident #1 and NA #1, who provided consistent explanations of the accidental transfer. The Director of Nursing stated NA #1 should not have given Resident #1 her account information for the money transfer application to buy groceries and she should have immediately notified herself (the Director of Nursing) or the Administrator when she became aware the $300.00 was accidentally put into her account. The Administrator confirmed that she educated NA #1 that she should not take money from the residents for any reason. The Administrator stated she would have immediately refunded Resident #1 his $300.00 if she had been made aware.The facility provided a corrective action plan that was not acceptable to the State Agency. When addressing how the facility identified other residents as having potential to be affected by the same deficient practice, they did not address all cognitively impaired residents. The facility's monitoring plan did not address how the facility would monitor to ensure the deficient practice would not recur for all cognitively impaired residents. Additionally, as of 1/23/2026 the State Agency had not received an initial report for the allegation of misappropriation involving Resident #1 as the victim and NA #1 as the perpetrator.

Based on record review, and resident and staff interviews, the facility failed to implement the abuse policy and procedures when the Administrator was not immediately notified of an allegation of misappropriation of funds resulting in delayed protection, reporting, and investigation for 1 of 3 residents reviewed for misappropriation of property (Resident #1). Findings included:Review of the facility's abuse policy and procedures, last reviewed on 11/14/2025, revealed: Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately, regardless of the shift worked. The notified supervisor will report the suspected abuse immediately to the Administrator or designee and other officials in accordance with state law. The abuse policy and procedure additionally stated: Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will perform the following. initiate an investigation within 24 hours of the allegation of abuse that focuses on causative factors and interventions to prevent further injury, and the center will protect patients from further harm during an investigation. The policy further indicated the Administrator, or designee would report allegations to the appropriate stated and local authority(s) involving misappropriation of property within 24 hours if the event did not result in serious bodily injury.Resident #1 was admitted to the facility on [DATE].The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #1 was assessed as cognitively intact.During an interview on 1/22/2026 at 10:49 AM conducted on the telephone, the Social Worker stated Resident #1 informed her on 1/12/2026 that he inadvertently sent $300.00 to Nurse Aide (NA) #1 at Christmas time. Resident #1 told the Social Worker that NA #1's account on the money transfer application was negative and she would repay him after receiving her paycheck on 1/16/2026. The Social Worker stated she doubted the truthfulness of the resident's account and decided to wait to see if NA #1 would return the money. The Social Worker elaborated to say the information provided by Resident #1 did not make sense to her. On 1/16/2026, NA #1 was not answering phone calls from the Social Worker and was not scheduled to work. At 4:00 PM on 1/16/2026, the Social Worker notified the Administrator of Resident #1's concern that NA #1 was not going to return his funds. The Social Worker stated she should have notified the Administrator immediately on 1/12/2026.The facility Administrator and the Director of Nursing were simultaneously interviewed on 1/22/2026 at 4:46 PM. The Administrator confirmed she was notified on 1/16/2026 by the Social Worker that NA #1 owed Resident #1 $300.00. The Administrator stated that the Social Worker should have notified her immediately on 1/12/2026 of the funds that needed to be returned to Resident #1 by NA #1. The Administrator confirmed that NA #1 was on the schedule and had nurse aide assignments from 1/12/2026 to 1/16/2026, after which she was put on administrative leave to protect the residents. The Director of Nursing stated NA #1 should have immediately notified herself (Director of Nursing) or the Administrator when she (NA #1) became aware the $300.00 was accidentally put into her account. The Administrator revealed the local police department and adult protective services were notified on 1/16/2026 but did not make a formal report because the funds were returned to Resident #1. During a phone interview on 1/28/2026 at 8:59 AM, the Administrator stated that on 1/16/2026 she was rushing to submit the initial allegation report concerning the alleged misappropriation of funds from Resident #1. She explained she inadvertently transposed letters in the State Agency's email address, causing the report to fail to transmit. The Administrator further stated she did not receive any notification from her email service indicating the message had failed. She reported she was unaware the initial allegation report had not been received until 1/27/2026, when the surveyor informed her that the State Agency had not received the initial report as of 1/23/2026. The Administrator confirmed she sent the initial allegation report on 1/27/2026 to the correct email address for the State Agency. The Administrator confirmed NA #1's employment was terminated with the facility. The Administrator stated that NA #1 took advantage of Resident #1 and that if she had come forward immediately on 12/27/2025 when the $300 was transferred to her money transfer application account by Resident #1, she would have been disciplined with a suspension, but likely not terminated from her employment. The facility provided a corrective action plan that was not acceptable to the State Agency. As of 1/23/26 the State Agency had not received an initial allegation report for the allegation of misappropriation involving Resident #1 as the victim and NA #1 as the perpetrator. The facility's corrective action plan incorrectly stated that the initial allegation report was sent to the State Agency on 1/16/2026.

Based on record review, and staff, Pharmacy Consultant, Medical Director, and Corporate Medical Director interviews, the facility did not ensure a resident was free of a significant medication error when Resident #1 received 60 milligrams (mg) of oxycodone (a short-acting opioid which is a class of drug used to reduce moderate to severe pain). Oxycodone 60 mg was not prescribed to Resident #1. On 11/28/25 Resident #1 was given oxycodone 60mg medication prescribed to another resident. This deficient practice affected 1 of 5 residents reviewed for significant medication error.Findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a brain disorder that primarily affects movement) with dyskinesia (involuntary, erratic movements), dementia, and palliative (specialized medical support for people with serious illnesses) care.Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively impaired and did not receive opioid medications.Review of Resident #1's active and discontinued orders revealed she did not have an order to receive oxycodone.Review of a medication related incident report dated 11/28/25 indicated that Resident #1 was administered 60 mg of oxycodone that was intended for another resident. The incident report revealed Resident #1 was assessed, the Nurse Practitioner (NP) and Director of Nursing (DON) were notified, an intravenous (IV: within a vein) fluid bolus (a single, large amount of intravenous (IV) fluids administered quickly to a patient) and naloxone (a medication used to reverse opioid overdoses) were ordered, neurological checks (a quick, simple assessment of your nervous system (brain, spinal cord, nerves) by a healthcare provider, checking things like alertness, reflexes, balance, strength, and senses to spot problems like weakness, numbness, or confusion, often using questions, and lights) remained stable, and no distress was observed.Review of the facility's investigation report revealed on 11/28/25 during a medication pass, Nurse #1 administered 60 mg of oxycodone to Resident #1 that was intended for another resident. The DON and the Unit Manager were immediately notified and assessed Resident #1. The Nurse Practitioner was notified by the Unit Manager, and naloxone and 1 liter (L) of IV fluid were ordered. Resident #1 remained alert and her vital signs remained stable. Resident #1's resident representative was notified of the incident. Resident #1 was monitored after the administration of 60 mg of oxycodone per the facility's neurological (neuro) check protocol (every 15 minutes (min) x 2 hours, then every 30 min x 2 hours, then every 60 min x 4 hours, then every 8 hours until at least 72 hours had elapsed).Review of Resident #1's Neuro (neurological) Check Flow Sheet revealed her neuro checks and vital signs were performed per the facility's neuro check protocol and Resident #1 remained stable.Resident #1's medical orders were reviewed. She had an order dated 11/28/25 for naloxone HCL (hydrochloric acid) liquid 4 mg/0.1milliliters (ml) one (1) spray alternating nostrils every 2 minutes as needed for signs of opioid overdose; may be repeated every 2 to 3 minutes for unresponsiveness or difficulty breathing, until individual is breathing (respiratory rate greater than 10 per minute). Resident #1 also had an order dated 11/28/25 for sodium chloride solution 0.9 % (a sterile mixture of 0.9 grams of salt (sodium chloride) dissolved in 100 milliliters of water; a salt concentration like that of human blood and bodily fluids) one (1) liter intravenously one time only for hydration for a 1-day bolus.An interview was conducted on 12/18/25 at 11:29 AM with Nurse #1. Nurse #1 stated she was in training and Nurse #2 handed her medication (oxycodone) intended for Resident #1's roommate. Nurse #1 stated she thought they were for Resident #1 and gave the medication (oxycodone) accidentally to her. Nurse #1 stated she recalled she verified Resident #1's name. Nurse #2 informed her she gave the medication to the wrong resident. Nurse #1 stated she notified the Unit Manager, who called the NP, and received orders. She stated Resident #1 was closely monitored and a few hours after receiving the medication she became sleepy and received one dose of naloxone. Nurse #1 continued to monitor Resident #1, and she was acting like her normal self. Nurse #1 stated the incident was reported to the next oncoming shift.Review of Resident #1's medication administration record (MAR) revealed she received one dose of naloxone at 2:15 PM on 11/28/25.An interview was conducted on 12/17/25 at 6:15 PM with Nurse #2 who was training Nurse #1 on 11/28/25. Nurse #2 stated Nurse #1 asked if she could take the medications into the resident room. Nurse #2 stated she told Nurse #1 the medication was for Resident #1's roommate. Nurse #2 stated she was still at the medication cart preparing Resident #1's medications at that time. Nurse #2 stated she went into the room and saw Nurse #1 standing in front of Resident #1, and she immediately knew Nurse #1 gave Resident #1 the wrong medication. Nurse #2 stated she did not hear or see Nurse #1 confirm Resident #1's name. Nurse #2 stated she immediately walked out of the room and told Nurse #1 she gave the medication to the wrong resident, and they needed to report it. Nurse #2 stated they reported the incident to the Unit Manager, who reported it to the provider and family representative. Nurse #2 stated she and Nurse#1 assessed and monitored Resident #1. Nurse #2 stated when Resident #1 became sleepy she was administered naloxone and responded to it, and Resident #1 stated she felt fine. Nurse #2 stated Resident #1 also received IV fluid as ordered and Nurse #1 monitored her throughout the shift. Nurse #2 stated she checked on Resident #1 throughout the rest of the shift, and she remained at her baseline. Nurse #2 stated she notified the oncoming nursing staff of the incident. Nurse #2 further stated when administering narcotics the 5 rights of medication administration should be followed (the right patient, the right time and frequency of administration, the right dose, the right route, the right drug). Nurse #2 stated along with the 5 rights, a resident should be verified by name and their picture in their electronic medical record (EMR).An interview was conducted with the Unit Manager on 12/17/25 at 3:03 PM. She recalled a nurse had notified her Resident #1 received the wrong medication on 11/28/25 immediately after the error had occured. She stated she notified the NP and received orders for naloxone and an IV fluid bolus, and the facility's neuro check protocol was initiated. The Unit Manager stated Resident #1 kept telling the staff she was ok. The Unit Manager further stated when administering narcotics staff should identify the correct resident, verify the order, ensure you have the correct medication and the right resident.An interview with Director of Nursing (DON) was conducted on 12/18/25 at 1:34 PM. She stated Nurse #1 and Nurse #2 were passing medications together and Nurse #1 gave Resident #1 the wrong medication. Once Nurse #1 and Nurse #2 realized the error, the Unit Manager was notified and the Unit Manager notified me (DON). The provider was notified and orders were given. Nurse #1 and Nurse #2 were placed on administrative leave pending the investigation. The DON further stated staff were expected to use the 5 rights of medication administration and administer medications per the facility's policy. This included a minimum of 2 identifiers for residents including name, date of birth , and/or the resident photograph in their EMR. The DON stated should a medication administration error occur, the Unit Supervisor, DON, Provider, and resident representative were to be notified.An interview with Pharmacy Consultant was conducted on 12/17/25 at 3:12 PM. She stated she conducted a pharmacy review on 11/28/25 but was not aware an error had occurred. The Pharmacy Consultant stated she was not notified of the medication error. She stated the oxycodone Resident #1 received was an immediate release type (a conventional dosage form designed to release the entire dose of the active drug relatively quickly after administration, typically within minutes of ingestion) and could cause significant sedation if a resident was not used to that kind of a dose. She further stated during review of Resident #1's medications, the accidental oxycodone administration would not have had any interactions with the medications Resident #1 was prescribed.In an interview with the Nurse Practitioner (NP) she stated she was called by nursing staff on 11/28/25 and was informed Resident #1 received the wrong medication (oxycodone 60 mg). She stated she ordered naloxone, an IV fluid bolus, and frequent vital signs. The NP stated the Unit Manager informed her that after receiving the naloxone and the IV fluids Resident #1 was fine.An interview with the Medical Director was conducted on 12/17/25 at 3:52 PM. He stated oxycodone at 60 mg might cause side effects however he would not be able to tell how an individual would react because reactions could be different based on the person.An interview with the Administrator was conducted on 12/18/25 at 1:54 PM. The Administrator stated it was her expectation for nursing staff to follow the 5 rights of medication administration when giving medications. Staff were expected to confirm a resident's identity by looking at their picture in their electronic medical record and asking their name and date of birth . If a resident cannot answer or the nursing staff was unfamiliar with the resident, they should always check their picture in the EMR and ask for confirmation from a familiar staff member. The Administrator indicated in the event of a medication error the DON, herself (Administrator), the Provider, and resident representative should be notified.The facility provided the following corrective action plan.1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 11/28/25 at approximately 12:30 PM during medication pass, a medication error occurred when Resident #1 was accidentally administered oxycodone 60mg that was intended for her roommate, by Nurse #1. The Director of Nursing (DON) and the Unit Manager were immediately notified, and Resident #1 was assessed by the licensed nurse. The assessment included obtaining vital signs, neurological status, respiratory status, and sedation level. During the assessment Resident #1 was alert and oriented, unlabored breathing, pulse rate normal, respirations normal, and O2 saturation normal.The Nurse Practitioner was notified of the medication error by the Unit Manager, and the following orders were obtained: naloxone HCL liquid 4 milligrams (mg)/0.1 milliliter (mL)-1 spray, alternating nostrils every 2 minutes as needed (PRN), and 1liter (L) normal saline (a mixture of sodium chloride and water) IV (within a vein) bolus (a single, large amount of intravenous (IV) fluids administered quickly to a patient). The naloxone and the 1 L of normal saline IV bolus were administered. Resident #1 was administered 1 dose of naloxone, remained alert, and her vital signs remained stable. Resident #1 was assessed by the licensed nurse and the Unit Manager following the administration of naloxone. Her vitals were stable, she was alert and oriented, no signs, symptoms or indication of being in distress.Resident #1's representative (grandson) was notified and informed of the medication error and interventions on Friday, 11/28/25 at 1:30 PM.On 11/29/25 Resident #1 continued to be evaluated every shift for signs and symptoms of any adverse reaction to the medication (erroneously) administered. She was alert and communicated to the staff at her baseline. She offered no complaints of shortness of breath or difficulty breathing and denied pain.On Monday, 12/1/25, Resident #1 was assessed by the Nurse Practitioner. It was noted that the resident was in no acute distress, lungs were clear, and she displayed appropriate mood/affect. She was clinically stable and exhibited no on-going adverse effects from the medication error.Resident #1 continued to be closely monitored for 72 hours through the neurological (neuro) check protocol (every 15 minutes (min) x 2 hours, then every 30 min x 2 hours, then every 60 min x 4 hours, then every 8 hours until at least 72 hours had elapsed). Nursing documentation was completed every shift. She continued to remain alert and oriented, and her vital signs were within normal limits throughout the monitoring period.Nurse #1 was hired on 11/25/25. She completed her on-line education on 11/28/25. Her completed education included medication administration. Nurse #1's first day of orientation on the floor was 11/28/25 with Nurse #2 assigned to orient Nurse #1. Nurse #1 was the nurse that administered Resident #1, the oxycodone 60mg that was intended to be administered to her roommate. Nurse #2 pulled the medication for Resident #1's roommate and instructed Nurse #1 to administer the medication. Nurse #2 entered the room and identified Nurse #1 standing at the bedside of the wrong patient (Resident #1) for which she administered the medication.The Nurse Practice Educator (NPE) educated both nurses and medication assistants on medication administration, adhering to the 5 rights of medication administration to include the right patient, the right medication, the right dose, the right route, the right time. On 11/28/25 the nurses and medication assistants also were educated on the safe handling of controlled substances.Staff must verify all residents using two identifiers, such as: resident's full name, date of birth , photograph in the electronic medical record (Point Click Care or PCC and medication administration record or eMAR). When able, the residents should be asked to state their full name and date of birth . Staff compare the residents' identifiers with the eMAR in PCC, the medication label, and the resident photograph. The residents' room number and bed assignment should be verified as supporting information only. A resident's room number should never be used alone as an identifier. If the resident is disoriented, non-verbal, or cognitively impaired staff verify their identity using the photo identification in PCC and confirm the resident's identity with another licensed staff member. Staff should confirm the medication label matches the resident's name, as well as confirm the medication name, the dose, the route, and the time was correct. Nurses and Medication Aides should verify the resident's name, room number, photograph in electronic medical record and MAR prior to medication administration to ensure the correct resident was administered medications as prescribed per their physician's orders. On 12/1/25, a Root Cause Analysis was completed by the Administrator and the Director of Nursing regarding the medication error. It was determined that Nurse #2 failed to follow the facility's medication administration policy, including the required 5 Rights verification (right resident, right medication, right dose, right route, right time) when she asked Nurse #1 to administer medication that she pulled from the medication cart during Nurse #1's orientation. Nurse #1 failed to verify the resident identifiers prior to administering the controlled medication. In addition, the Root Cause Analysis identified that Nurse #1 and Nurse #2 had not completed the new hire orientation process to include medication administration skills checklist and education. Upon further review of facility systems and practices, it was determined that the cause of the errors was as follows: failure to enforce medication administration policies, including the required 5 Rights and resident identification process, incomplete orientation and competency validation for licensed nursing staff prior to medication administration, inadequate supervision during orientation allowing medication administration outside approved training protocols, a breakdown in accountability and communication resulting in reliance on another nurse's preparation and identification rather than independent verification.2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.All residents have the potential to be affected by the medication administration error.Residents with a brief interview for mental status (BIMS) score of 11 or less were assessed by the DON on 12/4/25 to ensure that they did not have any signs or symptoms of having the wrong medication administered. No concerns were identified. Assessments included a neurological assessment including level of consciousness, orientation to person/place/time as able, speech clarity, and presence of confusion or behavioral changes; vital sign monitoring which included blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation; a cardiovascular assessment which included heart rate and rhythm, presence of chest discomfort, dizziness, or palpitations (feelings of having a fast-beating, fluttering or pounding heart); a respiratory assessment including respiratory effort, breath sounds, shortness of breath, or changes in oxygen needs; a gastrointestinal assessment including nausea, vomiting, abdominal discomfort, or changes in appetite; a pain assessment including new or worsening pain or discomfort; a medication-specific side effect monitoring based on each resident's current medication profile which included observation for signs of over-sedation, adverse drug reactions, or allergic responses; a review of medication administration records (MAR) for accuracy and timeliness; and staff interviews and resident observations for any reported changes from baseline. Residents were monitored for any deviation from baseline status. No adverse signs or symptoms were identified, and no further medical intervention was required. Residents with a BIMS of 12 or greater were interviewed to ensure that they were administered the correct medication by the Director of Nursing on 12/5/25. No concerns were identified. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. By 12/5/25, Licensed Nurses and Certified Medication Assistants were educated on adhering to the resident rights of medication administration by the Nurse Practice Educator, the Director of Nursing, and/or the Nurse Manager. Any nurse who was not educated will be educated prior to their next shift. All newly hired Licensed Nurses and Certified Medication Assistants will be educated during their orientation regarding the resident rights of medication administration by the Nurse Practice Educator or by a Nurse Manager. The overall responsibility for ensuring completion, compliance, and ongoing education will be overseen by the Director of Nursing (DON). The Director of Nursing, Nurse Practice Educator (NPE), and Unit Managers were formally notified of their roles and responsibilities by the Regional Consultant Nurse on 12/5/25, at which time implementation of the education plan was initiated. The Regional Consultant Nurse implemented the corrective action on 12/5/25 which included assigning education responsibilities to the NPE and Unit Managers, directing oversight responsibilities to the DON, and requiring documentation of completed education and follow-up for any staff not present.The Nurse Practice Educator conducted an audit of current licensed nurses and Certified Medication Assistants. The Nurse Practice Educator reviewed their personnel files for completed education and skill competencies checklist; this was completed by 12/4/25. Any identified concerns were addressed. The Nurse Practice Educator educated both nurses on medication administration, adhering to the 5 rights of medication administration and safe handling of controlled substances on 11/28/25.On 12/5/25 The Resource Operator educated the scheduler on the new hire orientation onboarding process to include validating completion of mandatory training prior to new staff being assigned on the schedule. On 12/5/25 The Regional Nurse Consultant educated the Director of Nursing and Nurse Practice Educator regarding ensuring licensed nurses and medication aides completed education and the skills competency checklist on medication administration prior to being scheduled on the floor. The Nurse Practice Educator and/or the Director of Nursing will conduct an audit of licensed nurses and medication aides' personnel files to ensure 5 rights of medication administration education and medication administration skill competencies have been completed upon hire. The Nursing Home Administrator (NHA) will conduct biweekly audits of new hire files to ensure education/competencies are completed for 12 weeks. 4. How will the facility monitor its corrective actions to ensure the deficient practice will not recur?Auditing was initiated on 12/5/25 to evaluate compliance with the facility's medication administration policy, including adherence to the 5 Rights of medication administration and resident identification procedures. The DON and Nurse Managers will complete random audits of medication administration passes as follows: no less than 2 patients per medication cart every shift for 7 days a week for 2 weeks; no less than 2 patients per medication cart every shift for 5 days a week for 2 weeks; no less than 2 patients per medication cart every shift for 3 days a week for 2 weeks; no less than 2 patients per medication cart every shift for 2 days a week for 6 weeks.The results of the quality monitoring will be reported by the Director of Nursing or Nurse Managers to the Quality Assurance Performance Improvement Committee Meeting monthly for 3 months. Quality Monitoring schedules may be modified based on quality monitoring findings. The Quality Assurance Performance Improvement Committee members consist of, but not limited to, the Executive Director, Director of Clinical Services, Nursing Supervisor, Medical Director, Social Services Director, Activities Director, Maintenance Director, Minimum Data Assessment Nurse, and at least one direct care staff. The facility will audit to ensure compliance with the deficient practice through audits and education. Date of Compliance 12/8/25.The facility's corrective action plan was validated by the following:On 12/18/25 the facility's plan of correction was validated upon review of the sign-in sheets for in-service education provided to all licensed nurses and medication aides on the 5 rights of medication administration per medication policy and procedures. Review of the monitoring audits revealed they were completed as stated in the corrective action plan with no concerns identified. Interviews conducted with licensed nurses and medication aides revealed they had received education on medication administration. Medication Administration was observed as part of the complaint investigation survey and no errors were noted. The compliance date of 12/8/25 for the corrective action plan was validated.

Based on record review and staff interviews, the facility did not maintain accurate records related to documentation of medication administration for 1 of 7 residents reviewed for accurate medical records (Resident #2). The findings included:Resident #2 was admitted to the facility on [DATE] with diagnoses which included chronic pain syndrome and fibromyalgia (a chronic condition causing widespread body pain, fatigue, sleep problems, and cognitive difficulties).A review of Resident #2's physician orders revealed an order dated 12/12/25 for oxycodone-acetaminophen 5-325 milligrams (mg) give one (1) tablet by mouth every 6 hours as needed for pain.Resident #2's individual narcotic record sheet for oxycodone-acetaminophen 5-325 mg was reviewed. The narcotic record revealed Resident #2 received one (1) oxycodone-acetaminophen 5-325 mg tablet on 12/12/25 at 4:30 PM and at 10:00 PM.A review of Resident #2's December 2025 Medication Administration Record (MAR) indicated oxycodone-acetaminophen 5-325 mg was not documented as administered on 12/12/25 at 4:30 PM or at 10:00 PM.During a phone interview with Nurse #3 on 12/18/25 at 11:03 AM she confirmed she signed Resident #2's individual narcotic record sheet for oxycodone-acetaminophen 5-325 mg on 12/12/25 at 4:30 PM. Nurse #3 stated she thought she had signed the oxycodone-acetaminophen 5-325 mg tablet off in Resident #2's MAR, and if her initials were not there it was an error on her part. She stated when administering narcotics to any resident she would typically hit (highlight) the medication on the MAR as soon as she pulled the narcotic from the locked box, sign the medication out in the narcotic count book, administer the medication to the resident, and return to the MAR and sign the MAR record.Attempts to reach Nurse #4 who signed Resident #2's individual narcotic record sheet for oxycodone-acetaminophen 5-325 mg on 12/12/25 at 10:00 PM were unsuccessful. Nurse #4 was no longer employed at the facility.An interview was conducted with the Director of Nursing (DON) on 12/18/25 at 1:34 PM. She stated medications were supposed to be documented on both the MAR and narcotic sheet when they were administered to a resident.During an interview with the Administrator on 12/18/25 at 1:54 PM she stated narcotics should be documented on both the narcotic sheet and the MAR.

Based on observations, record review, and resident, staff, Nurse Practitioner, (NP) Psychiatric NP and Medical Director interviews, the facility failed to assess a resident for self-administration of her enteral feedings (a method of delivering nutrition directly into the gastrointestinal tract, typically through a feeding tube, for individuals who cannot consume food orally) and to put effective interventions in place after Resident #13 was repeatedly observed by staff putting unidentified liquids in her gastronomy tube (g-tube [provides nutrition via a liquid formula delivered through a flexible tube that is surgically placed through the abdomen into the stomach]); rummaging through the trash for food /liquids; chewing and spitting out food items into the trash can; obtaining food as a prize for bingo; and disconnecting herself from her g-tube pump and removing the tube feeding formula bag during continuous feedings. Resident #13 had a diagnosis of vascular dementia and had an order for NPO (nothing by mouth) status due to dysphagia (difficulty swallowing). She was determined to have impaired insight and judgement by the Psychiatric NP. On 9/15/25 Resident #13 was observed by the surveyor administering to herself via bolus (administration of a limited volume of formula through a feeding tube over brief periods of time) the contents of a bottle labeled Jevity (tube feeding formula) dated 9/12/25 that contained a light tan milk-like liquid. The Medical Director indicated Resident #13 self-administering her tube feedings put Resident #13 at risk of serious injury/harm from aspiration (accidental inhalation of foreign substances, such as food, liquid, or air, into the lung which can lead to aspiration pneumonia), overfeeding, and infection. The deficient practice occurred for 1 of 1 resident reviewed for tube feeding Resident #13).Immediate Jeopardy began on 9/15/25 when Resident #13 was observed self-administering via her g-tube the contents of a bottle labeled Jevity dated 9/12/25 that contained a light tan milk-like liquid. Immediate Jeopardy was removed on 9/20/25 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective.The findings included:A hospital Discharge summary dated [DATE] stated Resident #13 had a g-tube placement in 2015 secondary to a stroke. The discharge summary stated Resident #13 was admitted on [DATE] due to a swelling in her left hand and upper left extremity. She was diagnosed with left internal jugular vein thrombosis (a medical condition where a blood clot forms in a blood vessel and stops blood flow) and pneumonia. Her g-tube dislodged on 3/6/25 and she was treated for hypoglycemia (a condition where the blood sugar drops below normal) which was resolved after initiation of tube feeds. She was discharged to the facility on 3/8/25.Resident #13 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and gastrostomy (opening of the stomach) for enteral feedings, malnutrition and vascular dementia. Review of Resident #13's face sheet indicated Resident #13 was her own responsible party.A physician's order dated 3/8/25 read Jevity 1.5 Cal administer continuously via pump at 60 milliliters (ml) per hour 24 hours per day or until total nutrient delivered.The manufacturer's instructions for Jevity indicated careful handling was required to prevent potential for microbial contamination. Microbial contamination can lead to serious harm and/or death. All medical foods, regardless of type of administration system, require careful handling because they can support microbial growth.A physician's order dated 3/9/25 read NPO.Resident #13's care plan had a focus of tube feeding dated 3/12/25 which stated, Resident had an enteral feeding tube to meet nutritional needs r/t (related to) an inability to consume sufficient calories and/or nutrients by mouth safely due to NPO status, Gastrostomy, Vascular Dementia, CVA, Hemiplegia Affecting Left Nondominant Side, Dysphagia, Cachexia, Severe Protein-Calorie Malnutrition. Interventions included flush tube with 15 milliliters of water before and after each medication pass, flush tube with 15 milliliters of water with each medication, flush tube with 15 milliliters of water between each medication, check placement of tube daily and before administering feedings and medications, check for clogs in tube daily and before administering feedings and medications, check for gastric residual volume prior to feeding or medication administration, and monitor labs.A physician's order dated 3/14/25 specified to flush tube with 50 ml of water every 4 hours during continuous tube feeding.A Nurse Practitioner (NP) progress note dated 4/4/25 stated it had been reported by nursing that Resident #13 has been taking herself off tube feeding and had a blood sugar of 44 on 4/3/25 due to it not running. She was also observed by the NP taking gauze, tape and supplies off a nursing cart. When asked to return the supplies she did so. Resident was further noted to have a cup of water which she stated was to flush her feeding tube. She did not have a syringe. Resident received education that she cannot swallow properly and so she needs to be more careful and not to attempt to eat or drink.A NP progress note dated 4/7/25 stated Resident #13 had lost weight since admission since she had been disconnecting her tube feeding at times. The note further stated Resident #13's blood sugars were less than 100 when not running her tube feeding continuously. There was no mention of educating the resident within the note. A nursing progress note written by Nurse #9 dated 4/10/25 stated Resident #13 repeatedly stopping tube feeding, turning off pump, disconnecting tube, clamping off tube frequently throughout shift. She was trying to be off continuous feed more than she is allowing it to infuse throughout the course of the shift. Resident #13 was also getting up in wheelchair and going into other residents' rooms. She also was digging through the trash can in the day room more than once. She asked to keep partially used feeding bottles and flush bag when replaced daily. It was explained that once it had been accessed for 24 hours bacterial growth begins. It was further explained that only unpunctured bottles are shelf stable. Resident #13 continued to be found getting the bottles out of the trash and trying to store them in her closet.Nurse #9 was not interviewed.A physician's order dated 4/11/25 read Jevity 1.5 Cal. Administer continuous via pump 65 ml per hour 24 hours per day. A progress note written by Nurse #10 dated 4/14/25 revealed Resident #13 continued to pause her continuous feeding. The nurse spoke to Resident #13 about stopping her feeding without informing the nurse. The note also stated Resident #13 had to go to a local emergency department to have her g-tube replaced due to giving herself a bath. When her glucose was checked her range was 58/34. Resident #13 was given sugar water, med pass with sugar and a glucose injection in her right arm. Blood glucose was rechecked and her level increased to 101. The note additionally stated when resident is not on her feeding her glucose level decreases and education was provided.Nurse #10 was not interviewed.A speech therapist note dated 4/22/25 indicated speech therapy services were not indicated at this time. There were no other speech therapy assessments completed.A progress note dated 5/8/25 written by the NP revealed Resident #13 had been hoarding anything she could find in the facility and had developed a large pile of things by her bed. She stated they were her things and did not want them touched. The note further revealed the NP placed an order for a psychiatric consult due to paranoia, hoarding and anxiety. A nursing progress note written by Nurse #11 dated 5/21/25 read that Resident #13 had turned off her tube feeding and unhooked her g-tube to go out of her room for short periods of time. Resident #13 was educated that she is on continuous feedings at this time and is at risk for weight loss. An initial psychiatric evaluation by the Psychiatric NP dated 5/22/25 revealed Resident #13 was diagnosed with hoarding disorder and other specified anxiety disorders. She was referred due to paranoia and signs of hoarding and anxiety. During this evaluation, Resident #13 was noted to have multiple snacks in her wheelchair. She also was noted to have excessive oral secretions and had a cup in her wheelchair to spit in. Resident #13 was noted to exhibit extreme hoarding tendencies, often collecting medical items and belongings from others in her room. She had no explanation for doing this. Resident #13 was assessed as having limited insight and poor judgement. Her cognition was intact. Resident #13 was ordered fluoxetine (antidepressant that treats depression, anxiety and other disorders) 20 mg (milligrams) each morning for anxiety and hoarding. Follow-up included psychiatric follow-up for management of anxiety, hoarding and adjustment on a regular basis.A physician's order dated 5/23/25 read every day and night shift until 5/25/25 administer continuous Jevity 1.5 Cal via pump at 70 ml per hour. Increase by 20 ml per hour every four hours, until goal rate of 130 ml per hour. On at 8:00 PM and off at 8:00 AM. A physician's order dated 5/24/25 instructed staff to flush tube with 120 milliliters of water before each feeding and flush tube with 120 milliliters of water after each feeding.A medical provider order was written on 5/24/25 for fluoxetine 20 milligrams (mg) via g-tube once a day for anxiety and hoarding behaviors.A physician's order dated 5/25/25 specified Jevity 1.5 Cal administer every day and night shift via pump at 130 ml per hour 12 hours per day. On at 8:00 PM and off at 8:00 AM. Review of Resident #13's medical record revealed no assessments or physician orders for self-administration of her tube feedings. A follow-up psychiatric evaluation by the Psychiatric NP dated 6/5/25 revealed Resident #13 exhibited fair insight and judgement during this session.Resident #13's care plan dated 7/2/25 reflected behaviors such as retrieving items out of trash cans to include food items; self-administering water, soda, and enteral feeding in her g-tube; and putting food items in her mouth, chewing them up, and spitting them out. Interventions included: educate and remind resident that according to her physician's orders she is NPO status and cannot eat or drink by mouth and she can only receive 100% nutrition/medications/water via G-tube via nurses and notify physician/family as indicated. Another focus of the care plan dated 7/2/25 was physical behaviors related to poor impulse control as well as going into other patients' rooms and taking items. Interventions included: remind resident she cannot go in other rooms and take things, psych (psychiatric) consult as needed, seek staff support, and Social Service visits. An additional focus of the care plan dated 7/18/25 stated Resident #13 had a decline in cognitive function or impaired thought processes related to dementia. Interventions included: observe for changes in cognitive status, allow resident to make choices about care and explain all interventions. Resident #13's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed she was assessed as having moderate cognitive impairment with no behaviors. Her assessment reflected the use of a feeding tube for 51% or more of her total calories. The assessment reflected Resident #13 needed extensive assistance from one person-assist for eating. Resident #13 utilized a wheelchair for mobility.A follow-up psychiatric evaluation by the Psychiatric NP dated 7/22/25 revealed reports that Resident #13 continued to take items that do not belong to her and store them in her room along with her own belongings that she has piled in her room. Resident #13 was assessed as having limited insight and poor judgement.A progress note dated 7/29/25 written by the NP revealed she was informed by nursing staff Resident #13 continued to roll around the unit taking things and placing them in her room. A physician's order dated 8/9/25 specified Jevity 1.5 Cal to be administered at 120 ml per hour, 12 hours per day. On at 8:00 PM and off at 8:00 AM.A follow-up psychiatric evaluation by the Psychiatric NP dated 8/19/25 revealed Resident #13 continued to take items that did not belong to her and couldn't explain why. Cognitive behavioral strategies were attempted but she was not cognitively able to participate. Evaluation further read, although she is fairly alert and oriented on basic cognition, screening, her insight and judgement are so impaired that I do not feel that psychotherapy is 'sticking' from visit to visit.During an interview with the Psychiatric Nurse Practitioner on 9/17/25 at 10:07 AM she reported Resident #13 had no insight or judgement about her behaviors and how they may be harmful. She reported when Resident #13 was questioned about going through the trash she stated she was looking for something to use to make crafts for her grandchildren.A nursing progress note written by Unit Manager #1 dated 9/3/35 stated Resident #13 was found outside engaged in self-feeding with a syringe via g-tube utilizing several bottles of sports drink and juice to flush the tube. Resident #13 was educated about physician orders, the feeding process and safety measures. A review of Resident #13's September 2025 MAR recorded a Jevity 1.5 enteral feeding was started at 8:00 PM on 9/12/2025 by Nurse #6. There was no allotted time and/or space on the MAR to document when the second bottle of Jevity 1.5 enteral feeding bottle was started for Resident #13. Therefore, there was no documentation on the MAR when Nurse #6 started a second bottle of Jevity 1.5 enteral feeding for Resident #13 on 9/12/2025.A phone interview was conducted with Nurse #7 on 9/16/25 at 10:03 AM who stated Resident #13's tube feeding stayed on the pole of the tube feeding pump after it was turned off in the morning on 9/13/2025. She stated either Resident #13 unhooked herself or the night shift nurse did this. Nurse #7 stated on 9/13/25 at 7:00 AM when she assumed care Resident #13 was unhooked from the feeding pump and dressed. She reported she had caught Resident #13 with water in a sports drink bottle approximately one month ago. She stated Resident #13 used the water to flush her tube. Nurse #7 stated she stopped Resident #13 from flushing her tube and disposed of the sports drink bottle. She indicated this occurred only once and she provided education to the resident. During an observation on 9/14/25 at 9:30 AM as the survey team was entering the facility, Resident #13 was observed in a wheelchair to the left of the facility's front entrance on the concrete sidewalk. She was observed holding her gastrostomy tube (g-tube) with her left hand and holding a milk-like substance in a clear bottle in her right hand. Resident #13 was observed on 9/15/25 at 7:10 AM self-propelling herself via wheelchair into the room leading outside into the smoking area. A black bag was observed on the back of the wheelchair with two bottles of clear liquid and a bottle with a milk-like substance with no labels on the bottles observed.A continuous observation occurred on 9/15/25 from 7:20 AM until 7:30 AM of Resident #13 in a wheelchair in the living room that had the door that led out to the smoking area. She was positioned between a drink machine and a table with three clear plastic bottles on the table. Two of the bottles were small, unlabeled and filled with a clear liquid and one labeled (could not read the label) medium sized bottle that contained a light tan milk-like liquid. Resident #13 was observed connecting a syringe (60 milliliters) to the g-tube opening and turning the lock on the g-tube. She held her g-tube in her left hand and reached for one of the bottles with clear liquid with her right hand and filled the syringe with the clear liquid substance. Resident #13 then filled the syringe full of the light tan milk-like liquid while holding the g-tube upright and allowed the liquid to infuse by gravity. She followed with another syringe full of light tan milk-like liquid and used the piston of the syringe to push the remainder of the liquid into the g-tube. Resident #13 then filled the syringe with the clear liquid from one of the clear unlabeled plastic bottles to infuse via gravity. She continued and filled the syringe with the light tan colored milk-like liquid to infuse via gravity into the g-tube followed by a second syringe full of light tan milk-like liquid. She was observed using the piston to push the last syringe of the milky liquid into the g-tube. Resident #13 then filled the syringe full of clear liquid to flow via gravity into the g-tube. She then pushed the lock of the g-tube and placed the bottles that had the clear liquid into the black bag on the back of her wheelchair. She returned the syringe and piston into a plastic bag. The syringe and piston was observed in a plastic bag that was not labeled with the date and placed it in the black bag on the back of her wheelchair. The medium sized bottle was observed on the table and was labeled Jevity 1.5 with a label dated 9/12/25 0500 (5:00 AM) 130 ml/hr and there was approximately 100 milliliters left in the bottle. There was no expiration date observed on the bottle of Jevity 1.5. Resident #13 stated it was her bottle, and it came from her house. While the surveyor was addressing Resident #13 about the bottle of milky liquid Unit Manager #3 walked in and asked if there was a problem. Unit Manager #3 was shown the label of the bottle and informed the surveyor was attempting to identify the liquid Resident #13 was observed inserting in her g-tube and the surveyor returned the bottle to the table.In an interview with Unit Manager #3 on 9/15/2025 at 8:07 pm, she stated she had started at the facility a couple weeks ago and Resident #13 was a resident that did her own thing at the facility self-propelling through the hallways. She stated she had never seen Resident #13 self-administer an enteral feeding through the g-tube and on the morning of 9/15/25 she only recalled seeing Resident #13 with the Jevity bottle and the milk-like liquid in the Jevity bottle on the table in the living room.An interview was conducted with Resident #13 on 9/16/25 at 11:00 AM. She reported she did not get her tube feeding on 9/14/25 because it was never hooked up. She reported she was hungry and that was the reason she was observed giving herself a tube feeding the previous morning (9/15/25). Resident #13 stated she gave herself 3 tube feedings daily and sometimes she received tube feeding continuously at night. She further stated she disconnected her tube feeding to go to smoke and to use the bathroom at night. She reported the tube feeding solution she was using on 9/15/25 came from her home. Resident #13 indicated she would dig in the trash cans in order to use the items she found to make crafts for her grandchildren. She was not aware of the amount of formula she was ordered and could not articulate dangers of administering more tube feeding than ordered. A telephone interview was conducted with Nurse #6 on 9/15/25 at 6:55 PM who reported she was familiar with Resident #13. She stated Resident #13 had turned her tube feeding off when not asleep. Nurse #6 stated Resident #13 often does what she wants to do. She reported that she hung a bottle of tube feeding solution at 5:00 AM on 9/12/25. Nurse #6 stated Resident #13 must have taken the bottle down from the pole for the bottle dated 9/12/25 to be in Resident #13's possession. She further stated staff had discussed among themselves to not leave trash in Resident #13's room. Nurse #6 stated some nights Resident #13 had been caught self-administering her tube feeding and she would redirect her. She further stated Resident #13 would steal tube feeding solution from the top of the medication carts. Nurse #6 stated she had witnessed Resident #13 taking another resident's tube feeding off the medication cart and retrieved it from Resident #13. She stated she had not witnessed Resident #13 going through trash cans. Nurse #6 indicated Resident #13 kept empty bottles in her room and filled the empty bottles with water from the bathroom sink. She stated she had never seen Resident #1 get bottles out of the trash, but suspected Resident #13 was going through the trash to obtain them. Nurse #6 reported she would stop Resident #13 from filling the empty bottles with water. On 9/15/25 at 8:45 am a 1000 milliliter bottle of Jevity 1.5 with 1000 milliliters observed hanging on the pump for continuous feedings in Resident #13's room. A syringe packet was observed which was dated 9/15/25, the Jevity 1.5 bottle was labeled 9/14/25 2000 (8:00 PM) and a water bag was dated 9/13/25 0500 (5:00 AM). The tip of the tubing connected to the tube feeding formula and water was observed hanging downward from the pump with no end cover. When the tube feeding pump was turned on the settings were observed cleared. There was no flush or tube feeding infusion rate set on the pump. Resident #13 was not present in the room at the time of the observation.Review of Resident #13's September 2025 Medication Administration Record (MAR) revealed the 9/14/25 feeding was signed off at 8:00 PM by Nurse #1. The order specified for Jevity 1.5 Cal to be administered every day and night shift continuous via pump at 130 milliliters per hour. 12 hours per day (On at 8:00 PM and off at 8:00 AM). A telephone interview was conducted with Nurse #1 on 9/15/25 at 6:36 PM who stated 9/14/25 was her first time working with Resident #13. She reported that she worked from 7:00 PM to 7:00 AM on 9/14/25. She stated she was told in report by Nurse #7 that Resident #13 administered her own tube feeding. When Nurse #1 was asked if Resident #13 self-administered enteral feedings through the g-tube, Nurse #1 stated she was unaware if Resident #13 had an order for self-administration for tube feeding. Nurse #1 stated she was told Resident #13 gets up out of bed and disconnects the tube feeding. She stated she was also told that Resident #13 turned the pump on and off when she got up and at night. Nurse #1 stated Resident #13 was already hooked up to her tube feeding when she entered the room on 9/14/25 at 8:00 PM. Nurse #1 could not explain why there was still 1000 ml in the tube feeding formula bottle on 9/15/25 at 8:45 am. An interview was conducted with Unit Manager #1 on 9/15/25 at 3:03 PM who stated she had removed the Jevity and water bottle from Resident #13's room that morning. She reported the Jevity bottle was dated 9/14/25 at 8:00 PM and the water flush was labeled 9/13/25. Unit Manager #1 stated she removed the items because she observed there was no cover on the tip of the tubing that was inserted into the g-tube. Unit Manager #1 stated she could not recall how much tube feeding formula was in the Jevity bottle when she removed the bottle from the pole on 9/15/2025. An interview and observation were conducted with Resident #13 on 9/15/25 at 8:53 AM who stated sometimes she administered her tube feeding and sometimes the facility did it. She further stated she administered her tube feedings when she lived at home. Resident #13 indicated it was not a continuous feeding. Resident #13 stated she was not able to swallow and spit her saliva into a cup. She was observed with a cup to spit her saliva in during the interview and observation.During an observation on 9/15/25 at 4:30 PM Resident #13 was observed leaning into the trash can at the front entrance of the facility. Unit Manager #2 was observed outside at this time. Resident #13 was not observed taking anything out of the trash can. An interview was conducted with Unit Manager #2 on 9/16/25 at 12:00 PM who stated she was outside on 9/15/25 but did not see Resident #13 take anything out of the trash can. She reported she did not see Resident #13 at the trash can. During an observation of Nurse #4 hanging Resident #13's the tube feeding on 9/15/25 at 8:20 PM, an empty Jevity 1.5 bottle enteral feeding bottle labeled 9/15/2025 2000 (8:00pm) at 50 ml/hr was observed in the trash can, a 12-ounce unopened soda can was observed on the floor and a small 8-ounce apple juice bottle that was 1/2 full of a cloudy yellow substance was observed on the bedside table. Resident #13 stated the drinks were not hers. Nurse #4 started the tube feeding after the tube feeding solution was hung. At the end of the observation Nurse #4 left the room without emptying the trash which contained an empty Jevity 1.5 bottle or remove the bottle of apple juice and the can of soda.During an interview with Nurse #4 at 9/15/25 at 8:45 pm, she stated she was unaware of Resident #13's behavior of rummaging through the trash; however, she stated she was aware of Resident #13's behaviors concerning turning her enteral feeding pump on and off throughout the night. Nurse #4 reported she turns the pump back on when she hears the pump beeping which means it is not running. During an interview with the Activities Director on 9/15/25 at 8:15 PM she reported she was advised by the Speech Therapist last week that Resident #13 could not swallow. She stated the Speech Therapist asked her to consider other prizes other than food for bingo. The Activities Director stated she was not aware that Resident #13 could not have any nutrition or fluids by mouth. She reported this information was never reported to her. The Activities Director stated Resident #13 had received food prizes for winning bingo beginning 7/15/25. She stated the prizes consisted of oatmeal cakes, toaster pastries, and peanut-butter and cheese crackers. The Activities Director stated she had never seen the resident consume any food or fluids. A telephone interview was conducted with Speech Therapist on 9/17/25 at 11:20 AM. She reported Resident #13 was unable to swallow. Speech Therapist #1 stated she spoke with the Activities Director the previous week about considering other prizes other than food for bingo. Resident #13 liked to go to bingo and should not be given food prizes. The Speech Therapist stated there is a risk of choking if Resident #13 attempted to eat food and there was a risk of aspiration as she was not able to swallow. The Speech Therapist stated she was not working with Resident #13 and Resident #13 had never been on her caseload because the resident was not able to swallow. She reported Resident #13 had come to her on several occasions and asked to be evaluated to eat again. She reported that she had told Resident #13 when she was able to swallow her saliva they could work on an evaluation to eat again. The Speech Therapist further stated she had given Resident #13 ice chips when Resident #13 would come to her and discuss receiving nutrition by mouth and Resident #13 would have to spit them out because she could not swallow. She stated she had been made aware by staff that Resident #13 had food in her room but didn't take any action. She reported she felt the food couldn't be removed because it was the resident's property. The Speech Therapist stated she did not document when she gave Resident #13 ice chips.A telephone interview was conducted with Registered Dietician (RD) #1 on 9/17/25 at 11:44 PM who stated speech therapy was working with Resident #13 on her ability to eat so she had not addressed changing her feedings. She stated she reviews resident charts from home and does not work within the facility. The ST stated the resident had never been on caseload. She reported she was unaware of any concerns related to Resident #13 eating, self-administration of tube feeding or going through trash cans. She stated she could not address concerns related to swallowing but there was potential for infection due to cross contamination from self-administration of tube feeding and using items from the trash in her tube feeding. A phone interview was conducted with Registered Dietician #2 on 9/17/25 at 12:03 PM. She stated she was not aware that Resident #13 had disconnected her tube feedings and a concern with Resident #13 disconnecting her tube feedings was not knowing how much tube feeding solution she was receiving. Registered Dietician #2 further stated it would be important to monitor Resident #13's blood sugar to ensure it does not drop. Registered Dietician #2 stated another concern would be fluid overload. She stated she was unsure if she had ever met Resident #13 because she is only in the facility one or two days a week. She reported Register Dietician #1 was responsible for reviewing charts and she (RD #2) attends care plan meetings and meets with new admissions.During an interview with the DON on 9/15/25 at 8:37 PM, she was informed Nurse #4 was observed exiting Resident #13's room and leaving an empty tube feeding bottle in the trash can, a half of a bottle of cloudy apple juice and a canned drink in Resident #13's room. The DON stated Resident #13 was care planned for retrieving items from the trash and reported Nurse #4 was an agency nurse and was not aware to remove the bottles and trash from Resident #13's room. DON stated she would educate Nurse #4 on Resident #13's care plan for behaviors. The DON stated staff, including agency staff, were educated on Resident #13's behaviors including rummaging through trash but could not provide specifics and did not provide documentation. During an interview with the Director of Nursing (DON) on 9/15/25 at 4:48 PM she reported Resident #13 could not swallow liquids or food. She reported she was aware that the resident would go through the trash, ask other residents for drinks and would disconnect her tube feeding at times. The DON was also aware Resident #13 would chew food items and spit them out. She reported the resident had been educated about the dangers of these behaviors by the staff members when they made the observation. The DON indicated that the resident had not been assessed for self-administration of her tube feeding. The DON stated she was not aware the Activities Director was giving food for bingo prizes to Resident #13. The DON acknowledged the dangers of all these behaviors and stated staff members would redirect Resident #13 when they observed the behaviors. An interview was conducted with the facility Nurse Practitioner (NP) on 9/17/25 at 12:25 PM. She reported it was dangerous for Resident #13 to self-administer her tube feedings. She stated Resident #13 had low blood sugars in the past from not receiving her tube feedings because she disconnected herself from the pump. NP further stated she was aware of Resident #13 self-administering her tube feeding and putting sports drink in her g-tube. She further stated she had seen Resident #13 in the trash and had witnessed her steal items such as gauze, gloves and briefs from the nurse's cart and she convinced Resident #13 to return the items. The NP stated the Registered Dietician needs to be aware of a deviation in the amount of tube feeding solution Resident #13 received in order to adjust tube feeding to ensure Resident #13 receives an adequate number of calories. She stated she was not aware the Registered Dietitian had not been informed about Resident #13 disconnecting her tube feedings and she had not discussed this with the physician. The NP stated that Resident #13 was going to do what she was going to do and that she did not have time to call the physician every time Resident #13 had behaviors. She stated she had talked with Resident #13 about the dangers of not getting her full amount of tube feeding but Resident #13 voiced compliance but then would continue the behaviors.During an interview with the Medical Director on 9/18/25 at 11:10 AM he stated Resident #13 self-administering her tube feedings put Resident #13 at risk of serious injury/harm from aspiration, overfeeding, and infection. He stated he was not made aware of this behavior or the behaviors such as digging in the trash and chewing/spitting out food. and had he been made aware he would have recommended 100% supervision during Resident #13's tube feedings.The Administrator was notified of Immediate[TRUNCATE

Based on record reviews and interviews with staff and the facility Consultant Pharmacist, the facility failed to provide ongoing Abnormal Involuntary Movement assessments to assess for potential adverse medication reactions for 2 of 3 residents (Residents #75 and #1) reviewed for receiving antipsychotic medications. The findings included: 1. Resident #75 admitted to the facility on [DATE] with diagnoses including depression with psychosis.Resident #75's physician's order dated 10/25/2024 documented a revision of Quetiapine Fumarate (an antipsychotic) to 300 milligrams (MG) at bedtime. The admission Minimum Data Assessment (MDS) dated [DATE] indicated Resident #75 had cognitive impairment with no display of behaviors coded. The MDS was coded for Resident #75 receiving antipsychotic medications on a routine basis. Resident #75's care plan reviewed 9/16/2025 indicated a risk for complications related to the use of psychotropic and psychotic medications. Interventions included AIMS testing per protocol. Resident #75's medical record documented one Abnormal Involuntary Movement Scale (AIMS) assessment on file dated 8/23/24. There were no other abnormal movement assessments found in the medical record. In an interview on 9/19/25 at 1:31 PM, the Director of Nurses (DON) stated the facility used the AIMS assessment for residents on antipsychotics and no other assessments. She stated there were no other AIMS assessments completed for Resident #75 other than the one on 8/23/24. In a phone interview 9/19/2025 4:02 PM, the Pharmacy Consultant explained the AIMS assessments was to be conducted by nursing staff every six months after the initial AIMS assessment for residents receiving antipsychotics. The pharmacy consultant could not recall if she had discussed Resident #1's AIMS assessment with the Director of Nursing.In an interview 9/19/2025 at 5:07 PM, the Director of Nursing (DON) stated she started at the facility in February 2025. She stated the nursing staff were to conduct the AIMS assessments every 6 months unless there was a change in the resident and the electronic medical record would trigger when an AIMS assessment was due if the notification of AIMS assessment was activated. She stated Resident #1's and Resident #75's EMR may not have been activated to identify an AIMS assessment was due for the residents. 2. Resident #1 was admitted to the facility on [DATE] with diagnoses including a bipolar disorder.The quarterly Minimum Data Assessment (MDS) dated [DATE] indicated Resident #1 was cognitive intact with no display of behaviors coded. The MDS was coded for Resident #1 receiving antipsychotic medications on a routine basis and gradual dose reduction was recorded clinical contraindicated as of 8/12/2025. Resident #1's care plan reviewed 9/14/2025 indicated a risk for complications related to the use of psychotropic and psychotic medications. Interventions included AIMS testing per protocol.Physician orders dated 8/26/2024 included Quetiapine Fumarate 100 milligrams three tablets three times a day for bipolar depression. An Abnormal Involuntary Movement Scale (AIMS) assessment dated [DATE] in Resident #1's electronic medical record (EMR) reported Resident #1 was not experiencing involuntary movements, an adverse side effect to antipsychotic medications. There was no documentation of an AIMS assessment since 12/8/2024 for Resident #1 in the EMR. In an interview on 9/19/2025 at 3:00 PM, Unit Manager #2 stated she didn't know why an AIMS assessment had not been completed on Resident #1 and stated she was not aware Resident #1 needed an AIMS assessment. In a phone interview 9/19/2025 4:02 PM, the Pharmacy Consultant explained the AIMS assessments were to be conducted by nursing staff every six months after the initial AIMS assessment for residents receiving antipsychotics. The pharmacy consultant could not recall if she had discussed Resident #1's AIMS assessment with the Director of Nursing.In an interview 9/19/2025 at 5:07 PM, the Director of Nursing (DON) stated she started at the facility in February 2025. She stated the nursing staff were to conduct the AIMS assessments every 6 months unless there was a change in the resident and the electronic medical record would trigger when an AIMS assessment was due if the notification of AIMS assessment was activated. She stated Resident #1's and Resident #75's EMR may not have been activated to identify an AIMS assessment was due for the residents. In an interview 9/19/2025 at 7:00 PM, the Administrator stated the Director of Nursing was responsible for ensuring AIMS assessments were completed as recommended.

Based on record review, observations and staff interviews, the facility failed to secure medications in an unlocked medication cart for 1 of 4 medications carts (medication cart #1) and to discard an unlabeled open vial of insulin from a refrigerator in a medication room (Nursing Station #2 medication room) and secure the locked refrigerated controlled medication black box to a permanent structure in 2 of the 3 medication rooms (Nursing Station #1 medication room and Nursing Station #3 medication room) reviewed for medication storage. Findings include: 1. On 8/14/25 at 10:55 AM, a continuous observation began of an unlocked medication cart #1 located at Nursing Station #3. There was no nursing staff observed at medication cart #1 or at Nursing Station #3 and the lock on medication cart #1 was observed extending outward. Resident #80 was observed walking past the unlocked medication cart #1 and Resident #73 self-propelling his wheelchair past the unlocked medication cart #1. At 10:57 AM, Resident #60 was observed walking past the unlocked medication cart #1. At 11:00 AM, Resident #69 was observed self-propelling his wheelchair past the unlocked medication cart #1. At 11:03 AM, Nurse Aide #6 was observed walking past the unlocked medication cart #1 and Nurse #3 was observed exiting room [ROOM NUMBER] located across from Nursing Station #3 and walking past the unlocked medication cart #1 to enter the dirty utility room. At 11:04, Nurse #3 was observed addressing Resident #80 who was observed standing in front of the unlocked medicating cart #1 and assisting Resident #80 back to his room down the hall with medication cart #1 remaining unlocked. The continuous observation stopped at 11:06 AM when Nurse #3 returned to the unlocked medication cart #1.On 9/14/2025 at 11:06 AM in an observation and interview with Nurse #3, the locked-on medication cart #1 was observed extending outward. With the lock on medication cart #1 extending outward, the top drawer on the left side of medication cart #1 was opened and observed filled with multiple bottles of over-the-counter medications. Additionally, all four of the drawers on the right side of medication cart #1 were able to be opened and respiratory inhalers, ear and eye medications, a locked narcotic box, diabetic supplies and blood pressure cuffs were observed in the drawers. The three remaining drawers on the left side of medication cart #1 that contained residents' medications from the pharmacy would not open. Nurse #3 explained the lock on medication cart #1 was only halfway extended outward and the lock to medication cart #1 had to be extended completing out for the drawers with residents' medications to open. Nurse #3 stated to lock all drawers on medication cart #1 the lock had to be pushed in completely and stated medication cart #1 was not locked. Nurse #3 was observed using her hand to pull on the halfway extended outward lock to extend the lock outward completely that allowed the drawers with residents' medications to open. Nurse #3 stated that anyone including residents could have extended the lock on medication cart #1 to access residents' medications and also had access to other medications stored on the medication cart. She stated all drawers on medication cart #1 were to be locked when the nurse was not at medication cart #1 and explained when she went to help resident in room [ROOM NUMBER], she only pushed the lock halfway. Nurse #3 also stated medication cart #1 was not completely locked to allow nurse aides access to blood pressure supplies on medication cart #1.In an interview on 9/15/2025 at 2:37 PM, Regional Nurse Consultant stated medication cart #1 should been locked at all times when Nurse #3 was not present at medication cart #1. In an interview with the Director of Nursing on 9/15/2025 at 2:16 PM, she stated medication cart #1 should have been completely locked when Nurse #3 was not present at medication cart #1.2. On 9/19/25 at 11:22 AM, there was a vial of opened Lispro Insulin 100 units per milliliter observed in an illegible labeled medication bottle stored in the medication refrigerator in Nursing Station #2 medication room. The vial of Lispro insulin with an expiration date of 10/5/2027 was not labeled with an open date or a discard date.The manufacturer guide for Lispro insulin stated the vial of Lispro insulin should be discarded 28 days after opening and could be stored unrefrigerated for the duration of the 28 days.On 9/19/2025 at 11:25 AM, Unit Manager #2 stated she checked Nursing Station #2 medication room for medication expirations on 9/18/2025 and all nurses were responsible for checking medication rooms periodically throughout the week. Unit Manager #2 stated when checking the refrigerator temperature in Nursing Station #2 medication room on the morning of 9/19/2025, she did not see the medication bottle with the vial of Lispro insulin because she was pulled out of the medication room to conduct another task before checking the medications. Unit Manager #2 stated the vial of Lispro insulin should have been labeled with an open date and discard date on the vial of insulin. She also stated the medication container should have legible resident information recorded on the label. Unit Manager #2 explained she would ask her supervisor what to do with the vial of insulin and stated she would not use the vial of Lispro insulin for a resident due to no opened date and/or discard date on the vial of insulin. In an interview on 9/19/2025 at 6:04 PM, Director of Nursing stated the unlabeled vial of Lispro insulin with no open and/or discard date and legible resident information on medication container should not have been in the refrigerator in Nursing Station #2 medication room. The Director of Nursing explained insulin expires in 30 days after opening and the vial of Lispro insulin should have been labeled with a date it was open, and a legible resident label should have been on the medication bottle. The Director of Nursing stated that the vial of Lispro insulin was discarded.3. On 9/19/2025 at 11:35 AM, an unsecured (not secured to a structure that was not moveable) locked black box that was used to store refrigerated controlled medications was observed in an unlocked refrigerator in the locked Nursing Station #1 medication room. There was no lock observed outside the refrigerator. Unit Manager #1 stated she did not have the key to unlock the black box.On 9/19/2025 at 11:40 AM, Nurse #5 explained there was only one key to the locked black box in the unlocked refrigerator. Nurse #5 was observed removing the locked black box from the unlocked refrigerator and placing on the counter of the medication room. When Nurse #5 unlocked the black box, three unopened vials of Lorazepam (a controlled medication) 20 milligrams per 10 milliliters with an expiration date of March 2026 were observed in a medication bottle that had been filled by the pharmacy on 9/8/2025 for a resident. Nurse #5 stated that although Nursing Station #1 medication room was locked and the black box that stored controlled medications was locked, the locked black box was not secured to a permanent structure to prevent a person to remove the locked black box out of the locked medication room.On 9/9/2025 at 11:50 AM, in Nursing Station #3 medication room, the locked black box that was used to store refrigerated controlled medications was observed in a unlocked refrigerator and unsecured to a permanent structure. There was no lock observed outside the refrigerator. When Unit Manager #3 unlocked the black box, there were no controlled medications observed in the black box.In an interview on 9/9/2025 at 6:04 PM. Director of Nursing stated the black boxes that store refrigerated controlled medications in Nursing Station #1 medication room and Nursing station #3 medication room was not secured to a permanent structure to prevent removal of the locked black box from the medication rooms. She also stated the refrigerators in the medication rooms did not have a lock on the outside of the refrigerator. She explained that the refrigerated controlled medications that were stored in locked black boxes in the refrigerators were behind two locking mechanisms: the locked medication room doors and the locked black boxes and she considered the refrigerated controlled medications securely stored.

Based on record review, observation, and staff interviews, the facility failed to maintain an accurate medical record in documenting the administration of oxygen reviewed (Resident #39, and Resident #91) and medications (Resident #113) for 3 of 15 residents whose medical records were reviewed.1. Resident #113 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure) and heart failure. Physician's orders dated 7/25/2025 included Coreg 12.5 milligrams (mg) twice a day for blood pressure; hold for systolic less than 150 millimeters of mercury (mmHg). A review of Resident #113's July and August 2025 Medication Administration Record recorded Nurse #8 administered Coreg 12.5 mg with a blood pressure recording less than 150 mmHg: on 7/27/2025 with a blood pressure reading of 144/69 mmHg, 8/2/2025 with a blood pressure reading of142/63 mmHg, 8/3/2025 with a blood pressure reading of 146/66 mmHg, 8/8/2025 with a blood pressure reading of 142/78 mmHg, 8/9/2025 with a blood pressure reading of 144/75 mmHg, 8/10/2025 with a blood pressure reading of 135/79 mmHg, 8/15/2025 with a blood pressure reading of 133/63 mmHg, 8/16/2025 with a blood pressure reading of143/70 mmHg, 8/17/2025 with a blood pressure reading of 135/69 mmHg, 8/22/2025 with a blood pressure reading of135/59 mmHg, 8/24/2025 with a blood pressure reading of138/58 mmHg and 8/30/2025 with a blood pressure reading of 117/65 mmHg. In a phone interview on 9/19/2025 at 9:41 AM, Nurse #8, stated the documentation on the July 2025 MAR and August 2025 MAR was incorrect. Nurse #8 could not explain why she had recorded that the medication Coreg was administered on 7/27/2025, 8/2/2025, 8/3/2025, 8/8/2025, 8/9/2025, 8/10/2025, 8/15/2025, 8/16/2025, 8/17/2025, 8/22/2025, 8/24/2025 and 8/30/2025 and stated she did not document administration of the medication correctly. She explained Resident #113 would not have allowed her to administer the medication if her blood pressure was less than 150 mmHg. Nurse #8 stated the Resident's July MAR and August MAR reflected an inadequate record. In an interview on 9/19/2025 at 5:07 PM, the Director of Nursing stated Nurse #8 should not have documented the medication, Coreg, was administered to Resident #113 if not administered when the blood pressure was less than 150 mmHg. Therefore, Resident #113's July and August 2025 Medication Administration Records did not reflect an accurate record of Resident #113's medication administration. In an interview on 9/19/2025 at 7:00 PM, the Administrator stated Nurse #8 should have documented the administration accurately to ensure Resident #113's record was an adequate record. Findings included: 2. Resident #39 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypoxia (a medical condition where the lungs are unable to adequately provide oxygen to the body, resulting in a dangerously low level of oxygen in the blood), severe persistent asthma with acute exacerbation, acute bronchitis and hypoxemia. Resident #39's Physician order dated 7/24/25 included an order for oxygen at 3 liters per minute to maintain 90% and above oxygen saturation via nasal cannula. A review of Resident #39's September 2025 Medication Administration Record (MAR) recorded Resident #39 received 3 liters of oxygen via nasal cannula on 9/15/25 and recorded oxygen saturation was 97 percent (%) documented by Medication Aide #1 Observation on 9/15/25 at 8:44 am Resident #39 was in his room lying in bed wearing a nasal cannula and his oxygen concentrator on 4 liters per minute. During an interview with Medication Aide #1 on 9/15/25 at 1:15 pm, she stated she was the medication aide for Resident #39 on day shift (7:00 am until 3:00 pm) for 9/15/25. Medication Aide #1 further stated the oxygen concentrator read 4 liters per minute and she documented at 4 liters per minute. During an interview on 9/15/25 at 2:02 pm with the Director of Nursing (DON), she stated the nursing staff should be reading the physician orders and checking the oxygen concentrators for the correct liters per minute setting every shift for accurate documentation. 3. Resident #91 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD), altered mental status, chronic systolic heart failure, and wheezing. Resident #91's Physician order dated 7/5/24 for oxygen at 2 liters per minute via nasal cannula for hypoxia. A review of Resident #91's September 2025 Medication Administration Record (MAR) recorded Resident #91 received 2 liters of oxygen via nasal cannula each shift on 9/14/25 and recorded oxygen saturations of 97 percent (%) documented by Nurse #2. Observations on 9/14/25 at 9:22 am and 9/14/25 at 1:45 pm revealed Resident #91 was in his room lying in bed wearing a nasal cannula and his oxygen concentrator on 6 liters per minute. In a phone interview with Nurse #2 on 9/17/25 at 4:15 pm, she stated she was the nurse for Resident #91 during the night shift (7:00 pm to 7:00 am). Nurse #2 further stated she documented Resident #91 was on 2 liters per minute in the MAR. During an interview on 9/15/25 at 2:02 pm with the Director of Nursing (DON), she stated the nursing staff should be reading the physician orders and checking the oxygen concentrators for the correct liters per minute setting every shift for accurate documentation.

Based on record review and staff, Pharmacy Consultant #1 and Nurse Practitioner and Cardiologist interviews, the facility failed to prevent a significant medication error when a resident was administered blood pressure medication with a blood pressure recorded below the parameters ordered by the physician for 1 of 6 residents whose medication regimens were reviewed (Resident #113). Finding included: Resident #113 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure) and heart failure. Resident #113 was discharged from the facility on 9/2/2025. A review of Resident #113's blood pressure recorded in the electronic medical record from 6/6/2025 to 7/31/2025 ranged from 101/50 mmHg to 164/43 mmHg. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #113 was cognitively intact and was coded for hypertension. Resident #113's quarterly MDS dated [DATE] was coded for orthostatic hypotension (sudden drop in blood pressure when a person stands up after sitting or lying down that can cause dizziness). Resident #113's care plan dated reviewed last on 6/18/2025 included a focus for a risk for cardiovascular symptoms or complications. Interventions included administering medications as ordered, assessing for effectiveness and reporting abnormalities to the physician and assessing and monitoring vital signs as ordered and reporting abnormalities to the physician. Nursing documentation dated 7/15/2025 by Unit Manager #2 recorded Resident #113 blood pressure was 86/50 and the Nurse Practitioner was notified. Nurse Practitioner (NP) progress notes dated 7/15/2025 recorded while Resident #113 was having a therapy session, Resident #113 became lightheaded, dizzy and a drop in blood pressure. The NP recorded with Resident #113 positioned in bed with feet elevated, Resident #113 vital signs improved. NP rechecked on Resident #113 also later in the evening of 7/15/2025 with Resident #113 reporting she was feeling better and discussing with therapy Resident #113 needs and monitoring in therapy. NP progress notes further recorded Resident #113 had discussed with the NP that the cardiologist had recommended changing her medications and Resident #113 was scheduled to follow up with the cardiologist the following week. A review of the occupational therapy notes recorded on 7/15/2025 Resident #113 complained of feeling lightheaded during the therapy session and nursing was notified. On 7/17/2025 occupation therapy notes recorded Resident #113 decline sitting on the edge of the bed or getting out of the bed due to concerns of her blood pressure dropping when upright and nursing staff were notified. A review of the physical therapy notes on 7/15/2025 and 7/22/2025 recorded Resident #113 experienced dizziness and a drop in her blood pressure. On 7/15/2025, Resident #113's blood pressure was recorded as 84/69 mmHg after standing for therapy and on 7/22/2025 the blood pressure was recorded as 84/54 mmHg. Resident #113 was transferred back to bed and nursing staff notified. The physical therapy notes recorded no other complaints of dizziness or reports of drops in Resident #113's blood pressure during therapy session that were discontinued on 8/14/2025. The Cardiology Provider progress notes dated 7/24/2025 recorded Resident #113 had recent episodes of dizziness upon standing/positioning that were likely due to reduced heart function, inactivity and possible autonomic neuropathy from diabetes. Treatment plan included Midodrine (a medication used to treat low blood pressure that cases severe dizziness) 5 milligrams (mg) 30 minutes before therapy to stabilize blood pressure and prevent drops in Resident #113's blood pressure, monitor Resident #113's blood pressure twice daily and record blood pressure readings and hold Coreg if systolic (first number in blood pressure reading) blood pressure was less than 150 millimeters of mercury (mmHg). Physician's orders dated 7/25/2025 included Coreg 12.5mg twice a day for blood pressure; hold for systolic blood pressure (top reading of a blood pressure) less than 150 mmHg and Midodrine HCL 5mg once a day for orthostatic hypotension. The Medication Administration Record (MAR) for July 2025, August 2025 and September 2025 for Resident # 113 were reviewed. Midodrine 5mg was administered daily as ordered. Coreg 12.5mg was scheduled on the MAR twice a day at 9:00 AM and 9:00 PM for blood pressure with a parameter recorded to hold for systolic blood pressure less than 150 mmHg. In July 2025 from 7/25/2025 to 7/31/2025, 3 out of the 14 scheduled doses of Coreg 12.5mg were recorded on the MAR as administered to Resident #113 when the blood pressure was recorded less than 150 systolic.On 7/26/2025 with a blood pressure reading recorded as 132/75 mmHg.On 7/27/2025 with a blood pressure reading recorded as 144/69 mmHg.On 7/28/2025 with a blood pressure reading recorded as 142/78mmHg. Review of the occupational therapy note recorded on 7/28/2025 Resident #113 reported feeling dizzy with transfer to the bathroom. Nurse was notified and blood pressure was within the normal range. In the month of August 2025, 37 out of the 62 scheduled doses of Coreg 12.5mg were recorded on the MAR as administered to Resident #113 when the blood pressure was recorded less than 150 mmHg systolic:On 8/2/2025 with a blood pressure reading recorded as 142/63 mmHg. On 8/3/2025 with a blood pressure reading recorded as 146/66 mmHg. On 8/4/2025 with a blood pressure reading recorded as136/78 mmHg and140/76 mmHg.On 8/5/2025 with a blood pressure reading recorded as 128/62 mmHg.On 8/6/2025 with a blood pressure reading recorded as 146/70 mmHg.On 8/7/2025 with a blood pressure reading recorded as 126/76 mmHg. On 8/8/2025 with a blood pressure reading recorded as 125/80 mmHg and 142/78 mmHg.On 8/9/2025 with a blood pressure reading recorded as 144/75 mmHg and 144/75 mmHg.On 8/10/2025 with a blood pressure reading recorded as 123/67 mmHg and 135/79 mmHg.On 8/11/2025 with a blood pressure reading recorded as 135/79 mmHg.On 8/12/2025 with a blood pressure reading recorded as 128/64 mmHg. On 8/13/2025 with a blood pressure reading recorded as 117/61 mmHg. On 8/14/2025 with a blood pressure reading recorded as 104/60 mmHg and 129/76 mmHg.On 8/15/2025 with a blood pressure reading recorded as 128/61 mmHg and 133/63 mmHg. On 8/16/2025 with a blood pressure reading recorded as 143/70 mmHg.On 8/17/2025 with a blood pressure reading recorded as 143/70 mmHg and 135/69 mmHg.On 8/18/2025 with a blood pressure reading recorded as 120/68 mmHg.On 8/21/2025 with a blood pressure reading recorded as 121/76 mmHg.On 8/22/2025 with a blood pressure reading recorded as 100/71 mmHg and 135/59 mmHg.On 8/24/2025 with a blood pressure reading recorded as 138/58 mmHg.On 8/26/2025 with a blood pressure reading recorded as 122/74 mmHg and 131/75 mmHg.On 8/27/2025 with a blood pressure reading recorded as 133/72 mmHg.On 8/28/2025 with a blood pressure reading recorded as 127/70 mmHg and 129/74 mmHg.On 8/29/2025 with a blood pressure reading recorded as 129/74 mmHg and 130/72 mmHg.On 8/30/2025 with a blood pressure reading recorded as 122/79 mmHg and 117/65 mmHg. Review of the occupational therapy note recorded on 8/1/2025, Resident #113 was able to tolerate the therapy session but complained of dizziness during the therapy session with Resident #113's blood pressure recorded as 110/53. There were no other reports of Resident #113 experiencing dizziness or drops in blood pressure during therapy sessions. In September 2025 from 9/1/2025 to 9/3/2025, 1 out of the 3 scheduled doses of Coreg 12.5mg were recorded on the MAR as administered to Resident #113 when the blood pressure was recorded less than 150 systolic.On 9/2/2025 with a blood pressure reading recorded as 132/77 mmHg. The monthly Pharmacy Consultant's Medication Regimen Reviews dated 7/31/2025 and 8/30/2025 recorded Coreg was given and should have been held for systolic blood pressure less than 150 mmHg on 7/26/2025, 8/2/2025, 8/3/2025, 8/4/2025, 8/5/2025, 8/6/2025, 8/7/2025, 8/8/2025, 8/9/2025, 8/10/2025, 8/11/2025, 8/12/2025, 8/13/2025, 8/14/2025, 8/15/2025, 8/16/2025, 8/17/2025, 8/18/2025, 8/20/2025, 8/21/2025, 8/22/2025, 8/24/2025 and 8/26/2025. There was no documentation that the recommendations on MRRs dated 7/31/2025 and 8/30/2025 for Coreg were addressed by a medical provider or nursing staff. In an interview on 9/19/2025 at12:16 PM, the Certified Occupational Therapy Assistant stated Resident #113's had experienced some episodes of dizziness with a drop in her blood pressure during therapy. She explained Resident #113 was started on a medication to treat orthostatic hypotension that was administered to Resident #113 before therapy sessions and Resident #113 was able to participate more in therapy with decrease complaints of dizziness. In an interview on 9/17/2025 at 5:09 PM. Nurse #7 reviewed Resident #113's August 2025 and September 2025 MAR and stated based on her documentation on the MARs she administered Coreg to Resident #113 on 8/26/2025, 8/14/2025 and 9/2/2025. Nurse #7 stated based on the physician order on the August 2025 and September 2025 MARs to hold for systolic blood pressure less than 150 mmHg, the medication Coreg should not have been administered to Resident #113 when the blood pressure was recorded less than 150 mmHg. Nurse #7 explained she checked Resident #113 blood pressure before giving the medication and did not read the order completing before administering the mediation. In an interview on 9/17/2025 at 5:33 PM, when Medication Aide #1 read Resident #113 order for Coreg on the August 2025 MAR, she stated Resident #113's systolic blood pressure was less than 150 mmHg and asked what was wrong in administering Resident #113 the medication. When Medication Aide #1 re-read the physician order for Coreg administration, she stated based on the physician order on the August 2025 MAR, she shouldn't have administered the medication on 8/8/2025, 8/9/2025, 8/10/2025 and 8/22/2025 to Resident #113 based on the blood pressure recordings were less than 150 mmHg. Medication Aide #1 stated she did not know why she administered Resident #113 the medication with the order to hold the medication for blood pressure less than 150 mmHg. In a phone interview on 9/19/2025 at 9:41 AM, Nurse #8, who recorded administering 12 doses of Coreg to Resident #113 when the systolic blood pressure was recorded less than 150 mmHg, stated the documentation on the July 2025 and August 2025 MAR was incorrect. Nurse #8 could not explain why she had recorded on the MAR that the medication Coreg was administered on 7/27/2025, 8/2/2025, 8/3/2025, 8/8/2025, 8/9/2025, 8/10/2025, 8/15/2025, 8/16/2025, 8/17/2025, 8/22/2025, 8/24/2025 and 8/30/2025 but insisted Resident #113 knew what medications were administered and Resident #113 would not have allowed her to administer the medication. In an interview on 9/17/2025 at 5:50 PM, the Director of Nursing recalled Resident #113 experiencing some orthostatic hypotension with therapy sessions that was treated with medication. After reviewing the August 2025 MAR for Coreg administration, she explained if the nurses did not scroll down the MAR to view the entire medication order, the nurses may have not seen the hold order for the medication Coreg. She stated she did not know why the nurses did not hold the medication when the systolic blood pressure was recorded less than 150 mmHg and stated the medication; Coreg should have been held per the physician's order when Resident #113 systolic blood pressure was recorded less than 150 mmHg. The DON further stated she did not recall any negative side effects due to Resident #113 receiving the medication when the systolic blood pressure was recorded less than 150 mmHg. In an interview on 9/19/2025 at 4:02 PM, the Pharmacy Consultant stated receiving Midodrine HCL daily prevented Resident #113 from becoming hypotensive (less than 90/60 mmHg). In an interview on 9/17/2025 at12:42 PM, the Nurse Practitioner explained Resident #113 was on Coreg to conserve her heart function to alleviate the possibility of heart surgery. Resident #113 was experiencing some orthostatic hypertension, and the Cardiologist ordered the Coreg to be held when systolic blood pressure was less than 150. She stated she was not aware or notified that Resident #113 had been administered Coreg when Resident#113's systolic blood pressure was recorded less than 150. She explained that the Cardiologist had ordered Midodrine HCL that would have worked opposite of the Coreg medication and Resident #113's symptoms of orthostatic hypotension improved. In a phone interview with the Cardiologist on 9/19/2025 at12:20 PM, she stated Resident #113 was seen in July 2025 for orthostatic hypotension. She explained Resident #113 reported she was not able to stand up and participate in therapy because of feeling dizzy when standing. She stated she ordered parameters to hold Resident #113's blood pressure medication if systolic blood pressure was less than 150 and started Resident #113 on Midodrine HCL 5mg a day for the orthostatic hypotension. She explained she had not seen Resident #113's July 2025, August 2025 or September 2025 Medication Administration Records that indicated the blood pressure medication was given when a blood pressure was recorded less than 150. She explained Midodrine HCL was medication that Resident #113 received daily to elevate Resident #113's blood pressure and therefore, when Coreg was administered when Resident #113's systolic blood pressure was less than 150mmHg, Resident #113's blood pressure was able to remain in the normal range for blood pressures.

Based on record review and interviews with staff, Consultant Pharmacist, and the Nurse Practitioner, the facility failed to address irregularities identified by the Consultant Pharmacist during monthly drug regimen reviews (Residents #75, #113, #1, and #2) and to maintain documentation of the monthly drug regimen reviews within the facility and readily available for review (Resident #75). This deficient practice affected 4 of 5 residents reviewed for unnecessary medications. The findings included: 1.Resident #75 admitted to the facility on [DATE] with diagnoses including gastro-esophageal reflux disease with esophagitis, anxiety, polyneuropathy, and depression with psychosis. The admission Minimum Data Assessment (MDS) dated [DATE] indicated Resident #75 had moderate cognitive impairment with no display of behaviors coded. The MDS was coded for Resident #75 receiving antipsychotic medications on a routine basis. Resident #75's physician's orders revealed the following: Order dated 10/25/2024 documented a revision of Quetiapine Fumarate (an antipsychotic) to 300 milligrams (MG) at bedtime. Order dated 10/26/24 read Sucralfate Oral Tablet 1 gram (GM) 1 tablet by mouth three times a day for gastric protection and Metoprolol (blood pressure) 25 mg one-half tablet two times a day and to hold the dose if his systolic blood pressure (SBP) was less than 100 or his heart rate was less than 60. Order dated 4/30/2025 for Pregabalin (for pain) Oral Capsule 50 MG 1 tablet by mouth three times a day. Order dated 6/03/2025 for Hydroxyzine HCl (for itching and anxiety) tablet 25 milligrams (mg) 1 tablet by mouth three times a day. Order dated 7/24/2025 for Pantoprazole Sodium Oral Tablet Delayed Release 40 MG (for gastroesophageal reflux) 1 tablet by mouth one time a day. Order dated 8/29/2025 for Quetiapine Fumarate (an antipsychotic) 200 MG tablet at bedtime. Order dated 9/08/2025 for Psyllium Oral Packet (a fiber supplement) every 12 hours. 1a. Resident #75's medical record only had one an Abnormal Involuntary Movement Scale (AIMS) assessment on file dated 8/23/24. There were no other abnormal movement assessments found in the medical record. On 2/21/25, 3/30/25, 5/30/25, 6/29/25, 7/28/25, and 8/29/25, the facility Consultant Pharmacist drug regimen review noted for Resident #75 to have an AIMS, used to assess for adverse reactions to psychoactive medications) assessment done due to Resident #75 receiving an antipsychotic medication. The pharmacist noted on 6/29/25 that antipsychotic medications have the capacity to cause tardive dyskinesia and other movement disorders. She recommended a movement test, such as the AIMS assessment, be performed initially (within 30 days) and then at least every 6 months while Resident #75 continued the medication. A handwritten undated and unsigned comment documented noted. The reviews dated 2/21/25, 3/30/25, 5/30/25, 7/28/25, and 8/29/25 were unsigned and had no evidence of staff acknowledgement. In an interview on 9/19/25 at 1:31 PM, the Director of Nursing (DON) stated she was unaware the Consultant Pharmacist had recommended an AIMS assessment for Resident #75. She stated the facility used the AIMS assessment for residents on antipsychotics and no other assessments. She stated there were no other AIMS assessments completed for Resident #75 other than the one on 8/23/24. 1b. The pharmacist drug regimen review dated 2/21/25, 7/28/25, 8/29/25 for Resident #75 included recommendations for psyllium, a fiber supplement, to be given at least 2 hours apart from any other medication. The reviews dated 2/21/25, 7/28/25, and 8/29/25 were unsigned or had no evidence of staff acknowledgement. Review of the Medication Administration Records (MAR) from January 2025-September 2025 documented that psyllium was scheduled for administration at 6:00 AM and 5:00 PM. An entry on the MAR dated 9/8/25 noted the times for psyllium were changed to 5:00 AM and 5:00 PM within an hour of other medications. The Hydroxyzine, Pantoprazole, Pregabalin were scheduled to be administered at 6:00 AM, and Sucralfate was scheduled to be administered at 4:00 PM. Review of the September 2025 MAR documented that he was scheduled to receive psyllium at 5:00 AM, hydroxyzine (for anxiety and itching), pantoprazole (for gastroesophageal reflux), and pregabalin (for nerve pain and anxiety) at 6:00 AM. Resident #75 was scheduled to receive sucralfate at 4:00 PM and psyllium at 5:00 PM. In an interview on 9/19/25 at 11:37 AM, Nurse #6 stated she had administered Resident #75's medications on 9/18/25. She stated she provided him with his psyllium and sucralfate at the same time, though he refused to take the medications that day. She stated that because the medications were an hour apart, she administered them together and said there was no order or indication that she could not administer them together. In an interview on 09/19/25 at 10:42 AM, the Nurse Practitioner stated she had not seen the recommendations to separate the time of psyllium administration. She stated the psyllium could affect the absorption of the other medications taken with the psyllium and said it was good practice to separate them. In an interview on 9/19/25 at 12:07 PM, the Consultant Pharmacist stated she recommended separating psyllium from other medication administration times by 2 hours because it could affect how well the other medications were absorbed into his system. In an interview on 9/19/25 at 6:06 PM, the Director of Nurses (DON) stated she was not aware of the recommended administration time changes and confirmed that after reviewing the administration times of Resident #75's medications, he was receiving psyllium with other medications scheduled within the next hour regularly. She stated she had become the DON in February 2025 and had not worked on any of the Consultant Pharmacist recommendations. She stated the Nurse Practitioner received all of the recommendations and would make adjustments to orders and administration times on the MAR. She stated she had tried to make corrections in a resident's clinical record (no resident specified) and the Nurse Practitioner would adjust the DON's documentation after, so it was more efficient to allow the NP to receive them all directly. In an interview on 9/19/25 at 10:24 AM, the Nurse Practitioner stated she did not directly receive the Consultant Pharmacist's recommendations, but they were given to her by the facility to address. She stated she did not change information in the electronic medical record herself but reviewed them and return them to a nurse manager. She stated she would sign or initial the recommendations she reviewed. 1c. Resident #75's progress notes dated 8/22/24, 8/30/24, and 4/27/25 completed by the Consultant Pharmacist all documented that Medication Regimen Reviews were performed and a Comments/Recommendations were made. The progress notes indicated to see the reports. The facility was unable to provide the referenced Medication Regimen Review reports that were mentioned in the Consultant Pharmacist's progress notes for Resident #75 dated 8/22/24, 8/30/24, and 4/27/25. In an interview on 9/19/25 at 6:06 PM, the DON stated she could not find any additional documentation of the Consultant Pharmacist's monthly Medication Regimen Review reports. She stated she wasn't aware of where any additional Medication Regimen Review reports were stored. She further stated that she had asked other nurse managers to check to see if they had any recommendations filed in their office, but there were no additional Medication Regimen Review reports found. In an interview on 9/19/25 at 10:24 AM, the Nurse Practitioner stated she did not directly receive the Consultant Pharmacist's recommendations, but they were given to her by a nurse manager to address. She explained that she reviewed the recommendations, signed or initialed them, and then returned them to a nurse manager. In an interview on 9/19/25 at 6:57 PM, the Administrator stated she expected the facility Consultant Pharmacist's recommendations to be addressed. 2. Resident #113 was admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure) and heart failure. Physician's orders dated 7/25/2025 included carvedilol (a blood pressure reducing medication) 12.5 milligrams (mg) twice a day for blood pressure; hold for systolic (top number of a blood pressure) blood pressure less than 150 milliliters of mercury (mmHg). A review of Resident #113's monthly Medication Regimen Reviews (MRR) conducted by the Pharmacy Consultant reported on 7/31/2025 the medication, carvedilol, was administered to Resident #113 and should have been held for a systolic blood pressure less than 150 mmHg on 7/26/2025. The MRR dated 8/30/2025 for Resident #113 reported carvedilol was given and should have been held for systolic blood pressure less than 150 mmHg on 8/2/2025, 8/3/2025, 8/4/2025, 8/5/2025, 8/6/2025, 8/7/2025, 8/8/2025, 8/9/2025, 8/10/2025, 8/11/2025, 8/12/2025, 8/13/2025, 8/14/2025, 8/15/2025, 8/16/2025, 8/17/2025, 8/18/2025, 8/20/2025, 8/21/2025, 8/22/2025, 8/24/2025 and 8/26/2025. There was no documentation on or for the MRR dated 7/31/2025 or 8/30/2025 that the recommendation for Carvedilol had been addressed by the Director of Nursing or the Nurse Practitioner. There were no signatures, initials or dates recorded on the MRRs. The words, fixed and noted, were written near other medications with recommendations to clarify strength, frequency and diagnoses on 7/31/2025 MRR that were repeated recommendations on the 8/30/2025. There was no documentation beside the carvedilol recommendation to record the nursing recommendation had been addressed. In an interview on 9/19/2025 at 4:02 PM, the Pharmacy Consultant stated the monthly MRR recommendations were sent via email to the Director of Nursing and Administrator at the end of each month within a couple days after completion of the MRR. She explained the MRR dated 7/31/2025 recorded the nursing staff had not followed the parameter protocol as ordered by the physician to hold the medication, carvedilol on 7/26/2025. She explained on the MRR dated 8/30/2025 there was a trend identified of Resident #113 receiving carvedilol when the systolic blood pressure readings were less than 150 mmHg. The Pharmacy Consultant stated she could not recall discussing with the Director of Nursing or the Nurse Practitioner that Resident #113 was receiving carvedilol when the systolic blood pressure was recorded below the parameter of 150 mmHg. In an interview on 9/17/2025 at 5:50 PM, the Director of Nursing (DON) stated she started at the facility in February 2025. She explained that since February 2025 the process was the pharmacy consultant emailed the pharmacy recommendations to the DON, the DON provided the pharmacy recommendations to the Nurse Practitioner (NP) and the NP addressed the physician and nursing pharmacy recommendations. The DON stated the NP was responsible for communicating nursing recommendations to the nursing staff and did not recall the NP communicating concerns that Resident #113 was receiving carvedilol when systolic blood pressure was less than 150 mmHg to the DON. The DON also stated she had experienced problems with receiving emails and her email address had been changed multiple times since starting at the facility. In an interview on 9/17/2025 at12:42 PM, the Nurse Practitioner explained Resident #113 was on carvedilol to conserve her heart function to alleviate the possibility of heart surgery. Resident #113 was experiencing some orthostatic hypertension, and the cardiologist ordered the carvedilol to be held when systolic blood pressure was less than 150mmHg. She stated she was not aware or notified that Resident #113 had been administered carvedilol when Resident#113's systolic blood pressure was recorded less than 150mmHg. In a follow up phone interview on 10/1/2025 at 11:54 AM, she stated since March 2025 she had been addressing only the physician pharmacy recommendations, and the DON was responsible for addressing the nursing pharmacy recommendations. In an interview conducted on 9/19/2025 at 7:00 PM, the Administrator stated she did not think she was receiving pharmacy recommendations from the pharmacy consultant. She stated the Director of Nursing was responsible for receiving the pharmacy recommendations monthly and addressing the nursing recommendations and ensuring the physician/nurse practitioner addressed and returned the physician recommendations. She explained she was not aware who was maintaining copies of the addressed pharmacy recommendations at the facility. 3. Resident #1 was admitted to the facility on [DATE] with diagnoses including a bipolar disorder. Physician orders dated 8/26/2024 increase quetiapine (an antipsychotic medication) to 300 milligrams (mg) three times a day for bipolar depression. An Abnormal Involuntary Movement Scale (AIMS) assessment dated [DATE] in Resident #1's electronic medical record (EMR) reported Resident #1 was not experiencing involuntary movements, which could potentially be an adverse side effect to psychotropic medications. There was no documentation of an AIMS assessment since 12/8/2024 for Resident #1 in the EMR. A review of the monthly Medication Regimen Reviews (MRR) recorded on the electronic medical record EMR) recorded there were irregularities in the medication regimen noted and there were pharmacy recommendations for Resident #1 from January 2025 to August 2025. The facility was unable to provide copies of the pharmacy recommendations for Resident #1 for the period of 1/1/2025 through 8/31/2025. Resident #1's monthly Medication Regimen Review (MRR) dated 7/31/2025 conducted by the Pharmacist Consultant requested verification that an updated AIMS assessment had been completed and filed in the EMR for Resident #1. A review of Resident #1's August and September 2025 Medication Administration Record (MAR) recorded Quetiapine was administered three times a day as ordered with no behaviors documented for Resident #1. The facility was unable to provide a copy of the pharmacy recommendations for Resident #1 for the period of 8/1/2025 through 8/31/2025. In a phone interview 9/19/2025 at 4:02 PM, the Pharmacy Consultant explained the AIMS assessments was to be conducted by nursing staff every six months after the initial AIMS assessment for residents receiving antipsychotics. She explained when recommendations were not addressed, the recommendation was repeated the following month to be addressed and/or discussed with the Director of Nursing. The pharmacy consultant could not recall if she had discussed Resident #1's need for an updated AIMS assessment with the Director of Nursing. She stated she had been conducting a monthly MRR for Resident #1 and had emailed the physician and nursing recommendations to the Director of Nursing and Administrator at the end of each month from January 2025 to August 2025. The pharmacy consultant stated pharmacy recommendations were to remain with Resident #1 for the lifetime of his stay at the facility. The pharmacy consultant did not know who was responsible in maintaining storage of the pharmacy recommendations documenting that the pharmacy recommendations had been addressed. In an interview 9/19/2025 at 5:07 PM, the Director of Nursing (DON) stated she started at the facility in February 2025. She explained that since February 2025 the process was the pharmacy consultant emailed pharmacy recommendations to the DON and the DON provided the pharmacy recommendations to the Nurse Practitioner (NP) and the NP addressed the physician and nursing pharmacy recommendations. She stated the NP had access to the MAR to make changes as needed and referenced that the NP was a nurse. The DON stated the NP was responsible for signing the pharmacy recommendations and maintaining storage of the hard paper copy pharmacy recommendations addressed. The DON did not know where the NP stored the pharmacy recommendations. She stated she was not able to locate the pharmacy recommendations for Resident #1 for the period of 1/1/2025 through 5/31/2025 and 8/1/2025 through 8/31/2025. She stated the nursing staff were to conduct the AIMS assessments every 6 months unless a change in the resident and the electronic medical record would trigger when Resident #1's AIMS assessment was due if the notification of AIMS assessment was activated. She stated Resident #1's EMR may not have been activated by the nursing staff to identify an AIMS assessment was due for Resident #1. The DON further stated the NP was responsible to communication nursing recommendations to the nursing staff and did not recall the NP communicating Resident #1 needed an AIMS assessment and did not think the NP was communicating Resident #1 needing an AIMS assessment to the nursing staff. In a phone interview on 10/1/2025 at 11:54 AM, the Nurse Practitioner stated up until March 2025 she would address physician and nursing pharmacy recommendations monthly. She explained she would correct medication orders for the nursing staff on the MAR. She stated nursing recommendations like AIMS assessments were highlighted on the hard paper copy of the pharmacy recommendations and returned to the Director of Nursing to address. She stated since March 2025, she had only been addressing the physician recommendations, and the Director of Nursing was responsible for addressing all the nursing recommendations. She stated the hard paper copy pharmacy physician recommendations that had been addressed were returned to the Director of Nursing to maintain in the DON office. The DON stated her email had been changed multiple times since starting at the facility because she realized she was not receiving emails. In an interview conducted on 9/19/2025 at 7:00 PM, the Administrator stated she did not think she was receiving pharmacy recommendations from the pharmacy consultant. She stated the Director of Nursing was responsible for receiving the pharmacy recommendations monthly and addressing the nursing recommendations and ensuring the physician/nurse practitioner addressed and returned the physician recommendations. She explained she was not aware who was maintaining copies of the addressed pharmacy recommendations at the facility. 4. Resident #2 was admitted to the facility 11/30/2022 with diagnoses including anxiety disorder, bipolar disorder, depression, and peripheral vascular disease. A review of the monthly Medication Regimen Reviews (MRR) on the electronic medical record EMR) recorded there were irregularities in the medication regimen noted and there were pharmacy recommendations recorded for Resident #2 from January 2025 to August 2025. The facility was unable to provide copies of the pharmacy recommendations for Resident #2 for the period of 1/1/2025 through 5/31/2025 and 7/1/2025 through 7/31/2025. Resident #2's monthly Medication Regimen Reviews (MRR) dated 8/31/2025 conducted by the Pharmacist Consultant requested behavior monitoring be added to the morning dose of the clonazepam (an anti-anxiety/anti-seizure medication) order and to the divalproex sodium (an anti-seizure medication) order on the Medication Administration Record (MAR) and to add anticoagulant monitoring to the MAR. Physician orders as of 9/2/2025 included clonazepam 0.5 milligrams(mg) three times a day for anxiety, divalproex sodium delayed release 250 mg three times a day for bipolar depression, apixaban (anticoagulant) 5 mg two time a day for peripheral vascular disease, sertraline hydrochloride (HCL), an antidepressant 150 mg a day for bipolar depression. A review of Resident #2's September 2025 Medication Administration Record (MAR) revealed Resident #2 was administered medications as ordered. The MAR indicated when clonazepam (originally order on 5/2/2025) was changed to three times a day on 9/2/2025, behavior monitoring was not included on the MAR for the medication. There was no behavior monitoring attached to the divalproex sodium order on the MAR and sertraline HCL had been increased on from 100 mg (8/14/2025) to 150 mg on 9/11/2025. There was no behavior monitoring or anticoagulant monitoring included on the September MAR for documentation as requested in the 8/31/2025 MRR pharmacy recommendation. In a phone interview on 9/19/2025 at 4:02 PM, the Pharmacy Consultant explained when recommendations were not addressed, the recommendation was repeated the following month to be addressed and/or discussed with the Director of Nursing. The pharmacy consultant could not recall if she had discussed the monitoring behaviors and anticoagulants for Resident #2 with the Director of Nursing. She stated she had been conducting a monthly MRR for Resident #2 and had emailed the physician and nursing recommendations to the Director of Nursing and Administrator at the end of each month from January 2025 to August 2025. The pharmacy consultant stated pharmacy recommendations were to remain with Resident #2 for the lifetime of his stay at the facility. The pharmacy consultant did not know who was responsible in maintaining storage of the pharmacy recommendations documenting that the pharmacy recommendations had been addressed. In an interview 9/19/2025 at 5:07 PM, the Director of Nursing (DON) stated she started at the facility in February 2025. She explained that since February 2025 the process was that the pharmacy consultant emailed pharmacy recommendations to the DON, the DON provided the pharmacy recommendations to the Nurse Practitioner (NP) and the NP addressed the physician and nursing pharmacy recommendations. She stated the NP had access to the MAR to make changes as needed and referenced that the NP was a nurse. The DON stated that the NP was responsible for signing the hard paper copy pharmacy recommendations and maintaining storage of the pharmacy recommendations addressed and she did not know where the NP stored the pharmacy recommendations. She stated she was not able to locate the pharmacy recommendations for Resident #2 for the period of 1/1/2025 through to 5/31/2025 and 7/1/2025 through 7/31/2025. In a phone interview on 10/1/2025 at 11:54 AM, the Nurse Practitioner stated up until March 2025 she would address physician and nursing pharmacy recommendations monthly. She explained she would correct medication orders for the nursing staff on the MAR. She stated non-medications nursing recommendations were highlighted and returned to the Director of Nursing to address. She stated since March 2025, she had only been addressing the physician recommendations, and the Director of Nursing was responsible for addressing all the nursing recommendations. She stated the hard paper copy pharmacy physician recommendations that had been addressed were returned to the Director of Nursing to maintain in the DON office. In an interview conducted on 9/19/2025 at 7:00 PM, the Administrator stated she did not think she was receiving pharmacy recommendations from the pharmacy consultant. She stated the Director of Nursing was responsible for receiving the pharmacy recommendations monthly and addressing the nursing recommendations and ensuring the physician/nurse practitioner addressed and returned the physician recommendations. She explained she was not aware who was maintaining copies of the addressed pharmacy recommendations at the facility.

Based on record review, observations, staff interviews and Nurse Practitioner interview, the facility failed to administer supplemental oxygen as prescribed by the physician and failed to post cautionary signage indicating the use of oxygen for 3 of 9 residents reviewed for respiratory services (Resident #39, #91 and #49). 4. Resident #49 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #49 was cognitively intact and was coded as receiving oxygen therapy. Physician orders dated 8/25/2025 included an order for oxygen at three liters per minute via nasal cannula every shift. Resident #49's care plan last updated on 8/26/2025 documented Resident #49 was at risk for respiratory complications and was receiving oxygen at 3 liters per min. via nasal cannula every shift. On 9/14/2025 at 1:25 PM, Resident #49 was observed lying in bed receiving oxygen at 3 liters per minute via nasal cannula. However, there was no signage posted outside Resident #49's door indicating No Smoking - Oxygen in Use. During an interview on 9/14/2025 at 4:23 PM, Nurse #3, stated that signage indicating No Smoking - Oxygen in Use should have been posted outside Resident #49's door. She explained that it was the responsibility of the respiratory therapist to place the signage. In a phone interview on 9/16/2025 at 9:58 AM, Nurse #5 stated that Resident #49 should have had the appropriate signage posted. She was unaware that the signage was missing and said she did not check Resident #49's door on 9/14/25. As the weekend supervisor, she stated she had never been instructed by the Administration team to conduct resident rounds to verify oxygen signage on the weekend. On 9/14/2025 at 4:40 PM in an interview with Respiratory Therapist (RT) #2 confirmed that Resident #49 should have had a magnetic No Smoking - Oxygen in Use sign outside the door. RT #2 explained respiratory therapy staff are responsible for placing signage for new admissions and residents on their case load. However, nurses were expected to apply the signage when initiating oxygen therapy for residents not on the respiratory caseload. RT #2 acknowledged that respiratory therapy staff were expected to check weekly for proper signage but could not explain why the signage was missing in this case. In an interview on 9/15/2025 at 2:04 PM, the Director of Nursing (DON) stated that the facility uses magnetic signage to indicate oxygen use and no smoking. She explained that both nursing and respiratory staff were responsible for ensuring the signage was posted when oxygen was initiated. Since not all residents on oxygen were on the respiratory caseload, nursing staff were expected to ensure signage was in place. The DON also stated that during daily rounds conducted by Administration during the week and by the weekend supervisor on the weekends, staff should verify that appropriate signage is posted. Findings included: 1.Resident #39 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypoxia (a medical condition where the lungs are unable to adequately provide oxygen to the body, resulting in a dangerously low level of oxygen in the blood), severe persistent asthma with acute exacerbation, acute bronchitis and hypoxemia. Physician order dated 7/24/25 included an order for oxygen at 3 liters per minute to maintain 90% and above oxygen saturation via nasal cannula. Review of Resident #39's admission Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact and coded for oxygen therapy. Resident #39's care plan dated 7/31/25 included a focus for respiratory complications related to recent hospitalization, acute respiratory distress with hypoxia and acute exacerbation of severe persistent asthma. Interventions included oxygen via nasal cannula at 3 liters per minute as needed for hypoxia and to keep oxygen saturations (a measurement of how much oxygen present in the blood) greater than 90 percent (%). Observation on 9/15/25 at 8:44 am Resident #39 was in his room lying in bed wearing a nasal cannula and his oxygen concentrator on 4 liters per minute. A review of Resident #39's September 2025 Medication Administration Record (MAR) recorded Resident #39 received 3 liters of oxygen via nasal cannula on 9/15/25 and recorded oxygen saturation was 97 percent (%). In an interview with the Unit Manager #1 on 9/15/25 at 1:15 pm, she stated the oxygen concentrator level for Resident #39 should be at 3 liters per minute. During an interview with Medication Aide #1 on 9/15/25 at 1:15 pm, she stated she was the medication aide for Resident #39 on day shift (7:00 am until 3:00 pm) for 9/15/25. Medication Aide #1 further stated the oxygen concentrator read 4 liters per minute and documented at 4 liters per minute. Medication Aide #1 indicated the oxygen concentrator should have been set a 3 liters per minute and she could not change the levels on the oxygen concentrators. Medication Aide #1 stated Resident #39 was capable of adjusting the settings on his oxygen concentrator. During an interview on 9/15/25 at 2:02 pm with the Director of Nursing (DON), she stated the nursing staff should be reading the physician orders and checking the oxygen concentrators for the correct liters per minute setting every shift. In an interview on 9/17/25 at 12:41 pm with the Nurse Practitioner (NP), stated the nursing staff should be following the physician orders and checking the oxygen concentrators for the correct setting of liters per minute every shift. During an interview with the Administrator on 9/19/25 at 6:01 pm, she stated her expectations were that the nursing staff followed the physician orders and verifying the oxygen concentrators are set at the correct liters per minute. 2.Resident #91 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD), altered mental status, chronic systolic heart failure, and wheezing. Resident #91's Physician order dated 7/5/24 for oxygen at 2 liters per minute via nasal cannula for hypoxia. Review of Resident #91's quarterly Minimum Data Set, dated [DATE] revealed he was cognitively intact, coded for oxygen therapy and hospice. Resident #91's care plan dated 9/5/25 included a focus for respiratory complications related to recent hospitalization. Interventions included oxygen via nasal cannula at 2 liters per minute for hypoxia and to observe for signs/symptoms of respiratory distress. Observations on 9/14/25 at 9:22 am and 9/14/25 at 1:45 pm revealed Resident #91 was in his room lying in bed wearing a nasal cannula and his oxygen concentrator on 6 liters per minute. A review of Resident #91's September 2025 Medication Administration Record (MAR) recorded Resident #91 received 2 liters of oxygen via nasal cannula each shift on 9/14/25 and recorded oxygen saturations of 97 percent (%). In an interview with the Unit Manager #2 on 9/15/25 at 1:45 pm, she stated the nursing staff should be reading the physician orders and checking the oxygen concentrators levels every shift. In a phone interview with Nurse #2 on 9/17/25 at 4:15 pm, she stated she was the nurse for Resident #91 during the night shift (7:00 pm to 7:00 am). Nurse #2 indicated she knew Resident #91 had an order 2 liters per minute of oxygen. Nurse #2 further stated she did not check the level on the oxygen concentrator for Resident #91 during her shift. During an interview on 9/15/25 at 2:02 pm with the Director of Nursing (DON), she stated the nursing staff should be reading the physician orders and checking the oxygen concentrators for the correct liters per minute setting every shift. In an interview on 9/17/25 at 12:41 pm with the Nurse Practitioner (NP), stated the nursing staff should be following the physician orders and checking the oxygen concentrators for the correct setting of liters per minute every shift. During an interview with the Administrator on 9/19/25 at 6:01 pm, she stated her expectations were that the nursing staff followed the physician orders and verifying the oxygen concentrators are set at the correct liters per minute.

Based on record review, observations and staff interviews, the facility failed to administer enteral feeding formula at the correct rate as ordered by the physician for 1 of 1 resident (Resident #13) reviewed for enteral feedings (Resident #13). Findings included: Resident #13 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and gastrostomy (opening of the stomach) for enteral feedings, malnutrition and vascular dementia. Resident #13's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed she was assessed as having moderate cognitive impairment with no behaviors. The MDS assessment reflected the use of a feeding tube for 51% or more of Resident #13's total calories.Physician's orders dated 8/9/2025 included continuous eternal feeding via a pump at 130 milliliters (ml) per hour for 12 hours a day. The continuous eternal feeding (a way of providing nutrition right to the stomach or small intestine) was to start at 8:00 PM and stop at 8:00 AM. An order to flush the gastrostomy tube with 50 ml of water every 4 hours during continuous eternal feedings was written on 3/13/2025.On 9/15/2025 at 8:20 PM, Nurse #4 was observed hanging Resident #13's enteral feeding scheduled for 8:00 PM. Resident #13's enteral feeding set up consisted of two plastic bags: one bag contained 1000 liters of water used for water flushes and the second bag contained 1000 liters of the enteral feeding formula. Nurse #4 was observed programming the eternal feeding pump to infuse the eternal feeding at 50 milliliters per hour and the water flushes at 130 milliliter every 4 hours. Nurse #4 was then observed connecting the eternal feeding tubing to Resident #13 gastrostomy tube and turning on the eternal feeding pump to continuously administer the eternal feeding. Nurse #4 was observed exiting the room at 8:30 PM who reported she had completed the task of starting Resident #13's eternal feeding. On 9/15/2025 at 8:33PM, Nurse #4 was asked to verify with the surveyor the physician's order of the eternal feeding. Nurse #4 stated the physician's order for Resident #13's to receive the continuous eternal feeding at 130 milliliters per hour and to receive 50 milliliters of water flushes every 4 hours. She stated she had entered the settings of the eternal feeding incorrectly and needed to reset the eternal feeding pump for Resident #13's continuous eternal feeding. On 9/15/2025 at 8:34 PM in an observation and interview, Nurse #4 was observed re-entering Resident #13's room. The eternal feeding pump was observed infusing Resident #13's eternal feeding at 50 ml/hour and the water flush was set to infuse 130 ml every 4 hours. Nurse #4 was observed changing the setting on the eternal feedings pump to 130 ml/hour for the eternal feeding and water flushes were set at 50 ml every 4 hours. Nurse #4 stated the eternal feeding was not set on the eternal feeding pump as ordered by the physician and she had read the physician's orders wrong and had to reset the eternal feeding pump. The Director of Nursing (DON) was interviewed on 9/15/25 at 8:57 PM. The DON stated Resident #13 enteral feeding pump should have been set at the correct rates for the eternal feeding and water flushes as ordered by the physician.

Based on record review, resident interview and staff interviews, the facility failed to provide written notice of transfer/discharge to residents and to the Ombudsman for residents who were transferred from the facility to the hospital for 2 of 5 residents reviewed for hospitalization (Resident #1 and Resident #10). Findings included: 1. Resident #1 was admitted to the facility on [DATE]. Resident #1 was discharged from the facility and admitted to the hospital on [DATE]. Resident #1 returned to the facility on 5/27/2025. A review of Resident #1's electronic medical record (EMR) revealed no written notice of transfer/discharge was provided to Resident #1 related to the hospitalization on 5/23/2025. Additionally, there was no evidence that the Ombudsman had been notified of the transfer. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact. On 9/18/2025 at 1:20 pm in an interview with Resident #1, he stated he was unable to recall receiving a notice of transfer or a written letter notifying him of the reason he was discharged from the facility to the hospital on 5/23/2025. 2. Resident #10 was admitted to the facility on [DATE]. Resident #10 was discharged from the facility and admitted to the hospital on [DATE]. Resident #10 was readmitted to the facility on [DATE]. A review of Resident #10's EMR revealed no written notice of transfer/discharge was provided to Resident #10 related to the hospitalization on 6/18/2025. Additionally, there was no evidence that the Ombudsman had been notified of the transfer. The significant change MDS assessment dated [DATE] indicated Resident #10 was severely cognitively impaired. In an interview on 9/19/2025 at 2:35 PM, Nurse #5 explained the following information was sent with the resident when they transferred from the facility to the hospital: face sheet, order summary, medication administration record and the completed transfer form. Nurse #5 stated the nursing staff did not send a notice of transfer with the residents. On 9/19/2025 at 5:07 PM in an interview, the Director of Nursing stated the notice of transfer form was not given to residents transferred to the hospital by the nursing staff. On 9/19/2025 at 2:11pm in an interview, the Social Worker stated she started in April 2025, and she had not completed notice of transfer forms for Resident #1 and Resident #10. She added the Social Worker Assistant was responsible for ensuring residents transferred received a notice of transfer. On 9/19/2025 at 2:02 PM in an interview with the Social Worker Assistant, she explained notice of transfers were given to the residents and/or resident's representative by social services staff when transferred to the hospital. She stated the Ombudsman was emailed at the end of each month the number of transfers/discharge and sent a copy of each residents' notice of transfer. The Social Worker Assistant stated she did not have a notice of transfer for Resident #1 when he transferred to the hospital 5/23/2025 or for Resident #10 when she transferred to the hospital on 6/18/2025. She stated Resident #1 and Resident #10 should have been given a notice of transfer and could not explain why they were not given a notice of transfer. She explained since there was no copy of the notice of transfer for Resident #1 and Resident #10, the Ombudsman would not have received notification of the transfers. On 9/19/2025 at 7:00 PM in an interview, the Administrator stated the social services staff were responsible for sending a notice of transfer to the resident or resident representative when transferred to the hospital. She stated a notice of transfer should have been sent to the hospital with Resident #1 and Resident #10, the social services staff should have followed up with Resident #1 and Resident #10 the following day and notified the Ombudsman of the transfer.

Based on record review, and staff interviews, the facility failed to post accurate daily nurse staffing information for 3 of 6 days reviewed (9/12/25, 9/13/25, 9/14/25). The findings included: A review of the daily nurse staff posting by front office on 9/14/25 at 9:51 AM revealed a posting dated Friday, 9/12/25. There was a staff posting dated Saturday, 9/13/25 behind the posting for 9/12/25, and there was no staff posting for Sunday, 9/14/25. The daily nurse staff posting dated 9/12/25 included the Nurse Aide (NA) staffing numbers for the day shift (7:00 AM-3:00 PM) but did not include information about the staffing for the other shifts (3:00 PM-11:00PM and 11:00 PM-7:00 AM).The daily nurse staff posting dated 9/13/25 was blank except for prefilled NA numbers and hours. There was no other information on the posting, including the census, the staffing for the licensed nurses, or the total number of hours worked. In an interview on 9/19/25 at 6:06 PM, the Director of Nurses (DON) said she had started as the DON in the facility in July 2025 and had to check who was responsible for the daily posting on the weekends. She stated the weekend Nurse Supervisor was supposed to be responsible for maintaining the daily staffing posting on the weekends but had not been assigned or trained to do that so it had not been done. In an interview on 9/19/25 at 6:57 PM, the Administrator stated she was not sure who was responsible for maintaining the daily nurse staffing posting on the weekends but expected that it should have been part of the weekend Nurse Supervisor's duties. The weekend Nurse Supervisor was unable to be interviewed.

Based on record review, and resident, staff, Nurse Practitioner (NP), surgical specialist's staff and Medical Director interviews, the facility failed to administer the bowel preparation (the process of cleaning out the intestines) on two separate occasions. The first was for a scheduled colonoscopy (an exam used to look for changes in the large intestine) on 12/17/24 and the second was for a limited sigmoid colon (part of the large intestine that is close to the rectum) resection (the process of cutting out tissue or part of an organ) for a suspicious colon polyp (small growths on the lining of the large intestine) scheduled on 2/24/25. Review of the hospital discharge summary dated 2/24/25 revealed Resident #4 was placed under general anesthesia and the abdominal incisions had been made when the surgeon observed the colon was full of stool and aborted the surgery. The incisions were closed with sutures and a liquid topical skin adhesive and the resident returned to the facility. Resident #4 will require another colonoscopy before the surgery can be rescheduled. This was for 1 of 3 residents reviewed for professional standards in the provision of medical care (Resident # 4). The findings included: Resident #4 was admitted to the facility on [DATE] with diagnoses which included gastrointestinal hemorrhage, benign neoplasm of colon, peptic ulcer, and colon polyp. Review of Resident #4's consultation report dated 12/5/24 completed by the Gastroenterologist (a medical doctor who specializes in the treatment of the gastrointestinal tract) revealed a recommendation for a colonoscopy and provided the bowel preparation orders with instructions. Review of Resident #4's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 as cognitively intact. a. Review of Resident #4's physician orders dated 12/10/24 revealed the following: - Colonoscopy scheduled on 12/17/24 - Resident nothing by mouth (NPO) after midnight on 12/16/24 - On 12/16/2024: Add water to the Fill To level mark of the prep container. SHAKE until everything is completely dissolved. Okay to add [NAME] Light flavoring to the solution. When reconstituted, the solution should be used within 48 hours. Starting at 5:00pm, rapidly drink 8 ounces every 20 minutes UNTIL ALL THE SOLUTION IS GONE. Continue drinking clear liquids until bedtime - At 6:00 pm on 12/15/24 mix 2 capfuls of Polyethylene Glycol in 16 ounces of liquid and drink every 5 to 10 minutes. Take 2 Bisacodyl tablets. - At 7:00 pm on 12/15/24, mix 2 capfuls of Polyethylene Glycol in 16 ounces of liquid and drink over 5 to 10 minutes. Take 2 Bisacodyl tablets. - Clear liquid diet the day before procedure (No solid foods) Review of Resident #4's Medication Administration Record (MAR) for December 2024 revealed the follow: - bowel preparation to be given on 12/16/24 at 5:00 was not initialed as administered - bowel preparation to be given at 6:00 pm on 12/15/24 had an X in the signature block was not administered. - bowel preparation to be given at 7:00 pm on 12/15/24 was not entered on the MAR for administration - nothing by mouth (NPO) order showed a start date of 12/17/24 on December MAR A progress noted dated 12/17/24 completed by the previous Director of Nursing (DON) revealed Resident #4 was unable to attend the colonoscopy appointment scheduled for 12/17/24 because he drank a 1/2 can of soda and had not completed the bowel preparations. The previous DON called the provider's office to get the procedure rescheduled. The procedure was rescheduled for 1/7/25. It was noted the provider would send new prescriptions for the bowel preparations needed for the colonoscopy procedure. During a phone interview with the previous DON on 3/20/25 at 9:33 am, she stated she was made aware this incident on 12/17/24 by Nurse #1. Nurse #1 first reported to the previous DON that Resident #4 did not have orders for bowel preparations but later admitted that she did not give the bowel preparations to Resident #4. The previous DON further explained she called the provider's office and rescheduled the colonoscopy and notified Resident #4's family of the situation. Attempts were made to interview Nurse #1 via phone but were unsuccessful. Nurse #1 no longer worked at the facility. During an interview with the Nurse Practitioner (NP) on 3/19/25 at 10:36 am, she stated she reviewed and approved Resident #4's 12/5/24 gastroenterology consultation report on 12/6/25. The NP further stated the consultation report included the bowel preparation orders for the scheduled colonoscopy on 12/17/24 and expected the nursing staff to administer the bowel preparation for Resident #4 prior to his colonoscopy scheduled on 12/17/24. b. Review of Resident #4's consultation note dated 1/16/25 completed by the Gastroenterologist revealed a colon polyp that was eating into the colon lining and a referral to a surgeon for a partial colectomy (surgical procedure where part of the large intestine is removed) was recommended. Review of Resident #4's surgical consultation note dated 1/29/25 completed by the surgeon revealed the colonoscopy was completed on 1/7/25 and revealed a 20 cm (centimeter) x 15 cm polypoid lesion (small, raised growth that protrudes from the lining of an organ or cavity such as the intestines) that was very suspicious for adenocarcinoma (a type of cancer that starts in the glands that line the organs). The surgeon's assessment and plan was Resident #4 required a limited sigmoid colon (part of the large intestine that is close to the rectum) resection (the process of cutting out tissue or part of an organ). The date for the surgery and the bowel preparation instructions were not included on the consultation report dated 1/29/25. Review of Resident #4's physician order dated 2/5/25 revealed an order for nothing by mouth (NPO) after midnight on 2/23/25 for surgery scheduled on 2/24/25. During an interview with the Scheduler on 3/18/25 at 3:20 pm, she stated she did not remember when Resident #4 returned from his surgical consultation appointment on 1/29/25. She further stated she did not receive any paperwork from the surgeon's office from Resident #4. The Scheduler indicated she reviewed the consultation report and the consultation report did not note any bowel preparation orders. She further indicated she did not recall receiving any telephone orders from the surgeon's office. The Scheduler did not follow up with the surgeon's office to inquire if any paperwork had been given to Resident #4. An interview was conducted with Medication Aide #1 on 3/18/25 at 1:30 pm. Medication Aide #1 explained she worked on 1/29/25 and remembered Resident #4 going to his appointment. Medication Aide #1 did recall if Resident #4 returned from his appointment with any paperwork. She further stated if Resident #4 had returned with any paperwork she would have given the paperwork to Unit Manager #1. A phone interview with Unit Manager (UM) #1 was conducted on 3/18/25 at 6:38 pm. UM #1 stated she was not employed at the facility during January 2025. During an interview with Resident #4 on 3/19/25 at 9:05 am, he stated he did not remember his appointment on 1/29/25 and does not remember if he was given any instructions at that appointment. Resident #4 further stated he did not have any fears of returning to the hospital for the surgical procedure. Review of the Nurse Practitioner's (NP) note dated 2/4/25 revealed Resident #4's surgery was scheduled for 2/14/25 but was rescheduled to 2/24/25 for a robotic (surgical technique that uses a computer-controlled system of robotic arms to assist surgeons) sigmoid colon resection. The NP's note documented Resident #4's current orders were reviewed. During an interview with the Nurse Practitioner (NP) on 3/19/25 at 10:36 am, she stated she did not know why the surgery date changed from 2/14/25 to 2/24/25. The NP indicated she did not remember receiving or seeing any bowel preparation orders for Resident # 4's surgery scheduled on 2/24/25. The NP further stated the Scheduler emailed her on 2/5/25 and requested an order for NPO for Resident #4 after midnight on 2/23/25 and she entered the order in the computer. When asked why she did not question if Resident #4 needed bowel preparations prior to the surgery scheduled on 2/24/25, the NP explained she felt it was the surgeon's office responsibility to follow up with the facility about bowel preparations needed prior to the surgery. Review of Resident #4's February 2025 Medication Administration Record (MAR) revealed no order for nothing by mouth (NPO) for 2/23/25. A progress note dated 2/21/25 completed by the Scheduler documented the family was made aware of Resident #4's surgery was scheduled for 2/24/25 for a colon polyp removal and Resident #4 would be held overnight for observation. During a phone interview with UM #2 on 3/19/25 at 7:42 pm, she stated she was not employed at the facility in January 2025. UM #2 further stated she started working at the facility in February 2025. The UM #2 indicated she never received any bowel preparation instructions for Resident #4 for his scheduled surgery on 2/24/25. She does not know for sure if UM #1 was given the paperwork from this appointment or if Resident #4 received any paperwork. The UM #2 indicated she did not follow up with the surgeon's office. A progress note dated 2/24/25 at 9:11 am completed by UM #1 documented she received call from the general surgeon who inquired if Resident #4 had received bowel preparation prior to the procedure this morning. She notified provider that an order was not received from his office to give bowel preparation and Resident #4 did not receive a bowel prep. A phone interview with Unit Manager (UM) #1 was conducted on 3/18/25 at 6:38 pm, she stated Resident #4 did not have an order for bowel preparation for scheduled surgery on 2/24/25. She did not follow up with surgeon's office to inquire about any bowel preparation instructions. A progress noted dated 2/24/25 at 3:44 pm completed by UM #1 documented Resident #4 returned from hospital from having laparoscopy procedure on the right side of abdomen; noted with 5 surgical wounds closure with glue. The areas were noted with mild redness, no discharge, no swelling. Resident #4 denied nausea and rated his pain a 5 out of 10. UM #1 called the surgical center to receive surgical discharge orders due to no paperwork received on return. Resident #4's vitals signs were within normal limits. Review of the surgical discharge summary dated 2/24/25 revealed the information was faxed to the facility at 1:27 pm which included the instructions for medication changes and post operative instructions for general anesthesia care and laparoscopy care instructions. The NP initialed she received and reviewed this discharge summary at 3:00 pm on 2/24/25. During an interview with the Surgical Specialist's nurse on 3/19/25 at 8:15 am, she stated she remembered Resident #4 and indicated the standardized list of instructions which included bowel preparation instructions was given to Resident #4 at this consultation appointment scheduled on 1/29/25. The Surgical Specialist's nurse further explained that these standardized instructions were given to Resident #4 even though the surgery had not been scheduled on the day of his appointment. During an interview with the Surgical Specialist's scheduler on 3/19/25 at 11:33 am, she stated Resident #4 was given the standardized surgical instructions which included bowel preparation instructions on 1/29/25 at his surgical consultation visit. She further stated the surgical procedure could not be completed on 2/24/25 because the tattoo ink markings (temporary or permanent ink marks placed in the colon to help surgeons locate specific areas or lesions during procedures) were not visible, and Resident #4 had not completed the bowel preparation prior to the surgery. The surgery had not been rescheduled according to the surgeon's office and Resident #4 would need another colonoscopy prior to scheduling the second surgery. Review of the hospital discharge summary dated 2/24/25 completed by the general surgeon revealed Resident #4 was placed under general anesthesia, urinary catheter placed, arterial line in left arm placed, abdominal incisions made for placement of robotic arms. The summary further revealed no evidence of any tattoo ink markings visible and noted the colon was full of stool. The general surgeon called the facility and inquired if Resident #4 had received bowel preparations over the weekend as had been ordered by surgeon's office and was informed Resident #4 did not have bowel preparations. The procedure was aborted at that time. The instruments were removed from the abdomen. The abdomen was cleaned and dried and incisions were closed with suture and Dermabond. Resident #4 returned to the facility. An attempt to interview the general surgeon on 3/19/25 was unsuccessful as he was out of the office on vacation. During an interview with the Director of Nursing (DON) on 3/20/25 at 11:45 am, she stated she has been employed at the facility since 2/13/25. The DON stated she was aware of the surgery scheduled for Resident #4 and offered the explanation of a communication breakdown as to why Resident #4 did not receive the bowel preparation prior to the surgery. The DON further stated going forward that any resident going out for an appointment, the facility will look at the cognitive level of the resident and make a decision if the resident needs a staff member to accompany them to the appointment. The DON indicated that she would meet with the Scheduler after the outside appointments and discuss any information and/or orders received. She stated her expectations of the nursing staff were to follow the provider's orders and follow up or ask questions with the provider's offices in regard to any paperwork and/or instructions given to the residents. The DON further indicated discussions with the nursing staff pertaining to the importance of documentation would be done. During an interview with the Assistant Administrator on 3/20/15 at 12:15 pm, she stated the consultation paperwork was sent with Resident #4 with preoperative instructions but did not have the bowel preparation instructions. The Assistant Administrator further stated the general surgeon's office called the facility and gave the bowel preparation instructions to the Scheduler but was unsure what happened with those bowel preparation instructions. The Assistant Administrator explained her expectations of the nursing staff were to follow up with the provider's offices to ensure instructions were given and followed. In a phone interview with the Medical Director on 3/20/25 at 1:41 pm, he stated he was aware that Resident #4 needed to have a colon polyp removed and was scheduled for surgery. The Medical Director was unaware the surgical procedure could not be completed due to Resident #4 not having his bowel preparations prior to the surgery. The Medical Director further explained that he expected the nursing staff to follow up with provider's offices on any instructions given to the residents but especially with any colonoscopy or procedures which involved the colon a bowel preparation would need to be completed and the nursing staff should have followed up with the general surgeon's office.

Based on record review, and resident and staff interviews the facility failed to ensure cognitively intact residents who were assessed as unsafe smokers were supervised while smoking and did not have smoking materials in their possession for 2 out of 4 residents reviewed for smoking (Residents #1 and #2). Findings included: 1. Resident #1 was admitted to the facility on [DATE] with medical diagnoses which included Huntington's disease and ataxia (lack of muscle coordination and control). Resident #1's care plan updated on 8/25/23 revealed that he may smoke while supervised per the smoking evaluation due to a history of unsafe smoking habits. Interventions: Ensure that appropriate cigarette/e-cigarette device(s) disposal receptacles are available in smoking areas, lighters/lighter fluid or matches must be maintained by center staff, e-cigarette charging must occur at the nurses station, educate patient/health care decision maker on the facility's smoking policy, inform family and significant others that the patient needs supervision while smoking, inform and remind patient of location of smoking areas and times, monitor patients compliance to smoking policy, maintain patients smoking materials at nurses' station, and provide education/material regarding smoking cessation as needed and as resident will allow. A smoking evaluation dated 10/9/24 revealed that Resident #1 required supervision when smoking due to unsafe smoking habits (has a history of sharing/selling smoking material). Resident #1 was educated on the facility's smoking policy and outcomes of the smoking evaluation. Failure to comply with the smoking rules could result in termination of the smoking privileges and/or initiation of a discharge plan. The 12/16/24 quarterly Minimum Data Set (MDS) assessment revealed Resident #1 had no cognitive impairments and was independent with all activities of daily living (ADL). An incident report dated 12/22/24 at 6:39 PM and completed by the Nurse Supervisor revealed that Resident #1 inappropriately extinguished a cigarette with his shoe, and he had loose frayed jeans. Nurse Aide (NA) #4 observed Resident #1 standing in the smoking area alone. He did not have a cigarette in his hand, but she saw smoke and flames at the bottom of his pants and shoes. The flames were around the bottom 1 inch hem of his pants that were noted to be ragged and frayed. NA #4 stomped out the pants that were dragging on the ground and Resident #1 was trying to assist. NA #4 saw a smoldering cigarette on the ground and extinguished it with her foot and took Resident #1 inside. NA #5 was noted to come up the hall and accompanied Resident #1 back to his room. NA #5 noted some additional smoke and tossed a cup of water from Resident #1's bedside onto the hem area of his pants. NA #5 assisted Resident #1 with removal of his pants, shoes, and socks as NA #4 went to get the nurse. The shoe heels were damaged and the hem of his pants. There were no obvious signs of injury. The Nurse Supervisor entered the room, assessed Resident #1, and did not identify any trauma. As NA #5 was assisting Resident #1 looking for socks, she discovered approximately 30 lighters. NA #5 notified Nurse #3 lighters. The lighters were confiscated and locked up for safekeeping. A skin assessment was completed by (Nurse #3) and there were no injuries noted. (Resident #1) also denied injuries. The Maintenance Assistant entered the building at 6:55 PM to verify safety measures were in place. There was a fire blanket and an updated fire extinguisher available in the smoking area. The ashtrays were emptied, and the red smother can was available. A nursing progress note dated 12/22/24 at 8:58 PM by the previous DON revealed #1 had on frayed, loose jeans and inappropriately extinguished a cigarette using his shoe instead of the designated area. Resident #1 was noted by Nurse Aide (NA) #4 to have a small flame coming from bottom of his right pant leg. When the flame was observed, per staff, NA #4 extinguished the flame immediately for safety. Nursing performed a head-to-toe assessment with no noted injuries. A skin check assessment dated [DATE] of Resident #1 revealed that he had no skin issues, and a foot evaluation was completed. During a phone interview with Nurse #3 on 2/12/25 at 10:46 AM, she revealed that on 12/22/24 NA #4 reported that she had seen Resident #1 out in the smoking area with his pants on fire. He was then accompanied back to his room by the NA #4 and NA #5. Nurse #3 stated that she then notified the Nurse Supervisor, and both went to evaluate him. She was told by NA #5 that Resident #1's pants were still singed when she attempted to take his pants off. There were no injuries, burns, or open skin areas. Resident #1 was then put on 1:1 supervision for the rest of the day without being able to go outside to smoke. He then needed to be evaluated by the previous DON to be cleared for future smoking activity. Nurse #3 stated that there was a mass number of lighters in his room, which were collected and put in a secure area for the previous DON to review. Nurse #3 indicated that she had worked at the facility as a short contract agency nurse and could not speak to Resident #1's past. She believed that he was a supervised smoker prior to 12/22/24. A phone interview attempt was made with NA #4 to discuss the events on 12/22/24, however, the NA was unable to be reached during the investigation. NA #5 was interviewed via telephone on 2/12/25 at 3:54 PM. She revealed that Resident #1signed himself out of the building on 12/22/24. He returned to the facility, went to the smoking area, and NA #4 noticed that his pants were on fire. NA #4 brought him back in the facility, and NA #5 helped escort him to his room. That was when she noticed that his pant leg was still partially on fire. NA #4 went to notify the nurse. She noticed that Resident #1 was not acting right, and with Resident #1's permission, she looked through his drawers for socks and found around 20 lighters. Before the event on 12/22/24, she just assumed Resident #1 was an unsupervised smoker because she saw him in the smoking area on his own many times before. There was a list of smokers located with the smoking materials bin that was updated multiple times, but she could not provide a when the last time it was updated. A phone interview was conducted with the Nurse Supervisor on 2/12/25 at 4:03 PM. She revealed that on 12/22/24, NA #4 notified her Resident #1 was smoking and he was on fire, which she had to put out. When the Nurse Supervisor asked Resident #1 about the incident, he said that he could not remember he was smoking and on fire. In his room, he had a lot of lighters that were confiscated. She explained that he often left the facility and went to the store. She was also told by NA #4 and NA #5 that his pant leg was still smoking when he was brought inside the facility. His pants were taken off, and she performed a skin check without any injuries noted. Resident #1 was then put on 1:1 supervision. Resident #1 was interviewed via telephone on 2/12/25 at 11:31 AM. He stated that about a month ago, his pants caught on fire when he was outside in the smoking area and that was when his smoking privileges were reduced to being supervised. During an interview with the Assistant Administrator on 2/12/25 at 2:58 PM, she revealed that a staff member (unknown) contacted her on 12/22/24 about Resident #1's pants were on fire. She came to the facility to assess the situation. The Assistant Administrator stated that she had observed Resident #1 was not injured or harmed. Maintenance came out the same day to evaluate the safety of the smoking area, and Resident #1 was also educated. Resident #1 was a supervised smoker at the time of the 12/22/24 incident. The Assistant Administrator could not say how Resident #1 retrieved a lighter or cigarette. Resident #1 would leave the facility and go to the store, and what he purchased was unknown. Resident #1 was alert and oriented and was considered an unsafe smoker prior to 12/22/24 due to the history of sharing cigarettes. A phone interview was conducted with the previous DON on 2/12/25 at 11:57 AM, and she revealed that on 12/22/24 Resident #1 was outside in the smoking area, and he put a cigarette out with his foot. She stated that the bottom of his jeans was frayed. A staff member was not outside with him in the smoking area at the time. After that day, Resident #1 was then determined to be a supervised smoker. The previous DON indicated that she was unaware Resident #1 was a supervised smoker since 10/23/23. The previous interim Administrator was interviewed via telephone on 2/12/25 at 12:21 PM. He revealed that he heard what had happened with Resident #1 on 12/22/24 from the Assistant Administrator. She told him that a bag of lighters were found in Resident #1's room during the search. She told him that the fringe on his pants caught fire when he was putting out a cigarette in the outside smoking area. The previous interim Administrator could not recall whether Resident #1 was a supervised or unsupervised smoker prior to 12/22/24. All other details related to this incident; the previous interim Administrator stated that he could not recall. He indicated that he came in on the tail end of the situation and nursing performed all necessary research on the issue. During an interview with the Administrator on 2/12/25 at 5:05 PM, he revealed that Resident #1 was smoking unsupervised and retained smoking materials from an unknown source. Resident #1 should not have received any smoking materials from any source, and he should have been supervised while out in the smoking area during a designated smoking time. 2. Resident #2 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with medical diagnoses which included chronic obstructive pulmonary disease (COPD), congestive heart failure, and absence of right and left fingers. Resident #2's 01/12/23 care plan revealed that he acted in a problematic way by inappropriate smoking related to decreased safety awareness. The smoking interventions included: Nursing staff to assist resident to the designated smoking area during established/predetermined facility smoking times, not to leave resident unattended while smoking, supervise resident while smoking, document episodes of inappropriate smoking or potential smoking policy violations and report observations to Administrator and/or administrative staff, place smoking materials at nurses' station for storage, provide resident education on smoking policy, and provide a smoking apron for resident. The smoking evaluation dated 10/9/24 for Resident #2 revealed that he was an unsafe smoker and required direct supervision while smoking. He was re-educated on the smoking policy and was given a copy of the policy. The 11/11/24 significant change Minimum Data Set (MDS) assessment revealed Resident #2 had no cognitive impairments, had impairment on both sides of the upper limbs, and used a walker as a mobility device. He was also coded with current tobacco use. An incident report dated 1/8/25 at 1:45 PM completed by Nurse #1 revealed that Resident #2 came to Nurse #1 to re-wrap the bandage on his left hand. The bandage was visibly burnt. There was no damage to the skin, no burns, redness, or open areas noted. Resident #2 stated that he was outside smoking. He was not smoking during supervised smoking times, and no staff were there monitoring him. Resident #2 stated: It's no big deal. Resident #2 did not have any fingers on either hand. Nurse #1 was interviewed via telephone on 2/11/25 at 12:00 PM. She revealed that on 1/8/25 around 1:00 PM, she was walking down the hallway and noticed Resident #2's left hand bandage was burnt. Resident #2 asked Nurse #1 to change his bandages, which were covered by self-adherent wrap. He told her that he was outside smoking and dropped ashes on the bandage. He said it was no big deal, and he was reminded that he could not smoke unsupervised. Nurse #1 asked Resident #2 to come back to the unit where she was assigned, so that she could rewrap his hands. Resident #2 then went to Nurse #2 to rewrap the bandages. Only the left hand self-adherent wrap was burnt, and the right bandage looked like it was chewed. There were no injuries noted to either hand. Nurse #1 then notified the previous Director of Nursing (DON) and the previous interim Administrator about Resident #2's bandages and smoking unsupervised. She did not observe who gave or lit Resident #2's cigarette, but he told her that Resident #2 lit the cigarette for him. Nurse #1 indicated that supervised smokers get their cigarettes from a locked bin at nurses' station 3 behind a locked door. The assigned NA at each designated smoking time usually brought the bin outside, and the supervised smokers got one cigarette at a time. She was unsure about the process for unsupervised smokers, but only supervised smokers went out at the designated times. Resident #2 was interviewed on 2/11/25 at 1:05 PM, and he revealed that he did not smoke outside without being supervised on 1/8/25. He was outside with staff and when he ashed his cigarette, it singed his bandage and he could not feel it due to neuropathy. He said he did not get the cigarette from a resident, and he received it from staff during a designated smoking time. Attempts to interview by phone Nurse #2 were made, but he was unable to be reached during the investigation. NA #1, who was assigned to the smoking area at 7:30 AM on 1/8/25, was interviewed via telephone on 2/11/25 at 1:45 PM. She heard about the incident on 1/8/25 when Resident #2 was outside, someone caught him, and his bandage was singed. She had no idea how he got the cigarette or who lit it for him. NA #2, who was assigned to the smoking area at 10:30 AM on 1/8/25, was interviewed via telephone on 2/11/25 at 1:10 PM. He stated he was unaware that Resident #2 was smoking unsupervised on 1/8/25. There was a list of smokers on the smoking bin that held the cigarettes. Cigarettes were dispersed 1 at a time during designated smoking times, so that residents did not have any smoking materials in their possession. NA #2 stated he assisted the supervised smokers as needed, but he had never seen Resident #2 smoke on his own. NA #3, who was assigned to the smoking area on 1/8/25 at 2:30 PM, was contacted via telephone during the investigation, but she did not return the call. An interview with the Assistant Administrator was conducted on 2/11/25 at 11:18 AM. She revealed that she was called to the facility by a staff member (unknown) on 1/8/25 around 1:00 PM and reported that Resident #2 was outside smoking unsupervised. His hands were wrapped with bandages, he had no fingers, and he held the cigarette in between his palms. Resident #2 was supposed to use a special apparatus to assist him with smoking. After she arrived at the facility, she met with Resident #2. It looked like there was a small, singed area on one of his dressings (left), but she did not observe any open areas or exposure of any skin. The Assistant Administrator asked Resident #2 about the smoking incident earlier that day, but he could not remember who gave him the cigarette or who lit it for him. When she asked him why he went out on his own, he did not give any explanation and shrugged his shoulders and said: I won't do it again. The Assistant Administrator stated that she spoke to other residents outside, including Resident #1, and they stated they did not give Resident #2 a cigarette nor did they light it for him. It was explained to Resident #2 that due to his willful neglect of the smoking policy, his smoking privileges would be revoked, or he would be given a 30-day discharge notice if he were caught smoking unsupervised again. The Assistant Administrator stated that she, the previous interim Administrator, and previous DON spoke with Resident #2 and his family member on a conference call about his failure to abide by the smoking rules. The family member urged Resident #2 to follow the rules. The Assistant Administrator further stated, to her knowledge, that Resident #2 did not previously smoke unsupervised. However, in the past, he handed out cigarettes to other residents and refused to wear the smoking apron. The previous DON was interviewed via telephone on 2/11/25 at 12:37 PM. She revealed that she was out of the building on 1/8/25. She stated that Nurse #1 notified her about what happened on 1/8/25 when Resident #2 was allegedly caught smoking unsupervised without the required adaptive smoking device. She was involved on the phone during the conference call with Resident #2's family member after he was found smoking unsupervised on 1/8/24. The Assistant Administrator warned Resident #2 about the 30-day discharge notice because Resident #2 was caught smoking unsupervised. She could not recall how Resident #2 got the cigarette or lighter, but stated it was probably from one of the unsupervised smokers. The previous DON indicated that the smoking materials were kept locked up at nurses' station 3. There were bins that held smoking materials for all smokers, including unsupervised smokers, and were labeled with the residents' names. She believed Resident #2's unsafe smoking habits were related to him not having any fingers, otherwise, she was not aware of any other unsafe smoking habits. During a follow-up phone interview with the previous DON on 2/12/25 at 10:23 AM, she recalled that when Resident #2 was asked how he got the cigarette and lighter on 1/8/25, he said he found them on the ground. Often the smokers said I don't remember to any incriminating question related to smoking because they chose not to snitch on each other. Cameras were installed at the smoking area a week before she left the facility, which was 2/6/25. The previous interim Administrator was interviewed via telephone on 2/11/25 at 12:53 PM. He revealed that he could not recall the incident involving Resident #2 on 1/8/25. He stated that Resident #2 could smoke, but he needed an apparatus to assist that could fit in his hand. The previous interim Administrator indicated that the Assistant Administrator handled all situations with the smokers. During an interview with the Administrator on 2/12/25 at 5:02 PM, he revealed that Resident #2 was smoking unsupervised on 1/8/25 and retained smoking materials from an unknown source. He stated that Resident #2 should not have held smoking materials from any source, and he should have been supervised while out in the smoking area during a designated smoking time.

Based on record review, and interviews with staff, medical physician, responsible party, nurse practitioner and paramedic, the facility failed to ensure staff notified the physician when a resident (Resident # 13) was observed by nurse aides to be zonked, talking out of his head, not eating any of his supper meal and complaining of being tired in conjunction with a new rash observed on multiple areas of his body by multiple staff members. Additionally, one staff member referenced the rash as a death rash and thought the physician had already been notified. The resident was transferred to the hospital by emergency services when staff called 911 the following day. The resident was identified to be in septic shock and expired while hospitalized . (Sepsis occurs when an individual's immune system has a wide spread reaction to an infection which can lead to multi system organ failure and is considered life threatening. Septic shock is the last stage of sepsis and results in a low blood pressure). Additionally, the facility failed to notify the responsible party when Resident # 6 had a change in her narcotics. This was for two of five residents who were reviewed for change in condition and or treatment orders (Resident #13 and Resident #6). The findings included: Immediate jeopardy began on [DATE] when Resident # 13 was observed to have a rash, which was described by one staff member as a death rash, on multiple areas of his body in conjunction with a change in his mental status and eating habits without the physician being notified. Immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D to ensure education is completed and monitoring systems put in place are effective. The facility is being cited at a scope and severity level of D for example # 2 regarding Resident # 6. 1. Resident # 13 was admitted to the facility on [DATE]. Review of Resident # 13's [DATE] hospital discharge summary. The [DATE] hospital discharge summary listed the following diagnoses at the time of hospital discharge: proctocolitis (inflammation of the colon and rectum), failure to thrive, hyponatremia, emphysema, lung lesion, abdominal aortic aneurysm, aneurysm of the iliac artery, trochanteric avulsion fracture of the femur, external iliac artery occlusion, compression fracture of thoracic vertebra, compression fracture of lumbar vertebra with delayed healing, and urinary retention. He was discharged to the facility for rehabilitation on [DATE]. Review of physician orders revealed the resident was a full code. This order remained as an active order until the resident was discharged . Nurse # 5 had cared for Resident # 13 on [DATE] from 7:00 AM to 7:00 PM. Nurse # 5 was interviewed on [DATE] at 1:40 PM and again on [DATE] at 12:15 PM. Nurse # 5 reported the following information. The resident had been voiding and going to the bathroom on [DATE]. He did not recall any problems with the resident on his shift. Supper trays did not arrive till the end of the shift or after his shift, and he did not recall anyone mentioning to him that Resident #13 was having problems. He knew the resident was planning to go home. NA # 10 had cared for Resident # 13 on the 7:00 AM to 3:00 PM shift on [DATE]. NA # 10 was interviewed on [DATE] at 1:14 PM and reported the resident was fine on her [DATE] shift and he was excited because he was planning to go home. There were no nursing progress narrative notes for the date of [DATE] or any documentation the physician was consulted about changes in the resident's status. The next nursing narrative in the record was documented on [DATE] at 8:47 AM by Nurse # 5 who documented, Resident sent out to hospital via EMS on a stretcher. Resident presented with altered mental status only responding to name being called with eyes opening. Vitals: ,d+[DATE], 42, 97.7, 30 breaths/min (minutes), O2 (oxygen) saturation was undetectable with absent bilateral radial pulses. Rapid, shallow breathing with use of accessory muscles. Resident is full code, notified (provider) at approximately 0805 (8:05 AM) about residents condition and plan to send out to {name of hospital} O2 administered at 3 Liters and monitored with AED (automated external defibrillator) at bedside until EMS arrived at approximately 0815 (8:15 AM). ). ( A systolic blood pressure reading of less than 90 or a diastolic blood pressure reading of less than 60 is considered hypotension (low). A normal pulse is 60 to 100. Normal respirations are ,d+[DATE].) Nurse Aide (NA) # 8 cared for Resident # 13 from 3:00 PM to 11:00 PM on [DATE]. NA # 8 was interviewed on [DATE] at 12:44 PM and reported the following information. The resident had a rash on his body during her shift. It was on his arms, his back, his stomach, and top of his legs. She had never seen the rash on Resident # 13 before when she took care of him, and it was a new problem. He was also zonked like, not himself and did not want to eat. She was able to get him to drink some for supper but he ate nothing at all for his supper meal which was not like him. He usually would eat. The RN Supervisor (Nurse # 9) and Medication Aide (MA) # 1 came into the room to look at the rash that evening before Nurse #8 came on duty. One of them called his name trying to get him to respond. He did look up at that point and they asked him if he itched or was in pain. The resident was able to say no. She thought that someone put him on the physician's board to be seen. Near the end of the shift he livened up some. Medication Aide # 1 was interviewed on [DATE] at 1:44 PM and reported the following. She had been called by a Nurse Aide to look at Resident # 13 on the evening shift of [DATE]. He had a rash all over his body in various places. When she looked at the rash a thought process went through her head that it looked like what she had seen before as ringworm, but it was not raised. It was beyond her scope of practice to know what to do and therefore the Nursing Supervisor (Nurse # 9) was called. The resident wanted to be left alone. Nurse #9 was interviewed initially on [DATE] at 2:42 PM and reported she worked all over the facility as the evening shift (3:00 to 11:00 PM supervisor) and did not recall the resident well. She planned to review the record. Nurse #9 did report at that time that if there was something that needed to be communicated to a physician they could call and face time after business hours with a provider. If it was not deemed important, then it could be placed on a physician's communication board for a resident to be seen when they arrived at the facility the next time. Nurse # 9 was interviewed again on [DATE] at 12:41 PM and reported after looking at the resident's record she recalled the following information. On the evening of [DATE] the resident had a rash that appeared as red circles and white in the middle. To her it did not look like mottling ((discolored patches of skin which can result from a lack of blood flow to the skin). It was on his legs, arms and chest. The resident was sleepy. He did not carry on a conversation but he was able to answer questions. She did not know his baseline well. She did recall someone saying the rash was a death rash but she did not recall who said it or when it was said. She felt NA # 8 was a good Nurse Aide. She (Nurse #9) did not recall NA #8 mentioning that the resident did not eat or was zonked on the evening shift. According to Nurse #9 that did not mean that NA # 8 did not tell her. She (Nurse #9) could have been told and was not remembering. When she (Nurse #9) looked at Resident # 9's rash she did not take the resident's vital signs. She did not know if others had done so. She did not call the physician on her shift. On [DATE] at 2:39 AM Nurse # 8 documented a skilled evaluation which noted the following information. The resident's skin was warm and pink with brisk capillary refill. He was alert and oriented. His pulse registered 70 at 10:52 PM on [DATE], respirations16 at 10:52 PM on [DATE], oxygen level 100 % at 10:52 PM on [DATE]. The resident was documented to have brusing on his left forearm and brusing on his left wrist. There was no information in the nursing entry regarding any type of rash on the resident's body. Nurse # 8 had cared for Resident # 13 from 7 PM on [DATE] until 7:00 AM on [DATE]. Nurse # 8 was interviewed on [DATE] at 9:44 AM and reported the following information about caring for Resident # 13 on her shift. The resident had a rash on her shift which Nurse # 8 referred to as a death rash while being interviewed by the surveyor. When she arrived for work at 7 PM she thought the rash had already been reported to the physician and that the resident had already been checked by the physician. The rash was circular and showed up as redness on his skin. It appeared on his legs and his stomach. When interviewed by the surveyor what the plan was for the death rash, Nurse # 8 was not sure about that. She did not call the physician about further treatment orders concerning the death rash. She reported that the resident was stable and she checked his oxygen saturations which were okay. The Nurse Aide (Nurse Aide # 9) who had worked with him during the night shift had also said he was okay. Then at change of shift at 7:00 AM on [DATE] when she and another nurse (Nurse # 5), who had come into work at 7:00 AM, were counting controlled substances, a nurse aide approached them. She did not recall which nurse aide. The nurse aide let them know Resident # 13 was awake but would not say anything. She and Nurse # 5 went to the room. She grabbed a crash cart. The resident was still pink when they went into the room and they sent him out to the hospital. NA # 9 had cared for Resident # 13 from 11:00 PM on [DATE] until 7:00 AM on [DATE]. NA # 9 was interviewed on [DATE] at 10:00 AM. NA # 9 reported the following information. The resident was not doing too well. On rounds through the night, he would say he was okay but would complain of being tired and needing sleep. She checked on him each round and would encourage him to get some sleep. He also had a rash. She had never seen anything like it before and remembered asking herself, What kind of rash is this? It appeared as big splotches of red. The rash also appeared as squiggly, squiggly lines and it was on the resident's stomach, his buttocks and his scrotum. During her last rounds on night shift she asked him if he wanted water and he said nuh uh and nothing further. NA # 10 had cared for Resident # 13 on the 7:00 AM to 3:00 PM shift on [DATE]. NA # 10 was interviewed on [DATE] at 1:14 PM and reported the following information. She did rounds with the night shift NA (NA # 9) when she got to work. They looked in on Resident # 13 during that time. He was not talking at that point. NA #9 said he had not been like that during the night. According to NA # 10 at times the resident did not wake up and talk always and she continued the rounding with NA # 9. Around 8:00 AM she took Resident # 13 his breakfast tray and he would not wake up at that point and eat. She immediately went and got Nurse # 5. Nurse # 10 was assigned to care for Resident # 13 on the 7 AM to 7 PM shift of [DATE]. Nurse # 10 was interviewed on [DATE] at 11:03 AM and reported [DATE] was her second day working at the facility as an agency nurse. Nurse # 10 reported the following information. During report at 7:00 AM, Nurse # 8 had reported that Resident # 13 had a rash since the day before. That was all that was said about the rash. There was nothing said that would signify the resident's physician needed to be contacted right away. There was no mention that the rash was a death rash. After report, a Nurse Aide went to Nurse # 5. (Nurse # 5 was working on the hall, was a routine nurse at the facility, and knew the resident). The Nurse Aide let Nurse # 5 know that something was not right with Resident # 13. She and Nurse # 5 both went in the room. She (Nurse # 10) saw that the resident's breathing was wacky and his respirations were in the 40s. Nurse # 5, who routinely worked at the facility knew what to do and called 911. They (she and Nurse # 5) stayed with the resident until EMS arrived. The resident also had mottling on his legs, arms, and chest. Nurse # 8 had not left the facility while she and Nurse # 5 were waiting with the resident and she came into the room. Nurse # 10 reported that it was verified that what Resident # 8 had reported as a rash and had been seeing on the previous shift appeared as mottling to her. Nurse # 10 reported it was very evident the resident was mottled. During the interviews with Nurse # 5 on [DATE] at 1:40 M and again on [DATE] at 12:15 PM, Nurse # 5 reported the following information. He had already started his medication pass when a Nurse Aide came to get him. He did not recall which Nurse Aide. When he went to check the resident, the resident had mottling on all his extremities. The mottling was very noticeable. His breathing was rapid. The resident was not responding to a sternal rub. His vital signs were very low. He checked his code status and called 911. Review of EMS records revealed the following information. They were called at 8:05 AM on [DATE]. They were at the facility at 8:14 AM and at the resident's side at 8:17 AM. At 8:17 AM the paramedic documented the resident was nonresponsive. His blood pressure was ,d+[DATE], heart rate 121 and respirations 28. They were unable to get a good oxygen reading on him due to his fingers being cold. The paramedic documented in part, The nurse in the room stated that normally the patient is talkative is cussing them out however in the last hour he has become non-responsive and starting to breath fast. The patient does not normally wear O2. When I called the resident's name he would flutter his eyes but no other responses. He was very skinny and all of his ribs were showing. He was barrel chested. His skin was pink and looked like it began to model (mottle) on his legs, arms and the lower half of his stomach. The paramedic, who responded on [DATE], was interviewed on [DATE] at 4:04 PM and reported the following. Upon her assessment she found Resident # 13 to have mottling on his legs, arms, hands and feet. She described the mottling as blotchy skin, circular, reddish blue. There was no other rash that she saw on the resident's body. The only response he was making was that he would blink his eyes a little to his name. Otherwise he was nonresponsive. He was very thin and looked very sick to her. The hospital ER records, dated [DATE], noted the following information. The resident's skin was mottled upon arrival and he was nonresponsive. His systolic blood pressure was in the 70s and they were unable to obtain an oxygen level on him. Fluids, which had been started by EMS, were continued and lab work was done. The resident was intubated (a tube was placed down the resident's airway to facilitate breathing) soon after arrival (9:30 AM on [DATE]). Labs and diagnostic tests were performed. A central line (a long catheter for intravenous fluids which goes to a vein near an individual's heart) was placed at 11:40 AM. The resident was admitted to the Intensive Care Unit (ICU)for care. The resident's admitting ICU note indicated the resident's principle problem was septic shock which was secondary to pneumonia. The resident's chest x-ray showed multilobar bilateral pulmonary nodular opacity superimposed on emphysema, likely multilobar pneumonia although a component of neoplasm is not excluded. A review of the resident's hospital discharge summary included the following information. The resident expired at the hospital on [DATE]. While hospitalized his blood cultures had grown MRSA (Methicillin Resistant Staphylococcus Aureus). Sputum cultures had grown staph and pseudomonas. His urine specimen had grown staph and strep. By [DATE] he had minimal urine output and remained on full mechanical ventilation. Family was consulted by the hospital staff and the decision was made to make the resident comfort measure only. He was withdrawn from mechanical ventilation and his time of death was listed as 10:05 PM on [DATE]. The Director of Nursing was interviewed on [DATE] at 4:20 PM, [DATE] at 10:17 AM, and [DATE] at 1:25 PM and reported the following. It had not been called to her attention that the resident had a death rash on [DATE] or any problems related to his care before he was transferred out to the hospital. After hours the facility had a telehealth provider who could be called if needed for acute changes in condition. She had looked into the situation after the surveyor brought to her attention that the nurse was reporting the resident had a death rash on the evening prior to him being transferred to the hospital. She had found that no one had contacted the provider on [DATE] or on the morning of [DATE] before the resident was in an emergency situation. Resident # 13's medical physician, who served as the facility's medical director, was interviewed on [DATE] at 2:12 PM and again on [DATE] at 2:11 PM and reported the following. During the interview, the surveyor shared with the physician the interviews provided by the nursing staff as it related to how the resident's rash had been described in conjunction with what NA # 8 had observed on [DATE]. The medical director, reported the following. A rash by itself does not warrant immediate urgency or notification to the physician. A rash in conjunction with a change in mental status, change in vitals, any decline can be a red flag and can escalate the need to act. A death rash or mottling would indicate someone was in critical condition. If he had been called and told the resident had a rash on the evening of [DATE] as described by Nurse # 9, Nurse # 8, NA # 8, and NA # 9 along with information that the resident had been noted by NA #8 not to eat anything for supper, was talking out of his head, and zonked then he would have expected them to do a critical assessment of the resident to determine if fluids needed to be started and he would have had the resident sent out to the hospital. He had reviewed the record also and the vital signs noted in the facility record on [DATE] when EMS was summoned would have indicated the resident was in shock at the time EMS was called. Shock can happen quickly as sepsis occurs. The resident was very thin and his baseline indicated he was possibly immunocompromised and did not have the reserves a robust person to fight the infection and sepsis. Therefore, he did not feel the outcome would have been different for the resident if they had called the evening prior to [DATE]. The facility was notified of immediate jeopardy on [DATE] at 5:02 PM. The facility submitted the following immediate jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance F-580- Notification of Change in Condition: The facility failed to notify the Physician of a change of condition for Resident #13 in a timely manner and failed to have effective systems in place for Nursing staff to know what changes need to be reported and what needs to be reported immediately. The Director of Nurses and/or designee conducted a 30 day look back to review other residents identified with a change in condition to verify Physician and/or Provider was notified in a timely manner. This review was completed by the Assistant Director of Nursing (ADON) on [DATE] and consisted of a thorough review of change of condition assessments. A change of condition is identified as a significant change in the patient's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) Change of Condition assessments are located in our electronic medical record under the user defined assessments in Point Click Care. No additional concerns were identified. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete The Nurse Practice Educator (NPE) and/or designee re-educated Licensed Nurses on facility policy Change of Condition: Notification of and Physician/Advanced Practice provider (APP) Notification with emphasis on changes that require immediate physician notification and documentation by [DATE]. Changes requiring prompt notification include a significant change in resident physical, mental, or psychosocial status, an accident involving the resident that results in injury or the potential for requiring physician intervention, a need to alter treatment significantly, and a decision to transfer or discharge the resident. Additionally, re-education was completed with Certified Nursing Assistants on early identification of changes in condition and prompt notification of changes to the Licensed Nurse by [DATE]. The E-Interact Stop and Watch tool/alert was introduced as an early warning tool to be utilized by direct care givers as another mechanism to communicate changes in condition to the Licensed Nurse. The Director of Nursing and/or Nurse Practice Educator will track and verify that employees with scheduled time off, on leave of absence (FMLA), vacation, agency staff or PRN staff will be re-educated prior to returning to duty. New hires will be educated by the Nurse Practice Educator during the orientation process. Effective [DATE], the Director of Nursing and/or designee will review changes in condition by reviewing the change in condition assessments, and stop and watch alerts in the morning Clinical Meeting to verify prompt and/or immediate notification is communicated to the Physician and/or Provider. Removal of Immediate Jeopardy is [DATE]. Onsite validation of the immediate jeopardy removal plan was completed on [DATE]. Interviews confirmed that all staff were educated on significant changes in resident physical, mental, or psychosocial status, an accident involving the resident that results in injury or the potential for requiring physician intervention, a need to alter treatment significantly, and a decision to transfer or discharge the resident. Nurse aides indicated they would notify the nurse about any changes in condition of a resident. Additionally, re-education was completed with Certified Nursing Assistants on early identification of changes in condition and prompt notification of changes to the Licensed Nurse. Training was completed on the E-Interact Stop and Watch tool/alert and passed post testing required. The Stop and Watch tool/alert was successfully used for one resident who experienced shortness of breath. Verification was completed for all staff scheduled to work on [DATE] were re-educated prior to returning to duty. Review of documentation revealed 1 resident had a change in condition on [DATE] related to a fall; all facility policy and procedures were followed, MD/NP notified, no injury sustained requiring hospitalization . The immediate jeopardy removal date of [DATE] was validated. 13030 2. Resident #6 had diagnoses of history of dementia, left femur fracture, chronic pain syndrome, and neuropathy. Documentation on the most recent quarterly Minimum Data Set assessment dated [DATE] revealed Resident #6 was coded as having severe cognitive impairment with scheduled pain medication and receiving opioid pain medication for frequent moderate pain. Documentation in the physician orders for Resident #6 revealed an order dated as initiated on [DATE] and discontinued on [DATE] for 10 milligrams (mg) of Oxycodone Hydrochloride (HCL) extended release (ER) to be administered as 1 tablet by mouth every 12 hours for pain. Documentation in the physician order for Resident #6 revealed an order dated as initiated on [DATE] for 15 milligrams of Morphine Sulfate ER to be administered as 1 tablet by mouth every 12 hours for pain. This order was renewed and continued [DATE] through [DATE] for Resident #6. Documentation in a Nurse Practitioner (NP) #1 progress note dated as initiated on [DATE] and signed [DATE] revealed Resident #6 had an order placed on [DATE] to discontinue the Oxycodone ER and change to Morphine ER for the treatment of chronic pain. An interview was conducted with NP #1 on [DATE] at 9:21 AM. NP #1 revealed the Responsible Party (RP) for Resident #6 was very involved her care and emailed and communicated with the facility on a regular basis her concerns and questions. NP #1 indicated a month prior to the change of Oxycodone ER to Morphine ER for Resident #6, the pharmacy let her know that the medication Oxycodone was requiring prior authorization, and the medication Oxycodone would no longer be covered under her insurance. NP #1 stated she ordered the equivalent of pain medication strength in Morphine for Resident #6 so that she could be kept comfortable. NP #1 stated she puts the orders into the electronic medical record, but it was the responsibility of the nursing staff to notify the RP for Resident #6 of the change in medication. NP #1 did not feel like the medication change had altered Resident #6 in any way other than perhaps making her feel more comfortable allowing her to get more rest. The RP for Resident #6 was interviewed on [DATE] at 1:11 PM. The RP for Resident #6 provided the following information. Resident #6 had a slow healing femur fracture and had been taking 10 mg of Oxycodone ER twice a day since November of 2023 with no problems. The RP noted a change in Resident #6 in [DATE] in that she was sleepier and not as alert. The RP was notified by the Director of Nursing (DON) on [DATE] via an email Resident #6 had a change in medication from 10 mg Oxycodone ER twice a day to 15 mg Morphine ER twice a day on [DATE]. The RP for Resident #6 was not notified of this change in medication until the DON sent her the email after the RP raised concerns. Nurse #2, the Unit Manager for 100 and 200 halls, was interviewed on [DATE] at 3:05 PM. Nurse #2 stated it was her responsibility to confirm orders written by NP #1 and to notify the RP of any changes in the medication to include discontinuation of a medication and new medication orders. Nurse #2 stated she may have overlooked informing the RP of Resident #6 of a medication order change. The DON was interviewed on [DATE] at 1:36 PM. The DON stated she received an email on [DATE] from the RP of Resident #6 inquiring about what medications she was on because Resident #6 seemed drowsier. The DON stated she at that point discovered the RP had not been notified of the medication change from Oxycodone to Morphine for Resident #6. The DON revealed this was an oversight on the part of Nurse #2 and one on one education was provided to Nurse #2. The DON confirmed the facility received notice from the pharmacy the medication Oxycodone was no longer covered by insurance, and they recommended the equivalent of the medication in Morphine ER twice a day for Resident #6. The DON confirmed the RP should be notified of all changes in medication to include dosage, form, and frequency when the change occurs.

Based on record review, and interviews with staff, physician, and paramedic, the facility failed to ensure staff recognized the need for communication amongst themselves and with the physician to ensure a resident received medical services to address an emergency situation (Resident # 13). Resident # 13 reportedly had a death rash in conjunction with nurse aides' observations of him being zonked, talking out of his head, not eating any of his supper meal and complaining of being tired. The morning following these observations, which were noted by staff members on the previous evening and night shift, the resident was found by the morning shift staff nurses to be without a detectable radial pulse, without a detectable oxygen level, mottled skin (discolored patches of skin which can result from a lack of blood flow to the skin), and not responding to a sternal rub. The resident required emergency transfer to the hospital where he was identified to be in septic shock. (Sepsis occurs when an individual's immune system has a wide spread reaction to an infection which can lead to multi system organ failure and is considered life threatening. Septic shock is the last stage of sepsis and results in a low blood pressure). The resident's blood, sputum, and urine cultures were positive for bacterial growth, and he expired on [DATE]. The facility also failed to ensure that a resident (Resident # 2) who had sustained a head injury following a fall was assessed by a licensed nurse prior to the resident being moved. This was for two of five sampled residents reviewed for professional standards of practice (Resident #13 and Resident #2). The findings included: Immediate jeopardy began on [DATE] when Resident # 13 was observed to have a rash, which was described by one staff member as a death rash on multiple areas of his body in conjunction with a change in his mental status and eating habits observed by a nurse aide without staff taking action to ensure the resident received medical care. Immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity D to ensure education is completed and monitoring systems put in place are effective. Example # 2, which relates to Resident # 2, is cited at a scope and severity level of D. 1. Resident # 13 was admitted to the facility on [DATE]. Review of Resident # 13's [DATE] hospital discharge summary revealed prior to being admitted to the facility, the resident had been hospitalized from [DATE] to [DATE] after being found at home in poor living conditions by social services. The hospital discharge summary also contained the following information. Upon hospital admission on [DATE] the resident was found to be alert and oriented times three and reported to hospital staff he had not seen a primary physician in [AGE] years. The resident further reported he had been losing weight for the past year, had not been having a good appetite, and was falling more. He also reported he had been having some fecal incontinence over the past two to three days prior to going to the hospital on [DATE]. The hospital summary also noted the resident was severely malnourished, weighed 88 pounds, was 5'10 in height, and had chronic alcoholism. A CT (computerized tomography) scan conducted while the resident was hospitalized showed he had left upper cavitary interstitial scaring and a soft tissue density and nodularity in the right posterior upper lobe. There was no discrete solid pulmonary nodules bilaterally and it was recommended that he have a repeat CT scan in three months to evaluate the scaring in his lungs. Also, according to the hospital discharge summary, the vertebrae compression fractures were mostly chronic, and the left trochanteric fracture was considered acute but of unknown origin date. The resident was deemed to need protected weight bearing for his leg and a walker upon discharge. The [DATE] hospital discharge summary listed the following diagnoses at the time of hospital discharge: proctocolitis (inflammation of the colon and rectum), failure to thrive, hyponatremia, emphysema, lung lesion, abdominal aortic aneurysm, aneurysm of the iliac artery, trochanteric avulsion fracture of the femur, external iliac artery occlusion, compression fracture of thoracic vertebra, compression fracture of lumbar vertebra with delayed healing, and urinary retention. He was discharged to the facility for rehabilitation on [DATE] with an indwelling catheter for his urinary retention. On [DATE] Resident # 13 was seen by Nurse Practitioner (NP) who noted the following information. The resident appeared cachetic (appearance of weight loss and muscle mass loss) and denied any pain or discomfort. He knew he was at the facility for rehabilitation and told the NP he was looking forward to getting stronger. He was aware he had declined before his recent hospitalization of [DATE] and reported there had been someone getting groceries for him while he had been at home, but the person did not stay with him all the time. He drank alcohol on a regular basis and did not eat much because he was not hungry. Resident # 13's admission MDS (Minimum Data Set Assessment, dated [DATE], coded the resident as cognitively intact and able to independently roll in bed. He was able to walk 10 feet with supervision and or touching. He was independently able to go from a lying in bed to a sitting position. He required partial to moderate assistance with his bathing and hygiene needs. Review of physician orders revealed the resident was a full code. This order remained in effect through the resident's discharge. On [DATE] Resident # 13 was seen again by the NP who noted the following information. He reported feeling well and was attending therapy which he knew would help him get stronger. He reported he had been eating and drinking better since admission. He was afebrile and his heart rate and blood pressure were stable. The Nurse Practitioner was interviewed on [DATE] at 3:52 PM and reported the following. She had never seen a resident with such a low BMI (body mass index) reading and felt that signified he was not a well person. The last time she assessed Resident # 13 was on [DATE] and he indicated he was trying to eat better and get stronger. It was only about two weeks into his stay and it was too soon to determine how he would progress. Weight records for Resident # 13 included in part the following information showing the resident gained weight since admission up until [DATE]. [DATE]-88 pounds [DATE]-94 pounds [DATE]-94.1 pounds [DATE]-94 pounds [DATE]-97.2 pounds On [DATE] at 5:44 PM Nurse # 4 documented Resident # 13 was complaining of his catheter feeling weird during the shift of 7AM to 7PM. He had been found to have some swelling in his groin which he reported had happened before. The catheter was deflated and removed, and the resident refused to have the catheter reinserted. He was voiding in a urinal. The physician had been contacted and reported to monitor the resident and send him out if he had pain or problems voiding. Following Nurse # 4's note, there was no order entered into the electronic record to discontinue the catheter. There were no nursing progress notes documenting voiding patterns or problems with the resident's groin. On [DATE] at 4:24 PM the social worker entered a progress note documenting that she made a phone call to the resident's first family contact to set up discharge for the resident and left a voice mail. The facility social worker was interviewed on [DATE] at 3:49 PM and reported the following information. The resident's insurance had changed and he was wanting to go home on [DATE]. He had not completed his therapy goals yet and the facility felt it would be against medical advice. They wanted him to be completely independent before going home. He was walking with a walker but was unsteady. Prior to his hospitalization he had some home health services a few times per week. She had placed a phone call to the resident's family member on [DATE] to talk about the resident's choice to discharge on [DATE]. He had informed the facility staff that he was able to go home alone and no longer wanted to stay. There were no nursing progress narrative notes for the date of [DATE]. Nurse # 5 had cared for Resident # 13 on [DATE] from 7:00 AM to 7:00 PM. Nurse # 5 was interviewed on [DATE] at 1:40 PM and again on [DATE] at 12:15 PM. Nurse # 5 reported the following information. The resident had been voiding and going to the bathroom on [DATE]. He did not recall any problems with the resident on his shift. Supper trays did not arrive until the end of the shift or after his shift, and he did not recall anyone mentioning to him that Resident #13 was having problems. He knew the resident was planning to go home. NA # 10 had cared for Resident # 13 on the 7:00 AM to 3:00 PM shift on [DATE]. NA # 10 was interviewed on [DATE] at 1:14 PM and reported the resident was fine on her [DATE] shift and he was excited because he was planning to go home. Physical Therapist # 1 was interviewed on [DATE] at 1:56 PM and reported the following information. The resident participated in therapy on [DATE] by doing leg kicks while sitting on the side of the bed. He had a chronic cough. She did not do any exercises that would aggravate his cough. He would do chin to chest posturing to compensate for any breathing problems and therefore he tolerated his rehab session okay. He was able to converse during his therapy session on [DATE]. The resident was wearing a hospital gown and she could see his legs. There was no rash on his legs or discoloration during the therapy session. Nurse Aide (NA) # 8 cared for Resident # 13 from 3:00 PM to 11:00 PM on [DATE]. NA # 8 was interviewed on [DATE] at 12:44 PM and reported the following information. The resident had a rash on his body during her shift. It was on his arms, his back, his stomach, and top of his legs. She had never seen the rash on Resident # 13 before when she took care of him, and it was a new problem. He was also zonked like, not himself and did not want to eat supper. She was able to get him to drink some for supper but he ate nothing at all for his supper meal which was not like him. He usually would eat. The RN Supervisor (Nurse # 9) and Medication Aide (MA) # 1 came into the room to look at the rash that evening before Nurse #8 came on duty. One of them called his name trying to get him to respond. He did look up at that point and they asked him if he itched or was in pain. The resident was able to say no. She thought that someone put him on the physician's board to be seen. Medication Aide # 1 was interviewed on [DATE] at 1:44 PM and reported the following. She had been called by a Nurse Aide on the evening of [DATE] to look at Resident # 13 on the evening shift of [DATE]. He had a rash all over his body in various places. When she looked at the rash a thought process went through her head that it looked like what she had seen before as ringworm, but it was not raised. It was beyond her scope of practice to know what to do and therefore the Nursing Supervisor (Nurse # 9) was called. The resident wanted to be left alone. Nurse #9 was interviewed initially on [DATE] at 2:42 PM and reported she worked all over the facility as the evening shift (3:00 to 11:00 PM supervisor) and did not recall the resident well. She planned to review the record. Nurse #9 did report at that time that if there was something that needed to be communicated to a physician they could call and face time after business hours with a provider. If it was not deemed important, then it could be placed on a physician's communication board for a resident to be seen when they arrived at the facility the next time. Nurse # 9 was interviewed again on [DATE] at 12:41 PM and reported after looking at the resident's record she recalled the following information. On the evening of [DATE] the resident had a rash that appeared as red circles and white in the middle. To her it did not look like mottling. It was on his legs, arms and chest. The resident was sleepy. He did not carry on a conversation but he was able to answer questions. She did not know his baseline well. She did recall someone saying the rash was a death rash but she did not recall who said it or when it was said. She felt NA # 8 was a good Nurse Aide. She (Nurse #9) did not recall NA #8 mentioning that the resident did not eat or was zonked on the evening shift. According to Nurse #9 that did not mean that NA # 8 did not tell her. She (Nurse #9) could have been told and was not remembering. When she (Nurse #9) looked at Resident # 9's rash she did not take the resident's vital signs. She did not know if others had done so. She did not call the physician on her shift. On [DATE] at 2:39 AM Nurse # 8 documented a skilled evaluation which noted the following information. The resident's skin was warm and pink with brisk capillary refill. He was alert and oriented. His pulse registered 70 at 10:52 PM on [DATE], respiratons16 at 10:52 PM on [DATE], oxygen level 100 % at 10:52 PM on [DATE]. The resident was documented to have brusing on his left forearm and brusing on his left wrist. The nurse also entered the resident's catheter was intact (which was incorrect given that the resident's catheter had been removed and never replaced). There was no information in the nursing entry regarding any type of rash on the resident's body. There was no blood pressure reading documented within this entry. Nurse # 8 had cared for Resident # 13 from 7 PM on [DATE] until 7:00 AM on [DATE]. Nurse # 8 was interviewed on [DATE] at 9:44 AM and reported the following information about caring for Resident # 13 on her shift. The resident had a rash on her shift which Nurse # 8 referred to as a death rash while being interviewed by the surveyor. When she arrived for work at 7 PM she thought the rash had already been reported to the physician and that the resident had already been checked by the physician. The rash was circular and showed up as redness on his skin. It appeared on his legs and his stomach. When interviewed by the surveyor what the plan was for the death rash, Nurse # 8 was not sure about that. She knew he was very malnourished and they were supposed to try to get him to eat. He typically would eat things like oatmeal cakes and kool-aid rather than nutritious food. Through the night he was stable and she checked his oxygen saturations which were okay. The Nurse Aide who had worked with him during the night shift had also said he was okay. NA # 9 had cared for Resident # 13 from 11:00 PM on [DATE] until 7:00 AM on [DATE]. NA # 9 was interviewed on [DATE] at 10:00 AM. NA # 9 reported the following information. The resident was not doing too well. On rounds through the night, he would say he was okay but would complain of being tired and needing sleep. She checked on him each round and would encourage him to get some sleep. He also had a rash. She had never seen anything like it before and remembered asking herself, What kind of rash is this? It appeared as big splotches of red. The rash also appeared as squiggly, squiggly lines and it was on the resident's stomach, his buttocks and his scrotum. During her last rounds on night shift she asked him if he wanted water and he said nuh uh and nothing further. NA # 10 had cared for Resident # 13 on the 7:00 AM to 3:00 PM shift on [DATE]. NA # 10 was interviewed on [DATE] at 1:14 PM and reported the following information. She did rounds with the night shift NA (NA # 9) when she got to work. They looked in on Resident # 13 during that time. He was not talking at that point. NA #9 told NA #10 he had not been like that during the night. According to NA # 10 at times the resident did not wake up and talk always and she continued the rounding with NA # 9. Around 8:00 AM she took Resident # 13 his breakfast tray and he would not wake up at that point and eat. She immediately went and got Nurse # 5. Nurse # 10 was assigned to care for Resident # 13 on the 7 AM to 7 PM shift of [DATE]. Nurse # 10 was interviewed on [DATE] at 11:03 AM and reported [DATE] was her second day working at the facility as an agency nurse. Nurse # 10 reported the following information. During report at 7:00 AM, Nurse # 8 had reported that Resident # 13 had a rash since the day before. That was all that was said about the rash. There was nothing said that would signify the resident was in need of urgent medical attention. There was no mention that the rash was a death rash. After report, a Nurse Aide went to Nurse # 5. (Nurse # 5 was working on the hall, was a routine nurse at the facility, and knew the resident). The Nurse Aide let Nurse # 5 know that something was not right with Resident # 13. She and Nurse # 5 both went in the room. She (Nurse # 10) saw that the resident's breathing was wacky and his respirations were in the 40s. She could not recall how responsive he was. Nurse # 5, who routinely worked at the facility knew what to do and called 911. They (she and Nurse # 5) stayed with the resident until EMS arrived. The resident also had mottling on his legs, arms, and chest. Nurse # 8 was still at the facility and had not gone home yet when Nurse # 5 and Nurse # 10 assessed Resident # 13. Nurse # 8 came into the room after Nurse # 10 and Nurse # 5 were in the room. Nurse # 10 reported what Nurse # 8 had reported as a rash on the previous shift appeared as mottling to her. Nurse # 10 reported it was very evident the resident was mottled. The next nursing narrative in the record was documented on [DATE] at 8:47 AM by Nurse # 5 who documented, Resident sent out to hospital via EMS on a stretcher. Resident presented with altered mental status only responding to name being called with eyes opening. Vitals: ,d+[DATE], 42, 97.7, 30 breaths/min (minutes), O2 (oxygen) saturation was undetectable with absent bilateral radial pulses. Rapid, shallow breathing with use of accessory muscles. Resident is full code, notified (provider) at approximately 0805 (8:05 AM) about residents condition and plan to send out to {name of hospital} O2 administered at 3 Liters and monitored with AED (automated external defibrillator) at bedside until EMS arrived at approximately 0815 (8:15 AM). ( A systolic blood pressure reading of less than 90 or a diastolic blood pressure reading of less than 60 is considered hypotension (low). A normal pulse is 60 to 100. Normal respirations are ,d+[DATE].) During the interview with Nurse # 8 on [DATE] at 9:44 AM the nurse reported the following information about the end of her shift which ended on [DATE] at 7:00 AM. At change of shift at 7:00 AM on [DATE] when she and another nurse (Nurse # 5), who had come into work at 7:00 AM, were counting controlled substances, a Nurse Aide approached them. She did not recall which Nurse Aide approached them. The Nurse Aide let them know Resident # 13 was awake but would not say anything. She and Nurse # 5 went to the room. She grabbed a crash cart. The resident was still pink when they went into the room and they sent him out to the hospital. During the interviews with Nurse # 5 on [DATE] at 1:40 PM and again on [DATE] at 12:15 PM, Nurse # 5 reported the following information. He was working the dayshift on [DATE]. He had already started his medication pass when a Nurse Aide came to get him. He did not recall which Nurse Aide. When he went to check the resident, the resident had mottling on all his extremities. The mottling was very noticeable. His breathing was rapid. From the extent of the mottling, he (Nurse # 5) was not sure how it had gone undetected during the night shift. The night shift had reported that there was nothing wrong with the resident. The resident was not responding to a sternal rub. His vital signs were very low. He checked his code status and called 911. Nurse # 8 had her bag and was headed out the door. She did get the crash cart for him and Nurse # 10 before she left. He and Nurse # 10 stayed with the resident until EMS arrived. Night shift had reported to dayshift that the resident had been okay during the night. Review of EMS records revealed the following information. They were called at 8:05 AM on [DATE] (which was an hour and five minutes after the change of shift from night shift to day shift). They were at the facility at 8:14 AM and at the resident's side at 8:17 AM. At 8:17 AM the paramedic documented the resident was nonresponsive. His blood pressure was ,d+[DATE], heart rate 121 and respirations 28. They were unable to get a good oxygen reading on him due to his fingers being cold. The paramedic documented in part, The nurse in the room stated that normally the patient is talkative is cussing them out however in the last hour he has become non-responsive and starting to breath fast. The patient does not normally wear O2. When I called the resident's name he would flutter his eyes but no other responses. He was very skinny and all of his ribs were showing. He was barrel chested. His skin was pink and looked like it began to model (mottle) on his legs, arms and the lower half of his stomach. Patient was placed on 15L O2 NRB (oxygen by nonrebreather). The patients' vitals were obtained along with a BGL (blood glucose level). BGL was normal limits but the patient was hypotensive. I asked the patient staff at [name of facility} have they noticed anything new about the patient's daily life with them and they stated that he has not been wanting to eat or drink hardly and yesterday when they needed to place a {indwelling} catheter in him because he was not producing urine he refused. 12 lead (heart monitoring leads) placed on the patient and it read Afib. (a type of heart arrhythmia) 20 gauge IV (intravenous) obtained in the patient's right AC (anticubital). Patient was then moved with a drawsheet to the stretcher and secured. His respirations slowed down and he started to belly breath. Patient then taken to the ambulance where he was loaded and secured. Lactated Ringers (a type of intravenous fluid) started on the patient, wide open. The patient began snoring respirations again. Vitals obtained and his blood pressure went lower . According to the paramedic's report they transferred care to the hospital staff at 9:03 AM on [DATE]. The paramedic, who responded on [DATE], was interviewed on [DATE] at 4:04 PM and reported the following. Upon her assessment she found Resident # 13 to have mottling on his legs, arms, hands and feet. She described the mottling as blotchy skin, circular, reddish blue. There was no other rash that she saw on the resident's body. The only response he was making was that he would blink his eyes a little to his name. Otherwise he was nonresponsive. He was very thin and looked very sick to her. The hospital ER records, dated [DATE], further noted the following information. The resident's skin was mottled upon arrival and he was nonresponsive. His systolic blood pressure was in the 70s and they were unable to obtain an oxygen level on him. Fluids, which had been started by EMS, were continued and lab work was done. The resident was intubated (a tube is placed down their airway to facilitate breathing) soon after arrival (9:30 AM on [DATE]). Labs and diagnostic tests were performed. A central line (a long catheter for intravenous fluids which goes to a vein near an individual's heart) was placed at 11:40 AM. The resident was admitted to the Intensive Care Unit (ICU) for care. The resident's admitting ICU note indicated the resident's principle problem was septic shock which was secondary to pneumonia. The resident's chest x-ray showed multilobar bilateral pulmonary nodular opacity superimposed on emphysema, likely multilobar pneumonia although a component of neoplasm is not excluded. A review of the resident's hospital discharge summary included the following information. The resident expired at the hospital on [DATE]. While hospitalized his blood cultures had grown MRSA (Methicillin Resistant Staphylococcus Aureus). Sputum cultures had grown staph and pseudomonas. His urine specimen had grown staph and strep. By [DATE] he had minimal urine output and remained on full mechanical ventilation. Family was consulted by the hospital staff and the decision was made to make the resident comfort measure only. He was withdrawn from mechanical ventilation and his time of death was listed as 10:05 PM on [DATE]. The Director of Nursing was interviewed on [DATE] at 4:20 PM, [DATE] at 10:17 AM, and [DATE] at 1:25 PM and reported the following. It had not been called to her attention that the resident had a death rash on [DATE] or any problems related to his care before he was transferred out to the hospital. After hours the facility had a telehealth provider who could be called if needed for acute changes in condition. She had looked into the situation after the surveyor brought to her attention that the nurse was reporting the resident had a death rash on the evening prior to him being transferred to the hospital. She had found that no one had contacted the provider on [DATE]. The information that he had a rash had been put in the binder where information is left for the provider to request a resident be seen when they next come. She had talked to Nurse # 8 who reported that she did not see anything life threatening on the night shift of 7 PM to 7 AM beginning on [DATE]. The DON had questioned Nurse # 8 about why she had used the term death rash to describe the rash she saw to the surveyor. After thinking more Nurse #8 thought maybe she had later heard after the resident was transferred to the hospital that what he had been experiencing was a death rash. Resident # 13's medical physician, who served as the facility's medical director, was interviewed on [DATE] at 2:12 PM and again on [DATE] at 2:11 PM and reported the following. During the interview, the surveyor shared with the physician the interviews provided by the nursing staff as it related to how the resident's rash had been described in conjunction with what NA # 8 had observed on [DATE]. The medical physician reported the following. A rash by itself does not warrant immediate urgency or notification to the physician. A rash in conjunction with a change in mental status, change in vitals, any decline can be a red flag and can escalate the need to act. A death rash or mottling would indicate someone was in critical condition. The medical director was interviewed about actions that would have been taken if he had been called and told the resident had a rash on the evening of [DATE] as described by Nurse # 9, Nurse # 8, NA # 8, and NA # 9 along with information that the resident had been noted by NA #8 not to eat anything for supper, was talking out of his head, and zonked. The medical director reported he would have expected them to do a critical assessment of the resident to determine if fluids needed to be started and he would have had the resident sent out to the hospital. The medical director further reported the following information. He had reviewed the record also and the vital signs noted in the facility record on [DATE] when EMS was summoned would have indicated the resident was in shock at the time EMS was called. Shock can happen quickly as sepsis occurs. The resident was very thin and his baseline indicated he was possibly immunocompromised and did not have the reserves a robust person to fight the infection and sepsis. Therefore, he did not feel the outcome would have been different for the resident if they had called the evening prior to [DATE]. The facility was notified of immediate jeopardy on [DATE] at 5:02 PM. The facility submitted the following immediate jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance F-684- Quality of Care: Nursing staff failed to recognize when a resident experienced a change in condition warranting immediate action. The Licensed Nurses and/or designee completed a head to toe assessment to include vital signs on all residents by [DATE]. No additional residents were identified with an emergent change of condition that would require immediate medical attention. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete The Nurse Practice Educator and/or designee will provide education to Licensed Nurses on how to complete a focused physical assessment to include a thorough skin assessment with vital signs, to include any changes that would require immediate medical attention to include but not limited to; deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications by [DATE]. A post-test has been created and is in progress to validate knowledge and/or comprehension of education. The Director of Nursing, Assistant Director of Nursing and/or Nurse Practice Educator will ensure that the post-test have been completed. The Director of Nursing/Assistant Director of Nursing and/or Nurse Practice Educator will track and verify no Licensed Nurse (s) will be allowed to return to work with scheduled time off, on leave of absence (FMLA), vacation, agency nurses or PRN until they have successful completed the education/training and post-test. Starting [DATE], no licensed nurse will be permitted to work until required education is completed prior to the start of their shift. New hires will be educated by the Nurse Practice Educator during the orientation process. The Nurse Practice Educator and/or designee will educate Licensed Nurses on the importance of conducting a thorough skin assessment, documenting the assessment, and on specific measures to take if a new skin condition is identified; notifying the Physician/Provider by [DATE]. The Director of Nursing and/or Nurse Practice Educator will track and verify Licensed Nurses with scheduled time off, on leave of absence (FMLA), vacation, agency nurses, or PRN staff will be re-educated prior to returning to duty. Starting [DATE], no licensed nurse will be permitted to work until required education is completed prior to the start of their shift. New hires will be educated by the Nurse Practice Educator during the orientation process. The Nurse Practice Educator and/or designee re-educated Certified Nursing Assistants on early identification of changes in condition and prompt notification of changes to the Licensed Nurse by [DATE]. The E-Interact Stop and Watch tool/alert was introduced as an early warning tool to be utilized by direct care givers as another mechanism to communicate changes in condition to the Licensed Nurse. The Director of Nursing and/or Nurse Practice Educator will track and verify that employees with scheduled time off, on leave of absence (FMLA), vacation, agency staff, or PRN staff will be re-educated prior to returning to duty. Starting [DATE], no certified nurse aide will be permitted to work until required education is completed prior to the start of their shift. New hires will be educated by the Nurse Practice Educator during the orientation process. Effective [DATE], the Director of Nurses and/or designee will review changes in condition by reviewing the change in condition assessments, in the morning Clinical Meeting to verify a thorough assessment has been completed. Removal of Immediate Jeopardy [DATE]. Onsite validation of the immediate jeopardy removal plan was completed on [DATE]. Interviews conducted confirmed all licensed nurses received training on skin assessments and how to conduct a skin assessment. All nursing staff completed a skin assessment clinical competency validation and completed a skin assessment posttest. All residents received a skin assessment, and any issues identified were forwarded to the facility wound nurse or MD/NP. A new Interim Director of Nursing stated one resident had been admitted on [DATE].

Based on record review, and interviews with staff, Responsible Party, Nurse Practitioner and Medical Director the facility failed to 1) ensure staff were providing transfer assistance as care planned for a resident (Resident # 1) identified as at risk for injuries due to osteoporosis and 2) ensure mats were at the bedside to prevent injuries for a resident with a history of falls (Resident # 2). Resident # 2 sustained a large hematoma and fractured nose when she was found on the floor without a fall mat in place. This was for two of three sampled residents reviewed for accidents (Resident #1 and Resident #2). The findings included: 1. Resident # 1 was admitted to the facility on [DATE]. The resident had multiple diagnoses which in part included osteoporosis, osteoarthritis, spinal stenosis, chronic pain, dementia, hypertension, diabetes, a history of hip replacement surgery, and polyneuropathy. The resident also had a history of vertebrae fracture due to osteoporosis. Resident # 1's quarterly Minimum Data Set assessment, dated 8/5/24, coded the resident as severely cognitively impaired. The resident was also assessed to be totally dependent on staff for hygiene, bathing, and mobility needs. The resident was not assessed to have falls since the last assessment MDS assessment. Review of nursing notes from 8/5/24 to 8/11/24 revealed no falls or accidents. Review of Resident # 1's care plan, updated on 8/25/24, revealed the staff identified the resident was at risk for fractures due to her osteoporosis. This had been added to the care pan on 1/22/20 and remained part of the resident's active care plan. Staff were directed on the care plan to avoid pushing and pulling on her extremities and to also observe for signs of pain or discomfort. Additionally, staff members were directed on the care plan to use a mechanical lift with full body sling for all transfers. This intervention had added to the care plan on 4/5/20 and remained part of the resident's active care plan. On 8/2/24 at 3:14 PM Nurse # 7 documented the following information in a nursing entry. The resident was having some pain in her left knee. The knee was noted to have a little swelling. The Nurse Practitioner was notified and ordered the resident to have an ice pack as needed and an x-ray of the left knee. A family member was contacted at that time who was agreeable to the orders. Review of the x-ray report, dated 8/2/24, revealed the following information. The resident had marked degenerative spurring. The bones appeared diffusely demineralized with marked osteoarthritis. There was an old fracture of the tibia and fibula noted, but no acute fracture or dislocation was seen. On 8/7/24 the Nurse Practitioner (NP) saw the resident and documented the following information. The resident was having increased knee pain. The 8/2/24 x-ray had shown osteoarthritis and no acute fracture. The resident was calm, relaxed, and appeared comfortable. She was able to say she had left knee pain but was not able to say if she had bumped her knee or what had occurred. The NP noted the resident's pain appeared to be a worsening chronic pain and she was already receiving pain medication. The NP further noted she would order a topical analgesic cream to be applied four times per day. NA # 6 was interviewed on 9/25/24 at 5:00 PM and reported the following information. Prior to Resident # 1 being found with a fracture she and another Nurse Aide would stand and pivot the resident to bed. She (NA # 6) would work on second shift and there would be no lift pad underneath the resident when they came in. She did not understand how the other Nurse Aides were using a lift either if there had been no lift pad underneath her. Therefore, they lifted her in bed when they would find no lift pad beneath her. She (NA # 6) was not aware of any particular incident or transfer that had caused injury to the resident's leg. She had not complained after any specific transfer of more pain than usual. On 8/11/24 at 10:12 AM a telehealth visit was conducted for Resident # 1's complaint of pain all over. The provider noted the following information. The resident was seen for generalized pain and not acting herself. While on the telehealth call, the provider ordered a COVID test which was done and showed a positive result. At the time of the telehealth assessment, the resident repeated pain to the provider and that she need hospital. The provider further noted the resident would be sent to the hospital per her request for evaluation. A review of hospital emergency department records revealed an x-ray was completed for a second time on 8/11/24 while the resident was being evaluated at the hospital. This x-ray showed the resident had an acute fracture of the left distal femur involving the metaphysis with mild impaction and no displacement. There was also chronic deformity of the lateral tibial plateau suggesting a chronic healed fracture. There was also a chronic healed fracture of the proximal fibula. There was moderate to marked medial and lateral compartment osteoarthritis and osteopenia. (The distal femur, which was where the fracture was located, is right above the knee.) On 8/11/24 the resident returned to the facility without admission to the hospital. According to orthopedic records following the identification of the fracture, the resident was to wear a splint for immobilization to the knee. On 8/11/24 at 8:37 PM Physician # 2 documented the following note. Chart reviewed. Resident was complaining of left knee pain on 8/2. No h/o (history of) trauma. X-ray was obtained at that time which showed osteoarthritis with no acute fracture. Today was seen in ED with left distal femur fracture on x-ray, but also noted osteopenia, bone demineralization. Resident has h/o (history of) osteoporosis, on Alendronate. Resident has also been on pain medication throughout. Probable that fracture was of low energy 'pathological' type, given lack of trauma. It is also likely that resident had a hairline fracture that x-ray of 8/2/24 did not pick up, but became pronounced over the course of the week and was now apparent on x-ray from today. (Alendronate is a medication used to treat osteoporosis). Resident # 1's Responsible Party (RP) was interviewed on 9/24/24 at 1:10 PM and reported the following information. The resident had some swelling in her knee near the end of July and near the first of August. She underwent an x-ray of her knee at the facility, but even prior to that date the resident seemed to be having more pain and problems with her knee than usual. The RP could not recall an exact date that the change was noted. When the x-ray came back negative on 8/2/24, she continued to have problems. The resident was seen in the hospital ED (emergency department) because she was not acting right on 8/11/24. At that time, he (the RP) asked the hospital staff to also x-ray the resident's knee. The hospital x-ray showed the knee fracture. He was under the impression that the staff had been using a mechanical lift to transfer the resident, and he did not know how she could have broken her leg. The rehab director was interviewed on 9/26/24 at 10:30 AM and reported the following information. Resident #1 had been evaluated by the rehab department for the mode of transfer staff were to use for transfers. Prior to Resident # 1's fracture being identified the resident had been deemed to need a mechanical lift for safe transfers. It had not been safe to transfer her by standing and pivoting. She had brittle bones. Also, in order to use a sit to stand mechanical lift, a resident was required to be able to support a certain percentage of their weight or that type of lift would put too much pressure on their legs. Resident # 1 was not able to use the sit to stand mechanical lift either. For safety reasons, the staff were to use the total mechanical lift. The facility's medical director was interviewed on 9/25/24 at 5:10 PM and reported the following information. Resident # 1 had bone density problems in addition to advanced age. Due to the extent of her bone fragility and advanced age, the fracture she had sustained could have happened if the staff had been using a mechanical lift, turning and positioning her, and doing everything correctly. Her osteoporosis placed her at greater risk for the injury. Just because staff at times had transferred her by standing and pivoting her, did not indicate that the fracture occurred during that particular type of transfer. 2. Resident # 2 resided at the facility from 11/30/16 until her final discharge on 9/4/24. The resident in part had diagnoses which included stroke, atherosclerotic heart disease, osteoporosis, dementia with behavioral disturbance, contracture of the left and right leg, history of hallucinations, and anxiety. Resident # 2's quarterly MDS (Minimum Data Set) assessment, dated 8/16/24, coded the resident as rarely/never understood and unable to complete an interview for cognition. The resident was coded as being totally dependent on staff for bathing, dressing, and hygiene needs. The resident was also coded as needing total staff assistance to turn in bed, go from a sitting to lying position, and for transfers. Since the last MDS assessment, the resident was not coded as having falls. Review of Resident # 2's care plan, dated 8/30/24 revealed staff had identified the resident was at risk for falls. This had been added to the care plan on 9/13/19 and remained as part of the resident's active care plan up until her discharge date . One of the care plan interventions directed that the resident was to have fall mats to both sides of her bed. This showed on the care plan as initiated on 5/20/24 and remained part of the resident's active care plan up until time of discharge. Review of Resident # 2's record revealed a SBAR (situation, background, appearance, and review) progress note form completed by Nurse # 8 on 9/4/24 at 7:07 AM. The situation was noted to be a fall on 9/4/24. There was not a specific time of the fall. The nurse documented, Upon hearing a loud noise like a fall, the CNA found the resident on the floor at her bedside. Resident was assessed and assisted back to bed. Resident had a large bump on her forehead and a skin tear on both right and left leg. Nurse # 8 further noted the resident's vital signs were as follows: blood pressure 117/63, pulse 76, respirations 18, and temperature 97.4. Nurse # 4 documented the provider was notified on 9/4/24 at 6:05 AM with orders to send the resident to the ER (emergency room ). NA # 7 had cared for Resident # 2 on the shift which began at 11:00 PM on 9//3/24 and which ended at 7:00 AM on 9/4/24. NA # 7 was interviewed on 9/24/24 at 3:22 PM and reported the following information. Prior to the resident falling she had provided care to the resident around 3:00 AM when she changed her brief. She left the resident on her back in the middle of the bed in a safe position. She had been assigned to the resident a few times before the night of the fall. It had been her experience that the resident could use her upper body some. She had never seen any fall mats in the resident's room, and there were no fall mats in place at the time of the fall. The resident had resided in a room where she was close to the air and heating unit. Around 5:30 AM she was making rounds and found the resident on the floor. The resident was on the floor near the air and heating unit. Her head was in a pool of blood. There were two skin tears to her legs which appeared to not be new but had reopened. NA # 7 was interviewed regarding anything she had seen that might have contributed to the fall or injuries. NA # 7 reported the resident could move her arms from side to side and forwards and backwards. At times when care was being provided, the resident would make baby swats at the staff members. The NA thought the resident had moved her whole body somehow out of bed when she moved her upper body. At the time, she could not find another staff member to help her. Therefore, she picked Resident # 2 up from the floor and put her in the bed. About 20 minutes later, Medication Aide (MA) # 1 came into the room and got Nurse # 8. MA # 1 was interviewed on 9/24/24 at 4:45 PM and reported the following information. She had been assigned to Resident # 2 when the resident had sustained a fall. She had walked into the room to administer medications to Resident # 2's roommate. At the time, the curtain was partially closed and she (MA # 1) could only see Resident # 2's legs when she entered the room. She could see blood on the resident's leg. She walked completely around the curtain to Resident # 2's side of the room. She (MA # 1) also saw a towel with blood on it and the resident had a head injury. NA # 7 reported, I found her like this. She (MA # 1) did not ask NA # 7 if she found the resident in the bed or on the floor. When she saw blood, she knew it was beyond her scope of practice and she went to get the Nurse (Nurse #8) who was covering for her. Nurse # 8 called 911 and bandaged Resident # 2's head so that it would not bleed further. MA # 1 was interviewed about any factors which might have contributed to the fall and injury. MA # 1 further reported the following information. Earlier in the night the resident had been okay, but she did have confusion. The resident had been talking about going to get something. The resident also had the ability to move side to side some. It had been her (MA # 1's) experience that sometimes dementia residents could do things which were unexpected. The side on which she fell had the heating and air unit by the bed. On the unit there was additional plexiglass installed to vent the air. MA # 1 reported that if she had hit the plexiglass during the fall, it would also have hurt her. Review of a written statement by MA # 1, which was part of the facility's investigation into the fall and which was dated 9/5/24, revealed in part the following information. As they were preparing Resident # 2 for transport to the hospital following the fall, Resident # 2 continued talking about going somewhere, walking, seeing specific people (calling them by name.) Nurse # 8 was the nurse covering for MA # 1 on the night from 7:00 PM to 7:00 AM. Nurse # 8 was interviewed on 9/24/24 at 8:20 PM and reported the following information. MA # 1 had asked her to check Resident # 2 on the date of the incident. When she entered the room, she asked NA # 7 what had happened, and NA # 7 said she found the resident on the floor. NA # 7 had also placed the resident back in bed. She (Nurse # 8) had last seen the resident around 2:00 AM and she was in bed and okay. The resident would wiggle slightly and they tried to keep her in the center of the bed. At the time of her (Nurse #8's) assessment, the resident had a little blood on her forehead and an open skin tear to her right and left leg. She (Nurse #8) applied dressings, obtained vitals, and sent the resident to the hospital. She did not recall seeing a floor mat in place where NA # 7 had reported the resident had fallen. Review of hospital ER records, dated 9/4/24, revealed the following documentation. The resident was presenting from her nursing facility after fall. Patient is hemodyamically stable and nontoxic-appearing on arrival. She has significant trauma to the face including significant ecchymosis and periorbital ecchymosis and abrasions of the right foot and we will x-ray those was well. Following testing on 9/4/24, the ER physician noted the following information. Patient's lab work and CT imaging showed no traumatic injuries other than a nasal bone fracture. Patient will be given ENT (ears, nose, throat) follow up. She does have significant brusing and edema of the face. Steri-strips were placed over a skin abrasion on the forehead. Patient otherwise remained at baseline. According to the hospital record, Resident # 2 was discharged to another facility. On 9/4/24 the Nurse Practitioner made a progress note documenting the following information. According to the nursing notes the resident had fallen out of bed and sustained a large bump to her head and a skin tear to both her right and left leg. The resident had been evaluated at the hospital and the family had requested that the resident to be transferred to another facility in order to be closer to the family. Resident # 2's family member was interviewed on 9/24/24 at 12:10 PM and reported the following information. He visited about twice per week. He did not understand how the resident had fallen because her legs were crossed and she could not turn herself in bed. The DON (Director of Nursing) was interviewed on 9/24/24 at 2:50 PM and reported the following information. Although the resident had not had falls since her last MDS assessment, she had fallen earlier in the current year and the staff were to follow her care plan to prevent falls. The resident could move the top part of her body some. The resident had been found earlier in the year with her top part of her body partially hanging down from the bed onto the floor mat. Her lower body had still been in the bed at the time. The facility had investigated the incident which had occurred on 9/4/24. NA # 7 had reported that she had found the resident on the floor during last rounds. According to the DON, there was no witness to say how the fall had actually occurred. The facilty had done a plan of correction following the incident. The Administrator was interviewed on 9/25/24 at 2:25 PM and reported the following information. They had investigated Resident # 2's fall following the accident and injury. He spoke to NA # 7 and asked her to be honest, and if she had accidentally turned the resident out of bed while providing care, then he encouraged her to say so. NA # 7 had remained consistent in her interviews that she had found the resident on the floor. Resident # 2 resided with a resident who was cognitively impaired and could not report any information related to the circumstances of Resident # 2. The Nurse Practitioner was interviewed on 9/25/24 at 9:22 AM and reported the following information. She had often seen Resident # 2. She personally had witnessed the resident to have the capability to move some although she had contractures. The resident was very stiff. When the head of the bed was left up at any given angle, the resident at times would push her upper body back against the bed. Due to stiffness, her body did not completely conform to the bed mattress if the head of the bed was elevated. As she moved her upper body, her body would angle itself in the bed. She could become twisted in the bed and she (the NP) had witnessed this herself. A review of the facility's investigative files regarding Resident # 2's fall and injuries included a statement from the former Medical Director (Physician # 2). Physician # 2 wrote he had reviewed the resident's medical record and some photographs of her injuries. The physician further wrote, I see no evidence of direct trauma to the resident's face other than to her forehead. As I understand , she also sustained a nasal fracture. The ecchymosis surrounding her eyes extending down to her face and neck is likely due to 'tracking' or bleeding from the original trauma (in this case her forehead) which flows subcutaneously via gravity to the rest of her face. This should fully resolve over time. The physician further wrote, The resident has a history of falls with serious injuries and a history of osteoporosis. It was reported that she fell out of bed, an event that was unavoidable, and sustained the trauma then. Resident # 2's physician, who served as the facility's current medical director, also had submitted a note in regards to the resident's fall during the investigation. The physician noted Resident # 2 had a history of neurocognitive disorder secondary to Alzheimer's dementia with a history of behavioral disturbance, hallucinations, depression, and anxiety. The Medical Director further wrote, This resident historically has had history of fall from bed level with episode of agitation and disorientation. Reports in the past have indicated the resident intermittently gets aggressive with staff during patient care. A history of Alzheimer's dementia with major neurocognitive disorder associated with behavioral disturbance certainly increases risk of agitation, confusion, disorientation, disruptive behavior, falls and injuries in this patient population. In addition, specifically with underlying bone density disorder such as osteopenia, osteoporosis, general frailty related to advanced age, this patient population are significantly prone to major injuries with minor trauma and ground level fall. The physician further wrote, This resident of note is non ambulatory at baseline due to contractures of the lower extremities with muscle atrophy however these factors historically had not precluded falls from bed in these patient populations. The facility's Medical Director was interviewed on 9/25/24 at 5:10 PM and reported the following information. It would be difficult to say how exactly Resident # 2 had fallen. From his personal experience, he knew there were paraplegics and residents with contractures who had slid out of bed. This had historically occurred on multiple occasions. Just because a resident was unable to move their lower body and/or had contractures did not indicate they were not at risk for falling out of bed. He had reviewed Resident # 2's injuries she sustained from 9/4/24 and the injuries were consistent with a fall. The DON was further interviewed on 9/26/24 at 1:00 PM and reported the following information. Following Resident # 1's injury the facility had completed an investigation and assessed residents on the Unit where Resident # 1 resided to determine if there were any other injuries. They had also completed inservice training about transfers and conducted competency checks. Following Resident # 2's fall, they also did an investigation and another plan of correction. Their corporate office was involved after Resident # 2 fell . The facility initiated their own plan of correction and then also incorporated components into their plan of correction as requested by their corporate office. According to the DON, the combined plan of correction addressed all factors to ensure residents were safely transferred by their plan of care and that staff were following care plans to prevent accidents. The DON provided the plan of correction: Corrective Action for affected residents Resident #1 was sent to the ER for evaluation and treatment as indicated due to complaint of pain to left knee on 8/11/24. Resident had x-ray of left knee 1 or 2 views, which revealed the following conclusion; Marked osteoarthritis of the left knee. No definite acute fracture. XR Knee 3 views Left, was obtained during ER visit at the hospital, which revealed the following: Findings: Marked regional osteopenia. Lower thigh subcutaneous edema and soft tissue swelling. There is an acute distal femoral fracture involving the metaphysis, with mild impaction laterally but no significant displacement or angulation. During residents' investigative review, interviews of staff were conducted by Director of Nursing (DON), as well as review of resident record. Upon review of resident record, there were no trauma and/or accident identified prior to resident having swelling or identification of fracture. 8/11/24, resident record was reviewed by attending physician, which revealed, Probable that fracture was of low energy pathologic type, given lack of trauma. During investigative interview with nursing staff, it was revealed that an NA transferred resident from wheelchair to bed via stand pivot. Resident's care plan reflects the transfer status as a mechanical lift. Since 8/11/24, staff have been following resident plan of care and transferring resident by mechanical lift. Resident #2 sustained a fall with injury on 09/04/24 while residing in the facility. Resident transferred to the hospital for evaluation and treatment as indicated. Upon review of resident medical record obtained from the hospital, resident had a CT of Facial Bones WO Contrast completed. Per image impression, it is noted; Questionable left nasal bone non-displaced fracture. Resident no longer resides at this facility. It was noted during facility investigation, that bilateral fall mats were not in place at time of fall per resident's care plan, due to history of falls. Others having the potential to be affected All residents have the potential to affected. Skin checks completed on residents located on the 100/200 halls of the facility by the Nurse Administrative Team on residents who are not alert and oriented with a BIMS of less than 12. Skin checks completed and reviewed by Director of Nursing (DON) on 8/16/24. Pain assessments completed on residents located on the 100/200 halls of the facility by the Nurse Administrative Team. Residents who rated their pain 7-10 on a scale of 0-10, with 10 being the highest level, were communicated with the facility Nurse Practitioner. Pain assessments reviewed by Director of Nursing (DON). All assessments completed by 8/16/24. A whole house audit was completed by the DON to ensure fall mats were in place per resident plan of care, as related to fall interventions on 9/4/24. An audit was initiated by the DON and/or designee on 9/18/24 of falls for the past 30 days to ensure that facility policy NSG215 Falls Management was followed properly with visual observation/validation of the fall interventions according to the residents plan of care are in place to include fall mats as applicable, as well as mode of transfer being followed per resident plan of care. Audit completed 9/23/24. 100% audit of Fall Risk Evaluations completed by DON and/or designee to ensure each resident currently residing in the facility has an updated evaluation completed with the residents plan of care reviewed to ensure proper interventions are in place to potentially prevent falls. Audits completed 9/23/24. What measures will be put in place or what systemic changes Education provided to all licensed/certified nursing staff to include; RN/LPN/CMA/CNA, on facility policies; NSG234 Safe Resident Handling/Transfer Equipment which included competency check offs and OPS300 Abuse Prohibition by the Nurse Practice Educator (NPE) and/or designee to be completed by 8/16/24. No licensed and/or certified nursing staff shall be permitted to work until education has been received. Education provided to all licensed/certified nursing staff to include; RN/LPN/CMA/CNA, on facility policies; NSG215 Falls Management, NSG234 Safe Resident Handling/Transfer Equipment as relates to falls management, and OPS100 Accidents/Incidents by the Nurse Practice Educator (NPE) and/or designee to be completed by 9/23/24. No licensed and/or certified nursing staff shall be permitted to work until education has been received. Monitoring of Corrective action Facility administration met with the corporate office on 9/18/24 and reviewed their action plan which included the quality assurance monitoring with plans made to move forward. DON and/or designee will audit 5 random transfers daily x2 weeks (starting 8/19/24), then 5 random transfers bi-weekly x2 weeks, then 10 random transfers per month x1 month, to ensure that transfers are being executed properly per resident transfer status as care planned. DON and/or designee will audit falls daily x4 weeks (starting 9/23/24), then 5x/week (Monday - Friday) x2 months to ensure that facility policy NSG215 Falls Management has been initiated and properly executed to ensure facility policy/protocol was followed as indicated, to include ensuring resident fall interventions are in place as resident's care plan reflects. Results of these audits will be brought before the Quality Assurance and Performance Committee for any additional monitoring or modification of this plan monthly for 3 months. The Quality Assurance and performance Improvement Committee can modify this plan to ensure the facility remains in compliance. The Director of Nursing will be responsible for implementation of the plan. Date of Compliance: 09/23/24. The facility's plan of correction was validated by the following: Beginning on 9/24/24 at 9:05 AM a tour of the facility was conducted. Multiple residents were interviewed and the interviews did not reveal a lack of supervision to prevent accidents. There were no residents observed with extensive injuries which might signify traumatic accidents. Beds were observed to be in the low positions for unattended residents and staff were supervising residents. Multiple staff members were interviewed and reported they utilized a total mechanical lift to transfer Resident # 1. Staff also reported they had received inservice education about fall prevention as outlined by the facility in their plan of correction, and were knowledgeable they were to follow the plan of care for residents. The facility presented evidence of audits and inservice training per their plan of correction. The facility's compliance date of 9/23/24 was validated on 9/26/24.

Based on observation, and interviews with staff and Responsible Party the facility failed to follow up with an audiologist's recommendation when one of Resident # 5's hearing aids was lost and the other broken. This was for one of one sampled resident with hearing loss (Resident #5). The findings included: Resident # 5 was admitted to the facility on [DATE]. The resident had diagnoses in part which included stroke and dementia. The resident's quarterly Minimum Data Set assessment, dated 7/30/24, coded the resident as cognitively impaired, having impaired hearing, and as wearing no hearing aids. The resident's care plan, updated on 8/2/24, included the problem that the resident had impaired hearing. The care plan also included the information that Resident # 5's RP (Responsible Party) had reported the resident had hearing aids, but they were not working. This had been initially added to the care plan on 1/30/24 and remained part of the resident's active care plan. Review of the interventions on the care plan revealed staff were directed on the care plan in ways to communicate with the resident, but there were no interventions related to steps needed to take about the resident's malfunctioning hearing aids. Review of an audiology report, dated 9/6/24, revealed Resident # 5 was seen for a hearing aid check. The audiologist noted, The patient stated that the right one is lost, and the left one doesn't work. Under the audiologist evaluation detail, the following information was documented. Left hearing aid is intermittent. The receiver is damaged. Unsure of warranty of devices. Does it have a warranty? Could it get repaired and could they file loss/damage claim with company for a new right device? Directions on the consult indicated there needed to be follow up with the family to determine what the warranty information and repair information was for the hearing aid that was lost and the one that was damaged. Review of the record revealed no documentation the follow up had been conducted since 9/6/24. Resident # 5's RP (Responsible Party was interviewed on 9/24/24 at 8:38 PM and reported the following information. The resident had one hearing aid but that one did not help her hear. She used to have both hearing aids, but at some point, one of them became missing. The missing one was the one that she needed most to hear. It had been around 3 to 4 months since one of them had been lost. She (the RP) had talked to someone in the front office and it was her understanding that the facility was supposed to be checking on getting the resident new hearing aids. She (the RP) had been told that the resident would qualify for new hearing aids, but there had been no follow through, and the resident still had no hearing aids she could use. On 9/25/24 at 3:35 PM the ADON (Assistant Director of Nursing) was accompanied to Resident # 5's room. Resident # 5 was observed to be hard of hearing. In order for the resident to hear, the speaker had to talk very loudly to the resident and face the resident. The ADON located one hearing aide in the resident's room and the other was missing. The ADON was unaware about the steps being taken about the missing hearing aid. The facility social worker was interviewed on 9/26/24 at 2:30 PM and reported the following information. She (the social worker) had begun work in May 2024 and was still somewhat new. She was responsible for setting up hearing clinics at the facility. Resident # 5 had a care plan meeting in August 2024, and the RP mentioned the resident had hearing problems and needed hearing aids. The first hearing clinic that she (the social worker) had arranged since being employed was in September 2024. She had informed the RP that a consult would be set up and the resident would be seen in the hearing aid clinic. The Administrator and Director of Nursing were interviewed on 9/25/24 at 3:20 PM and reported they were unaware of problems with the resident's hearing aids. They indicated they would check on what had occurred. A follow up interview was conducted with the Administrator on 9/26/24 at 8:30 AM and the Administrator reported the following information. The audiologist had filed their consult with the recommendations directly into Resident # 5's facility electronic record without letting any of the staff know. Therefore, they had been unaware follow up needed to be done about warranty information until the issue had been brought to their attention on 9/25/24 by the surveyor that there had been a problem with the resident's hearing aids.

Based on record review and staff interview the facility failed to communicate, follow care planned interventions, and physician orders regarding bowel movements (Resident #5) and failed to provide wound care as ordered (Resident #7) for 2 of 4 residents reviewed for receiving care according to professional standards, care plans and residents' choice. Findings included: 1. Resident #5 had multiple diagnoses some of which included dementia, diabetes mellitus, intellectual disability and a motor disability. Documentation in annual wellness visit note written by Nurse Practitioner #1 dated 12/27/2022 revealed Resident #5 was seen in the emergency department of the hospital on 11/18/2022 for abdominal pain and treated for constipation. The note also revealed Resident #5 was seen in the emergency department of the hospital on 12/8/2022 for abdominal pain and treated for fecal impaction. Resident #5 had the following physician orders for treatment of constipation. Initiated on 5/7/2022 Glycolax powder to be administered by mouth as 17 grams mixed with 4 to 8 ounces of liquid one time a day. Initiated on 5/7/2022 Linzess to be administered as one 290 microgram capsule in the morning by mouth one time a day. Initiated 5/7/2022 Senna-Docusate Sodium to be administered as two tablets of 8.6-50 micrograms each by mouth on time a day. Initiated 6/20/2022 Milk of Magnesia suspension to be administered as 30 milliliters of 400 milligram/5 milliliters by mouth on an as needed basis at bedtime if no bowel movement in three days. Initiated 6/20/2022 A Dulcolax suppository to be administered as 10 milligrams inserted rectally as needed for constipation if no result from the milk of magnesia by the next shift. Initiated 6/20/2022 Fleet Enema to be administered as one dose of 7-19 grams/milliliters inserted rectally as needed if no result from the Dulcolax within 2 hours. If no result from the Fleet enema, call the medical doctor/advanced practice provider for further orders. Documentation on the annual Minimum Data Set assessment dated [DATE] revealed Resident #5 had moderately impaired cognition, was dependent for all activities of daily living (ADL) and had range of motion impairment on both sides of her upper and lower extremities. Documentation in the care plan for Resident #5, dated as last reviewed on 1/3/2023, revealed a focus area for a risk for gastrointestinal symptoms or complications related to constipation and gastroesophageal reflux disease. Some of the interventions included observation for complaints of abdominal pain and distention, administration of medications as ordered and observation for effectiveness and side effects, monitoring and recording bowel movements, assessment of symptoms of constipation, and documentation of frequency and consistency of stools. Documentation on the same care plan dated 1/3/2023 for Resident #5 revealed additional focus areas for exhibiting verbal behaviors related to uncontrollable crying that different family members are dead, symptoms of deficits in cognitive function, and potential for alteration in communication. Review of the documentation on the Medication Administration Record (MAR) for January 2023 revealed Resident #5 received the Glyolax powder, Linzess, and Senna-Docusate Sodium as ordered for that month. The MAR documentation for January 2023 also revealed Resident #5 did not receive any doses of Milk of Magnesia, Dulcolax suppository, or Fleet Enema. Documentation in a nursing alert note dated 1/26/2023 at 10:52 AM Resident #5 had a large bowel movement. Documentation in the electronic medical record under the nurse aide tasks revealed Resident #5 had a small soft/loose stool on 1/26/2023 at 7:36 PM. Documentation on a handwritten ADL (activity of daily living) record revealed Resident #5 was incontinent of bowel on 1/27/2023 with no notation of size, consistency, or number. There was no documentation on the paper ADL record or the electronic medical record of any bowel movements for Resident #5 on 1/28/2023, 1/29/2023, or 1/30/2023. Documentation in the electronic medical record under the nurse aide tasks revealed Resident #5 had a small soft/loose stool on 1/31/2023 at 2:56 AM. Documentation in a general nursing note dated 2/1/2023 at 6:25 PM written by Nurse #7 stated, Resident sent to [emergency room ] per in-house PA (physician assistant) [due to] [altered mental status] and uncontrollable crying. [Responsible party] made aware. Will follow up with the hospital for update. An interview was conducted with Nurse #7 on 2/6/2023 at 1:40 PM. Nurse #7 revealed the following information. Nurse #7 stated NA # 1 came to her at approximately 8:00 AM on 2/1/2023 and stated Resident #5 did not look like her normal self. Nurse #7 stopped what she was doing and went to assess Resident #5 and take her vital signs. Nurse #7 indicated she went to get the unit supervisor to assess Resident #5. Nurse #7 revealed Resident #5 was yelling and crying a lot. Nurse #7 revealed Resident #5 had periods where she would calm down, but she continued to cry and yell all morning. Nurse #7 stated, When the PA came in he sent her out. He said he didn't know what was going on so ordered us to send her out. Nurse #7 stated she asked the unit supervisor to look to see when the last time Resident #5 had a bowel movement but the nursing system is different then where the nurse aides chart bowel movements. Nurse #7 indicated the unit supervisor might have forgotten because the unit supervisor never got back to her about when Resident #5 had her last bowel movement. NA #1 was interviewed on 1/6/2023 at 2:08 PM. NA #1 indicated she was usually assigned to care for Resident #5 and was very familiar with her care needs. NA #1 stated she was not working at the facility on 1/31/2023 so she did not know how Resident #5 was the day prior to Resident #5 going to the emergency room . NA #1 stated on the morning of 2/1/2023 Resident #5 did not want to eat her breakfast and she kept on crying. NA #1 said she couldn't get Resident #5 to tell her what was wrong, so she went to get help from the nurse. NA #1 stated she knew that Resident #5 was not having an issue with her bowel movements because on 1/30/2023 Resident #5 had a solid bowel movement and it had not been three days. NA #1 said the documentation of the bowel movements of the residents was on paper and then it switched to the electronic medical record recently. NA #1 stated, She would have told me if her stomach was bothering her. The unit supervisor, Nurse #10, was interviewed on 2/6/2023 at 2:15 PM. The unit supervisor acknowledged Nurse #7 came to her on the morning of 2/1/2023 and told her Resident #5 was not acting right. Nurse #10 stated Resident #5 usually gave correct feedback when she was asked questions. Nurse #10 said Resident #5 had a runny nose and her eyes were crusty, so she thought maybe she had a cold. Nurse #10 stated Resident #5 denied being in pain. Nurse #10 stated she called the doctor and was told the PA would be into the facility that day and would assess Resident #5 when he arrived. Nurse #10 revealed when the PA came in to assess her, he wanted her to be sent to the hospital because he didn't know what else to do. Nurse #10 denied being asked by Nurse #7 to look when Resident #5 last had a bowel movement. An interview was conducted with Nurse Practitioner #1 on 2/4/2023 at 10:15 AM. Nurse Practitioner #1 stated Resident #5 was not a patient of the doctor she worked for, and she would only see this resident if nursing needed support. The Physician Assistant (PA #1) was interviewed on 2/6/2023 at 11:31 AM. PA #1 revealed he came to the building and was asked to assess Resident #5 on 2/1/2023. PA #1 stated he sent Resident #5 out to the hospital for crying and altered mental status. PA #1 indicated that altered mental status could mean anything from a stroke or a cardiac event so, he felt the best course of action was to send her to the emergency room because someone who was crying uncontrollably needed to be evaluated immediately. PA #1 stated that x-rays in the facility are not obtained quickly and if Resident #5 needed an x-ray the results would be obtained faster in the emergency room . PA #1 revealed he was not aware of her last bowel movement at the time of his assessment of Resident #5 on 2/1/2023. Review of the hospital emergency room provider notes for Resident #5 dated 2/1/2023 at 3:56 PM revealed the following information. Staff from the nursing home had contacted [emergency medical services] stating that the patient seemed more fatigued, had been crying excessively, and had possible abdominal distention. She does have a long history of constipation issues due to being bedbound, her contractures, and [motor disability]. Patient has been evaluated in the emergency department several times for fecal impaction.According to the patients MAR it does appear that she received Linzess, Docusate, and Dulcolax today. She also has several other constipation relief type medications that can be provided as needed. It is unknown when the patient last had a bowel movement. Review of the hospital discharge summary for Resident #5 dated 2/3/2023 revealed an x-ray in the emergency room revealed a stool impaction. Resident #5 received a milk of molasses enema and received the medication Lactulose with multiple bowel movements. A repeat x-ray suggested Resident #5 had an ileus (painful obstruction) but then tolerated a diet, denied any abdominal pain, and had present bowel sounds. An interview with the Interim Director of Nursing (IDON) was conducted on 2/4/2023 at 3:50 PM. The IDON stated the facility was working on a bowel protocol so that residents who are not having bowel movements can be recognized and treated prior to being sent to the emergency room . The IDON stated the facility NA's were using paper ADL sheets for documentation and she was teaching them to use the electronic system for recording ADLs to include documentation of bowel movement so it can be tracked easier. 13289 2. Record review revealed Resident # 7 was admitted on [DATE]. His diagnoses in part included lymphedema, venous insufficiency, and a history of cellulitis. Resident # 7's quarterly Minimum Data Set assessment, dated 1/5/23, coded Resident # 7 as being cognitively intact. Resident # 7's care plan, updated 1/18/23, noted Resident # 7 had an abrasion to his right thigh. Staff were directed on the care plan to provide treatment as ordered. A nursing note, dated 11/28/22, noted Resident # 7 had psoriasis to both lower extremities and he had developed abrasions to the back of his legs. Review of Resident # 7's orders revealed an order, dated 11/29/22, to daily cleanse the right lower posterior thigh with normal saline and apply calcium alginate silver. The wound was then to be covered with a dry dressing. Resident #7's January and February 2023 TARs (Treatment Administration Records) revealed the order to cleanse the right lower posterior thigh with normal saline and apply calcium Alginate with silver had not been signed as completed on the following dates: 1/6/23; 1/8/23; 1/9/23; 1/10/23; 1/16/23 and 1/23/22. On 2/2/23, Nurse # 6 signed she had completed the dressing change. On 2/3/23 at 1:25 PM Resident # 7 was interviewed and reported no one had changed his dressing the previous day (2/2/23) and that had not been the first time he had missed dressing changes. On 2/6/23 the facility provided a list of nurses who had been responsible for the dressing changes that had not been signed as completed. The list was as follows: 1/6/23-Nurse # 6 1/8/23-Nurse # 4 1/9/23 Nurse # 6 1/10/23 Nurse # 6 1/16/23 Nurse # 4 1/23/23 Nurse # 6 Nurse # 6 was interviewed on 2/6/23 at 4:05 PM via phone and reported the following. On 2/2/23 she had not done Resident # 7's dressing change although she had signed that she had. She had inadvertently signed for Resident # 7's dressing change when she had been doing Resident # 7's roommate's dressing change. At the end of her shift, she usually checked everything to make sure there were no flags of tasks she had not done. Resident # 7's dressing change had not flagged on the TAR as something that still needed to be done since she had signed for it. Therefore, she had not caught that she had not done it. She could not recall the specific details of the January dressing changes that were not signed as done by her. She typically documented if she did do a dressing change or reported to another nurse it had not been done. Given Nurse # 6 had signed for something she had not done without recognizing it, she was interviewed further about her workload. She reported that things were very busy on 2/2/23. She had 28 to 30 residents to medicate, was responsible for a tracheostomy resident, and another resident who needed help with his ostomy multiple times per day. According to the nurse she was rushed and had not recognized the error of the missed dressing change she had signed for. Nurse # 4 was interviewed on 2/6/23 at 4:30 PM via phone and reported the following. If she had done a treatment for Resident # 7, she would have signed for it, but she had not known that it was her responsibility to have done the dressing changes. She thought the facility usually had a treatment nurse. The ADON (Assistant Director of Nursing) was interviewed on 2/4/23 at 11:20 AM and reported the following. Resident # 7's wound area was a result of developing a small area of skin breakdown where he formally had psoriasis. Treatments were typically the responsibility of the treatment nurse and if the treatment nurse was not present, then they were the responsibility of the floor nurses. There had been changes in who was responsible for treatments in recent months. She (the ADON) had been doing treatments in December 2022 and then had transitioned into the role of the ADON. The facility had hired a treatment nurse, but the new treatment nurse was not present on the date of 2/2/23 when Resident # 7's dressing change was missed. The new treatment nurse had been in training at another facility on 2/2/23. A review of Resident # 7's most recent assessments by the facility wound NP (Nurse Practitioner) revealed a notation on 1/24/23 that the wound was stable and improving. The NP again noted on 1/31/23 that the wound was stable.

Based on record review, observation and staff, family & resident interviews the facility failed to assure two of 2 sampled residents (Resident # 9 and Resident # 7) received their medications. Based on record reviews and staff interviews, the facility failed to consistently follow established procedures for the accounting of controlled substance medications administered to 2 of 2 residents reviewed (Resident #7and Resident #2) who received a controlled substance medication on an as needed (PRN) basis. The findings included. 1. Resident #9 was admitted on [DATE]with diagnoses of pain in limb, [CONDITION(S)], major depressive order, pyelonephritis, [CONDITION(S)], and chronic pain syndrome. Resident #9's Minimum Data Set Assessment coded the resident as cognitively intact. The resident had an order for [MEDICATION(S)] ER 12-hour 9 mg orally every 12 hours for pain. Upon record review it was revealed that the last day the medication was documented as given was on 10/21/2022 at 7:00 pm. On 10/26/2022 at 3:40 pm, Resident #9 was interviewed and stated that he had not received his pain medication ([MEDICATION(S)]) for 5 days. He stated that the nurses told him that he needed a hard script to get any more of the medication. He informed the surveyor that his pain level was an 8 out 10, and he had not slept for the past few nights. In an interview with Nurse #4 on 10/26/2022 at 4:10 pm she revealed that she had called the pharmacy that morning about the availability of this medication. She relayed to the surveyor that the pharmacy stated the medication was held up for prior authorization, but they would send out 3 days' worth of the medication today. The Director of Nursing obtained a stat order for 1 tablet of [MEDICATION(S)] to be given, which was procured out of the automated dispensing machine and given at 5:14 pm. Surveyor noted that the resident was angry but took the stat medication. 2. Resident # 7 was admitted to the facility on [DATE] with a diagnosis of anxiety. Resident #7's minimum data set assessment, coded the resident as having mild cognitive impairment. Resident # 7 had a current order, which originated on 10/8/2022, for [MEDICATION(S)] (generic [MEDICATION(S)]) to be given every 8 hours as needed. Review of the October 2022 MAR (Medication Administration Record) medications revealed the resident received her last [MEDICATION(S)] dose on 10/22/2022 at 9:30 am and did not receive the next dose until 10/24/2022 at 3:23 pm. Review of Resident Council Meeting Notes of 9/21/22 revealed that running out of medications was an issue brought up under Nursing Issues. On 10/25/2022 at 11:15 am the Director of Nursing was interviewed and acknowledged there were problems with medication availability. On 10/25/2022 at 12:00 pm Resident # 7 was interviewed. The resident stated that she had not received any of her [MEDICATION(S)] for 4 days, until she received a dose yesterday evening. She stated that not being able to obtain her medications was her biggest concern. The resident stated to surveyor she wanted to have her [MEDICATION(S)] twice per day and would ask for it but the nurses did not have it. On 10/25/2022 at 2:37 PM Resident #7's Responsible Party was interviewed on the phone. He stated that he had been in the facility on Sunday and was made aware by Resident # 7 that she had not receive [MEDICATION(S)] ([MEDICATION(S)]) over the weekend. Interview with Nurse #3 on 10/26/2022 at approximately 11:00 am revealed the nurse was aware Resident # 7 had been requesting the [MEDICATION(S)] but stated it had not been available. A record review of Resident #7's Medication Administration Record (MAR) and Control Medication Declining Count Sheet found discrepancies in recording of doses given to the resident. Resident #7 had an order for [MEDICATION(S)] 0.5 mg orally every 8 hours as needed dated 10/8/2022. The MAR indicated that the medication was not given to the resident on 10/13, 10/19, 10/22, 10/23, 10/24, & 10/25. The declining inventory count sheet indicated that the medication was given each of those days, 10/13 at 10 am and 7 pm; 10/19 at 8 am and 7 pm; 10/22 at 9:30 am; 10/23 at 6:23 pm; 10/24 at 10:00 pm and 10/25 at 9:30 am. 3. Resident #2 was admitted to the facility on [DATE]. A review of Resident #2's admission orders revealed a physician's order was written on 7/15/22 for 7.5 milligrams (mg) [MEDICATION(S)] / 325 mg acetaminophen to be given as one tablet by mouth every 6 hours as needed (PRN) for pain. [MEDICATION(S)] / acetaminophen is a combination pain medication which contains an opioid pain reliever (a controlled substance). Review of Resident #2's August 2022 Medication Administration Record (MAR) indicated one dose of the PRN 7.5 mg [MEDICATION(S)] / 325 mg acetaminophen was administered to Resident #2 on 8/1/22 and on 8/5/22 (for a total of two doses). No other doses of PRN [MEDICATION(S)] / acetaminophen were documented on the August 2022 MAR as having been administered to Resident #2. However, review of Resident #2's Controlled Medication Utilization Record (a declining inventory record of each controlled substance medication dispensed for a resident) revealed 1 tablet of 7.5 mg [MEDICATION(S)] / 325 mg acetaminophen was taken from the inventory 6 times during the month of August 2022 on the following dates/times: --On 8/1/22 at 3:50 PM; --On 8/5/22 at 9:16 AM; --On 8/7/22 at 9:00 AM; --On 8/8/22 at 9:00 AM; --On 8/9/22 at 9:00 AM; --On 8/9/22 at 4:43 PM. An interview was conducted on 10/27/22 at 3:13 PM with Nurse #1. Nurse #1 was identified by her signature on Resident #2's Controlled Medication Utilization Record as having removed one tablet of 7.5 mg [MEDICATION(S)] / 325 mg acetaminophen from the medication (med) cart on 8/7/22 at 9:00 AM without documenting its administration to the resident on the MAR. During the interview, Nurse #1 reported that when she administered a controlled substance medication to a resident she would document taking the med out of the med cart on the Controlled Medication Utilization Record. When asked, the nurse stated she would also document administering this medication on the resident's MAR. She did not know why the medication administration was not documented on Resident #2's MAR. A telephone interview was conducted on 10/27/22 at 3:53 PM with Nurse #2. Nurse #2 was identified by her signature on Resident #2's Controlled Medication Utilization Record as having removed one tablet of 7.5 mg / 325 mg [MEDICATION(S)] / acetaminophen from the medication cart on 3 occasions (8/8/22 at 9:00 AM, 8/9/22 at 9:00 AM and 8/9/22 at 4:43 PM) without documenting its administration to the resident on the MAR. During the interview, Nurse #2 reported she normally documented the medication was pulled from the med cart on the Controlled Medication Utilization Record and its administration on the resident's MAR. The nurse stated she only worked 4 or 5 shifts at this facility as an agency (temporary) nurse. When asked, Nurse #2 did not know why she had failed to document the [MEDICATION(S)] / acetaminophen administration on Resident #2's MAR. An interview was conducted on 10/26/22 at 1:14 PM with the facility's Director of Nursing (DON). During the interview, the DON was shown both Resident #2's August 2022 MAR and his Controlled Medication Utilization Record for the PRN [MEDICATION(S)] / acetaminophen. The DON confirmed there were discrepancies between the two documents. When asked, she reported the two documents should match up. During a follow-up interview conducted on 10/26/22 at 2:15 PM, the DON reported education needed to be provided to staff on the importance of documenting on both the Controlled Medication Utilization Record and MAR when a controlled medication was pulled from the cart and administered to a resident. She reported that although the facility had self-identified some medications concerns, this issue was different and had not been addressed in their current plan of correction.

Based on record review, observation, psychiatric Nurse Practitioner, staff, and resident interviews, the facility failed to protect Resident #1 from physical abuse by Resident #2 who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She asked Resident #1 for a light for her cigarette and when he refused, she attacked him punching him in the face causing both residents to fall to the ground. Resident #2 continued hitting Resident #1 while both residents were on the ground. Resident #1 sustained 3 scratches to his face with bleeding and an abrasion to his left knee. This abuse affected 1 of 2 residents reviewed for resident-to-resident altercations. Findings included: Resident #2 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] indicated Resident #2 was moderately impaired for cognition and was ambulatory. The MDS indicated Resident #2 was a smoker. Resident #2's active care plan as of 3/25/22 noted she was a supervised smoker per the smoking assessment. Interventions included: Resident is a supervised smoker; Inform and remind resident of location of smoking areas and times; and Maintain resident's smoking materials at nurses' station. The active care plan also indicated Resident #2 exhibited physical behaviors related to cognitive loss/dementia (i.e., will charge or try to hit staff if she is told no. Interventions included: Observe for signs of physical aggression, e.g. (for example), rigid body position, clenched fists, etc. If resident becomes combative or resistive, postpone care/activity and allow time for her to regain composure. Resident #2's active psychiatric medications as of 3/25/22 included [MEDICATION(S)] (antipsychotic medication) 25 milligrams (mg) by mouth two times daily. A review of the facility's active smoking policy as of 3/25/22 revealed supervised smokers were allowed to smoke at designated times. The door to the smoking area was unlocked from 7:00 AM to 11:00 PM. During those hours, a staff member was assigned to observe smokers and assist them with smoking safely. A nursing note completed by Nurse Supervisor #1 dated 3/27/22 revealed an altercation with Resident #2 and Resident #1 on 3/26/22, resulting in 3 scratches to Resident #1's face and an abrasion to his left knee. Resident #1 refused emergency room evaluation. A review of the 5-day report completed by the Director of Nursing on 4/1/22 noted on 3/26/22 around 4:30 PM Nurse Supervisor #1 was called to the smoking area by Nurse #1. Resident #1 was noted with scratch marks and blood on his face and an abrasion to his knee with complaints of knee pain. Resident #1 was asked if he wanted an ambulance to go to the hospital or have Emergency Medical Services (EMS) assess him and he refused. Resident #2 was taken to Nurse Supervisor #1's office. When asked what happened with Resident #1, Resident #2 stated, he started some s**t with me, so I finished it. Resident #2 confirmed she put her hands on Resident #1. Resident #2 was immediately started on 1 to 1 (1:1) supervision. The investigation noted the facility Medical Director was notified on 3/26/22 of the altercation between the two residents and of Resident #1's complaint of knee pain. The physician ordered an x-ray of the knee. A review of the x-ray report dated 3/26/22 of Resident #1's knee revealed only normal [CONDITION(S)] changes, no acute abnormality. On 5/4/22 at 10:00 AM Resident #1 was interviewed. Resident #1 indicated he was sitting outside in the smoking area on 3/26/22 minding his own business when Resident #2 came outside and asked him for a light. Resident #1 indicated he told her no and she just punched me. I fell to the ground, and we rolled around, and she was still punching me until I got her off me and that was when Nurse Supervisor #1 and Nurse #1 came. On 5/4/22 at 12:00 PM Nurse Supervisor #1 was interviewed and stated after the incident on 3/26/22, Resident #1 and Resident #2 were interviewed separately. She stated she asked Resident #2 what happened, and Resident #2 stated Resident #1 started s**t with her, so she finished it. Resident #2 was asked if she put her hands on Resident #1 and she stated yes. Nurse Supervisor #1 indicated while Resident #1 was being assessed and treated, Resident #2 was put on 1:1 supervision, the Psychiatric Service nurse practitioner was notified and Resident #2's antipsychotic medication was increased back to the original dosing. She explained that Resident #2 recently had a Gradual Dose Reduction (GDR) of her antipsychotic medication. Nurse Supervisor #1 stated Resident #1 was interviewed after he was given first aid for his injuries. (Resident #1 had refused an ambulance to go to the hospital and refused Emergency Medical Services to assess him.) She noted Resident #1 was alert and oriented to person, place, time, and situation. She reported that Resident #1 said, she attacked me, I knew this was going to happen. Nurse Supervisor #1 revealed she did not assign a staff member to observe the smoking area on 3/26/22. She further revealed, I didn't realize we needed someone to observe the smoking area at all times. She stated there were 8 or 9 Nursing Assistants (NAs) in the facility, and she would rather have people working the floor. She indicated Resident #1 and Resident #2 had not had a physical altercation prior to the one on 3/26/22, but she knew of two times those two residents had verbal altercations. Nurse Supervisor #1 noted the door to the smoking area was unlocked, and residents that do not smoke could go out there if they wanted. Nurse Supervisor #1 stated safe smokers and supervised smokers' assessments were in their electronic charts. Nurse Supervisor #1 reported she knew that Resident #2 was a supervised smoker. In an interview on 5/5/22 at 3:30 PM, Nurse Supervisor #2 stated she knew Resident #2 to be verbally aggressive most of the time but had not seen physical behaviors from the resident. On 5/5/22 at 4:00 PM, Nursing Assistant (NA) #1 stated Resident #2 was a supervised smoker because of her cognition. NA #1 stated, she is very aggressive especially if she wants to do something, like smoke. NA #1 was not assigned to Resident #2 on 3/26/22 but had been assigned to her several times. Resident #3, who was assessed as cognitively intact, was interviewed on 5/5/22 at 4:30 PM, and stated he had been threatened by Resident #2 with being hit with a metal chair. He could not state a date or time. He further stated that a few months ago Resident #2 had spit on him. On 5/6/22 at 3:10 PM, the Social Worker stated Resident #2 did not like to be told no. She explained that when she was told no she would become aggressive, especially when it was about smoking. The Social Worker also indicated that some staff were better at re-directing Resident #2, because you needed to approach her in a way that was not demanding or negative. A review of notes of a psychiatry telehealth visit with the Nurse Practitioner on 4/1/22 revealed the physical altercation with Resident #2 and Resident #1 on 3/26/22 was completely instigated by Resident #2. The note indicated Resident #2 was prescribed an antipsychotic medication and that she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview with the psychiatric Nurse Practitioner (NP) on 5/5/22 at 4:30 PM, the NP stated she was called on 3/26/22 after the altercation between the two residents occurred. The NP stated she changed the [MEDICATION(S)] back to 50 mg by mouth at bedtime, which was the dose Resident #2 was getting prior to a gradual dose reduction on 3/11/22. The NP stated Resident #2 had always been outspoken and noted Resident #2 had a challenging life and the NP felt that was part of the reason Resident #2 was so aggressive. On 5/4/22 at 4:45 PM in an interview, the Administrator stated Resident #2 was assessed to be a supervised smoker. The smoking assessment indicated Resident #2 was observed sharing smoking materials with other residents and that was why she was a supervised smoker. She was unable to explain why Nurse Supervisor #1 was unaware the facility protocol was to assign a staff member to the smoking area between the times of 7:00 AM and 11:00 PM. The facility provided the following corrective action plan with a completion date of 3/28/22. 1. Resident #2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was assessed to be a Supervised Smoker; she has a care planned history of going to smoking area and looking for cigarette butts and asking other residents for smoking materials. Facility had a plan in place to have all smoking activities supervised by staff, however, on the date of this event, the supervisor (Nurse Supervisor #1) failed to assign someone to the smoking area, and Resident #2 went to the smoking area where she got into a resident-to-resident altercation with a male resident (Resident #1). Staff responded to the event and an immediate investigation was initiated. Resident #1 received first-aid care for the scratches he sustained on his face and an x-ray to rule-out injury to his knee, which was bruised during the altercation. The police were notified and responded to the facility without additional action taken. Resident #2 was placed on 1:1 and has continued 1:1 supervision since 03/26/22. Resident #2 had a Gradual Dose Reduction on 3/11/22 for her [MEDICATION(S)] (antipsychotic medication). Psychiatric Service provider notified and increased her [MEDICATION(S)] back to original dosing on 03/26/22. Social Service Director is actively working on finding alternative placement for resident that is appropriate for her level of care. The resident will not be transferred or discharged without the agreement of the responsible party. 2. All residents have the potential to be affected. Interviews were conducted with staff and residents to determine if there are any concerns with resident's behaviors. Interviews were conducted by nursing management and the Social Services Director commencing on 03/26/22 and completed on 03/28/22; no other issues were identified. 3. Education on Abuse Prevention and resident to resident altercations was initiated on 3/26/22 for all staff, including full time, part time, PRN (as needed) and Agency staff. No staff shall work without education provided; education was provided by the Clinical Management team. Weekend Supervisor was educated by the Center Nurse Executive to ensure that staff are scheduled for the Smoking Area for monitoring. 4. Nursing will monitor resident smoking areas for appropriate supervision from 7 am - 11 pm and will monitor Resident #2 1:1 daily to ensure compliance and safety for all; 1:1 monitoring continues for Resident #2. Results of these monitoring audits will be brought to the Quality Assurance and Performance Improvement Committee monthly with the QAPI Committee responsible for ongoing compliance. QAPI Committee Members Responsible: Administrator, Director of Nursing, Medical Director, Assistant Director of Nursing, Infection Preventionist, Social Services Director and the Activity Director. Onsite validation was completed on 5/6/22 through staff interviews, observation, and record review. Staff were interviewed to validate in-services completed on abuse intervention, reporting, notification, and action. In-services were also confirmed to be provided on resident-to-resident altercation intervention, reporting, notification, and action. Observation of 1:1 supervision for Resident #2 and a review of audits of 1:1 supervision verified 1:1 was implemented. Observation of the smoking area and review of audits of staff supervision of the smoking area validated supervision was implemented as indicated in the corrective action plan. Review of education conducted with the weekend supervisor (Nurse Supervisor #1) about assigning staff to observe smoking area verified education was completed. Review of residents audited for possible resident abuse and resident interviews verified no additional issues were identified. The facility's action plan was validated to be completed as of 3/28/22.

Based on observation, record review, police interview, and staff interviews the facility failed to prevent a resident with cognitive impairment and exit seeking behaviors from exiting the facility unsupervised on two occasions. On 1/30/21 Resident #125 exited the building from a first floor window and was found in a bush. This second incident on 5/21/21 resulted in Resident #125 being brought back to the facility by law enforcement after being found approximately a quarter of a mile from the facility. The facility also failed to implement the fall risk intervention of a fall mat at bedside (Resident #112), and to assess a resident (Resident #108) for safe smoking prior to allowing independent smoking and keeping smoking materials in her room. This was for 3 of 4 residents reviewed for accidents. Immediate Jeopardy began on 1/30/21 when Resident #125 exited the facility unsupervised through a first floor window. Immediate Jeopardy was removed on 9/1/21 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure interventions implemented are effective. Examples #2 and #3 were cited at scope and severity of D. Findings included: 1. Resident #125 was admitted to the facility on [DATE] with diagnoses that included dementia. Resident #125 ' s admission Minimum Data Set assessment dated [DATE] revealed she was moderately cognitively impaired with no behaviors. She was independent for bed mobility, transfers, walking, and locomotion on and off the unit. She was not coded for wandering. A nurse ' s progress note completed by Nurse #5 dated 1/24/21 revealed wandering occurred daily or almost daily. A wanderguard (an electronic alert system that alarms and locks the facility exit doors when cognitively impaired residents with wandering behaviors attempt to exit the building) was ordered on 1/24/21. There was no plan developed for Resident #125 for wandering when the wanderguard was initiated on 1/24/21. There were no elopement risk assessments completed for Resident #125 on admission or after the wanderguard was implemented on 1/24/21. 1a. A progress note written by Nurse #5 on 1/30/21 at 10:40 AM stated Resident #125 was seen at breakfast at approximately 8:30 AM on 1/30/21. When Nurse #5 went to administer medications at approximately 9:10 AM to Resident #125 she was not in her room. Nurse #5 did a sweep of the building twice and couldn ' t locate Resident #125. At that time Nurse #5 alerted her supervisor and an elopement alert (an elopement alert was when a building-wide alarm was activated notifying staff that a resident was unable to be located. All staff were to assist in searching the facility and grounds to locate the resident) was activated. Resident #125 was found outside of the window in the back of the building by Nurse #4. An event summary report completed by Nurse #4 for an incident on 1/30/21 read in part, Resident states she was going to her car to go home. Staff assisted her back inside facility, full body assessment completed. Resident placed on 1:1 observation due to elopement and resident had cut off wander guard prior to exiting facility. Compassionate care visit to be completed by family to assist in increased anxiety due to isolation from family [related to] COVID protocols. The report indicated during a full body assessment, scratches to lower extremities and hands were discovered. The event summary report also indicated Resident #125 was discovered missing at 9:10 AM on 1/30/21 and was found at 9:40 AM. Observation on 3/15/22 at 11:30 AM of the area behind the building where Resident #125 exited out of on 1/30/21 revealed an approximate two-foot drop from the window to the ground. The bushes outside the window were below the windowsill. The reported temperature on 1/30/21 was 35 degrees Fahrenheit at 9:00 AM (www.wunderground.com). The medical records department was approximately 25 feet from Resident #125 ' s room at the time. An interview was conducted with Nurse #4 on 3/15/22 at 11:20 AM who stated Resident #125 was found under a window in the back of the building. She reported the window was open. Nurse #4 stated Resident #125 was wearing a blouse and pants. Resident #125 had socks and shoes on. She reported Resident #125 ' s pants were pushed up to her knees as is the resident ' s usual preference. A phone interview was conducted with Nurse #5 on 3/15/22 at 1:52 PM who stated Resident #125 had attempted to exit the building since she was admitted to the facility on [DATE]. Nurse #5 stated she could not recall any details regarding Resident #125 being found in the bushes outside the back of the building. During an interview with the Corporate Maintenance Director (CMD) on 3/15/22 at 11:30 AM he stated a contractor was replacing some of the windows in the building on 1/30/21. He stated the windows in the Medical Records office had been replaced that day. The CMD reported when the contractor left, he zipped up the zip wall that had been placed at the door of Medical Records. Based on the investigation conducted by the facility it was determined Resident #125 entered the zip wall, opened the window, and pushed the window screen out to exit the building. She was found in the bushes under the window and the screen was ajar with the window raised. He reported locks were placed on the windows in the facility to ensure they are not able to be raised higher than six inches. The care plan for Resident #125 had a focus area initiated 1/30/21 for wandering and at risk for elopement related to expressions of a desire to leave the facility and resident has made one or more attempts to leave the facility. Interventions included monitor resident ' s location with visual checks encourage participation in activity preferences, utilize and monitor security bracelet, and utilize diversional techniques to redirect resident when she verbalizes or exhibits the desire to leave the facility. During an interview with the Receptionist #1 on 3/16/22 at 10:01 AM she stated Resident #125 tried to exit the building daily since her admission. An interview was conducted with Receptionist #2 on 3/16/22 at 4:06 PM who stated she was familiar with Resident #125 and she did wander frequently. 1b. An event summary report prepared by Nurse #5 for an incident that occurred on 5/21/21 read in part, Dinner trays were served, and resident [Resident #125] was not able to be located for dinner. Resident had been refusing to be in her room for most of the day. Resident wanting to hang out in front lobby throughout the day. Resident last seen sitting in lobby on the couch. Staff completed a search throughout the building and notified proper authorities. Resident was located by local authorities and brought back to the facility. There were no injuries. A phone interview was conducted with Nurse #5 on 3/15/22 at 1:52 PM. She stated she recalled the resident had eloped and was brought back to the facility by the police on one occasion. Nurse #5 stated she could not recall any additional details about e the 5/21/21 incident. An interview was conducted with the facility Social Worker on 3/16/22 at 9:35 AM. She reported she observed Resident #125 on the afternoon of 5/21/21. She stated Resident #125 attempted to exit the building via the front door but was unable to do so due to her wander alarm at approximately 5:30 PM. She revealed she had not informed any other staff members that Resident #125 attempted to exit through the front door. The social worker indicated the receptionist was present and the wander alarm prevented her from opening the door so was not concerned at that time. The Social Worker stated she was in her office at approximately 5:55 PM and received a phone call from the kitchen staff regarding the alarm going off on one of the dining room doors. She stated she went to the dining room and found the door ajar and turned the alarm off. She stated she looked out the door but did not see anyone so returned to her office. The Social Worker stated she immediately recalled Resident #125 had been at the front door. The Social Worker stated she did not see Resident #125 so she asked the charge nurse to help locate her at 5:56 PM. Resident was unable to be found in the facility or on the grounds so local law enforcement was contacted. Resident #125 was returned to the facility at 6:33 PM by local law enforcement. The Social Worker stated she was advised by local law enforcement Resident #125 was located at the intersection of a nearby street. The resident was confirmed to be absent from the facility grounds for 38 minutes. She revealed the law enforcement indicated the location Resident #125 was found was across the highway. When measured by the corporate Maintenance Director the likely path taken by Resident #125 measured 1,407 feet (0.26 miles). Observation on 3/16/22 at 9:30 AM of the facility revealed the facility front door faced a two-lane highway with a speed limit of 35 miles per hour. The recorded temperature on 5/21/21 at 6:00 PM was 81 degrees Fahrenheit (www.wunderground.com). During an interview with a former kitchen staff member on 3/16/22 at 7:00 PM she stated she recalled Resident #125 leaving the building on 5/21/21. She reported Resident #125 tried to enter the kitchen several times on that day. The kitchen staff member stated they locked the door to prevent Resident #125 ' s entry. She reported she was unaware of Resident #125 ' s exit from the building until the social worker contacted her after Resident #125 was discovered absent from the facility. She further stated the alarm on the dining room door was not her responsibility and was unaware Resident #125 exited from that door. The former kitchen staff member stated she did not advise anyone of Resident #125 ' s had attempts to enter the kitchen on 5/21/21. An interview with the local law enforcement agency on 3/15/22 at 4:05 PM revealed no report was filed by the agency and no one recalled the incident. The Administrator was notified of Immediate Jeopardy on 3/16/22 at 3:48 PM. On 3/18/22 the facility provided an acceptable credible allegation of Immediate Jeopardy removal that included: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Facility failed to prevent Resident # 125 from exiting the facility unsupervised on 1/30/21 and 5/21/21. A. On 1/30/21, Resident #125 exited the facility through an open window in an unlocked office on Wing 3 that had been under construction. The window had been removed during construction and the construction crew working on this room had left the office door unsecured. Resident # 125 had last been seen at breakfast approximately 8:30 a.m. Nurse went to give a.m. medications and noted resident was not in room. Search initiated, unable to locate resident in the facility, search expanded to exterior and Elopement Code (overhead announcement of an elopement for all staff to respond according to policy to search for missing resident). called at 9:10 a.m. Staff members looked for resident and supervisor found resident outside in a bush behind the building outside of window, all belongings including clothes, walker and cane were outside as well. Resident assessed outside to determine if any major injuries incurred, resident able to move all extremities with no issue no gross injuries noted, resident escorted back inside, resident had total body check performed to further determine no injuries incurred, resident noted to have 2 scratches to right hand, 2 scratches to left hand and smaller scratches noted to bilateral lower extremities. ADON (Assistant Director of Nursing), DON (Director of Nursing) and administrator notified, family notified. Immediate Action for the 1/30/21 unsupervised exit included: An Immediate plan of correction was initiated on 1/30/21 which included placing resident # 125 on 1:1 supervision, followed by implementation of 15 minute checks. Resident #125 had an updated Elopement Assessment completed on 1/30/21 and Wander Guard alert bracelet was placed on resident. Facility leadership completed a head count on 1/30/21 of all current residents and all residents were accounted for. The office door was locked to prevent further egress. Maintenance completed an egress audit on 1/30/21 to ensure all doors and windows were secure. Windows were secured with metal locking tabs. B. On 5/21/21 Resident # 125 resident exited the center through the dining room door. The dining room door alarmed at approximately 5:55 pm and the Director of Social Services responded, turned off the alarm, she then asked a nurse for assistance. At 5:58 Elopement Code was called and search initiated. Resident was unable to be located at the facility and the local Police Department as notified at 6:10 p.m. of a missing resident. Resident was found by the police and returned to the facility at approximately 6:33 p.m. Immediate Action for the 5/21/21 unsupervised exit included: On 5/21/21 Immediate plan of correction started and education initiated. On the evening of 5/21/21 the Maintenance Director came into the facility to inspect the dining room door and found the door plunger was malfunctioning and provided an immediate repair to the door. While in the facility on the evening of 5/21/21 the Maintenance Director completed an audit of all doors to ensure secure/function. On 5/21/21 Facility leadership completed a head count of all current residents and all residents were accounted for. Resident # 125 remains in the center and has had no Elopements since 5/21/21. Resident # 125 remains an Elopement Risk and has a Wander Guard alert bracelet. All residents who wander and those identified at risk for Elopement have potential to be effected. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 1/30/21 Maintenance Director added Window checks to the TELs system to ensure that windows are checked monthly. TELs system is an electronic system that maintenance work orders are entered into and routine maintenance assigned tasks are entered into and documented for compliance by the facility Maintenance Director. On 02/01/21 Education was completed on Elopement, by the Assistant Director of Nursing. This education included a review of the Elopement Policy and Procedure which includes: ensuring a heightened awareness with all staff of the residents at risk for elopement and the systemic measures to prevent unsupervised exits. Policy/ Procedure also includes monitoring and supervising residents who wander. Wander Guard Audit completed on 1/30/21 and 5/21/21 by nursing leadership on residents identified at risk to ensure that the Wander Guard was on per order and that it was properly functioning, no concerns noted. On 5/21/21 Education was completed with dietary staff on responding immediately to alarms sounding, by the Assistant Director of Nursing. On 5/21/21 Re-Education was initiated on Elopement Policy, by the Assistant Director of Nursing for all staff to include full time, part time, as needed (PRN), and contracted staff. This education was a review of the Elopement Policy and Procedure which includes ensuring a heightened awareness with all staff of the residents at risk for elopement and the systemic measures to prevent unsupervised exits. Policy/ Procedure also includes monitoring and supervising residents who wander. Education completed on 5/28/21. Alleged Date of immediate jeopardy removal: 5/29/21 The credible allegation of immediate jeopardy removal was verified on 3/18/22 by onsite validation. During the verification process it was revealed training was not fully completed until 8/31/21. Staff were interviewed and confirmed they received training from the Assistant Director of Nursing and Corporate Maintenance Director pertaining to elopements. An observation on 3/18/22 at 9:00 AM revealed Resident #125 interacted with staff in the hallway. An interview was conducted with the Administrator on 3/17/22 at 5:15 PM who stated the last of the employees were educated on 8/31/21 by the Corporate Maintenance Director when an elopement drill was conducted. An interview was conducted with Maintenance Worker #1 on 3/18/22 at 9:23 AM. He confirmed he received education regarding elopements on 8/31/21 from the Corporate Maintenance Director. The facility ' s immediate jeopardy removal date was determined to be 9/1/21 based on the validation. 2. Resident #112 was admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)], cerebral vascular infarction with [CONDITION(S)] ([CONDITION(S)]), diabetes mellitus and hypertension. Resident #112 had a history of falls. The Annual Minimum Data Set (MDS) dated [DATE] revealed Resident #112 was cognitively intact and demonstrated no moods or behaviors. He required extensive assistance with 1 staff physical assistance with bed mobility related to one-side impairment for upper and lower body, transfer, dressing and toileting. A review of the care plan dated 03/02/2022 revealed Resident #112 was at risk for falls related to [CONDITION(S)] with [CONDITION(S)], lack of safety awareness, a history of falls, and required 1 staff assist with transfers. Interventions included a floor mat to the left side of his bed. A review of the facility falls incident report dated 03/06/2022 revealed Resident #112 attempted to transfer from his bed to electric wheelchair and the wheelchair was not locked. The wheelchair rolled backward, and Resident #112 fell on the floor. Education was provided to Resident #112 to make sure his wheelchair is turned off and locked before transferring to and from the wheelchair. The report also revealed there was not a fall mat beside his bed at the time of the fall. An interview with Resident #112 on 03/15/2022 at 11:55 am revealed he remembered his fall on 03/06/2022 when he tried to get in his electric wheelchair from his bed. He stated he thought he could do it himself, but he didn't make it. An interview with Nurse #3 on 03/15/2022 at 12:06 pm revealed Resident #112 had a recent fall on 03/06/2022 after he attempted to transfer to his electric wheelchair from his bed, the wheelchair rolled out from under him, and he fell . Nurse #3 stated there was not a fall mat beside Resident #112's bed at the time of the fall. Interview with Nurse #6 on 03/17/2022 at 9:09 am revealed Resident #112 had moved rooms on 03/11/2022 and his fall mat didn't make it to his new room and was aware he was care planned to have a fall mat beside his bed. Interview with the Director of Nursing (DON) on 03/17/2022 at 9:17am revealed Resident #112 should have had a fall mat beside his bed as outlined in his care plan. The DON stated nursing is responsible for making sure the care plans are followed. 3. Review of the facility's smoking policy reviewed 11/4/19 indicated that the admitting nurse would conduct a Smoking Evaluation on all persons wishing to smoke, the person would only be able to smoke with direct supervision until evaluated by the interdisciplinary team, smoking status would be documented in the Care Plan, and if deemed independent, the resident would not be able to maintain own cigarettes and lighters unless the facility chose to provide a lock box. Resident #108 was admitted to the facility on [DATE] with diagnoses that included cancer and lung disease. Resident #108's admission Minimum Data Set (MDS) indicated she was cognitively intact and independent for transfers, locomotion on and off unit, and other activities of daily living. Her MDS did not indicate tobacco use. A Nursing Admission assessment dated [DATE] revealed Resident #108 used tobacco products daily or almost daily for the past year. A Quarterly Recreation Progress Note dated 3/1/22 indicated that Resident #108 enjoyed smoking. Record review for Resident #108 did not reveal a Smoking Evaluation. Record review of Resident #108's Care Plan did not indicate she used tobacco. During an observation on 3/16/22 at 10:25 AM, Resident #108 were observed smoking in the designated smoking area of the courtyard. During an interview on 3/16/22 at 10:30 AM, Resident #108 revealed she was able to smoke independently, and she kept her cigarettes and lighter in her room in her drawer or her jacket pocket. She indicated she received instruction from the other residents not to share cigarettes with other residents. She had not received instructions from staff or been asked about her smoking. During an interview on 3/16/22 at 11:10 AM, the Director of Nursing (DON) indicated that independent smokers were encouraged to provider lighters to staff to put into a lock box. She revealed residents are asked at admission if they smoked and the admitting nurse would complete a Smoking Evaluation. During an interview on 3/18/22 at 9:20 AM, Nurse #1 revealed when she had filled out the Admission Nursing Assessment, Resident #108 said she was going to quit smoking since she had been in the hospital for so long. Nurse #1 indicated she did not fill out the Smoking Evaluation because Resident #108 said she was not going to smoke. She further revealed she did not know when Resident #108 started smoking again because she no longer worked on that floor. During an interview on 3/18/22 at 9:25 AM, Resident #108 revealed she had been smoking in the facility since the day after she arrived. She indicated she had not had an intention to quit smoking. During an interview on 3/18/22 at 9:50 AM, the Administrator indicated most residents did not have the lock boxes in their room and were able to keep the cigarettes in their room but were encouraged to give lighters to staff. She further revealed the smoking policy likely needed to be revised to better fit the facility. The administrator revealed that Resident #108 had only recent started smoking again and that was why she did not have Smoking Evaluation completed.

Based on record review and staff interviews the facility failed to have two staff assist when providing care and repositioning a resident in bed to prevent the resident from falling from bed and sustaining an injury for 1 of 4 residents sampled for accidents (Resident # 12). Resident # 12 fell from bed during incontinent care and sustained a right distal femur fracture that required an immobilizer. The findings included: Resident # 12 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a care plan initiated on 4/7/14 and in place on 11/29/18 read in part, Resident # 12 is dependent for activities of living (ADL) care in (bathing, grooming, dressing, bed mobility, transfer, locomotion, toileting) due to chronic disease status [REDACTED]. The interventions included the resident required total dependence with 2 person assistance with bed mobility, transfers, and toilet use. Review of a care plan initiated on 4/7/14 and in place on 11/19/18 read in part, Resident # 12 is at risk for falls due [MEDICAL CONDITIONS], cognitive loss and no safety awareness. Review of a nursing assessment dated [DATE] revealed that Resident # 12 was at moderate risk for falls. Review of the most recent quarterly Minimum Data Set (MDS) completed on 11/22/18 revealed that Resident # 12 had short and long term memory problems and severely impaired cognitively for making daily decisions. Resident # 12 required total dependence and 2 person physical assistance with bed mobility, transfers, and toilet use. Review of the facility Event Summary Report, completed by Nurse # 1 dated 11/29/18 at 11:35 AM read in part, Nurse Aide NA # 1 reporting resident fell out of bed. Upon entering room found resident on the floor to the left side of the bed with her head lying at the foot end of the bed, urine noted on floor under resident. Right lower leg angled out to the side of her body. NA reporting that she was changing resident and had her turned on her left side, resident had a hold of the bedrail, reports somehow she flipped out of the bed to the floor. NA reports states that right leg slid in some food that was on the floor. Asked Resident if she was having some pain in her neck and head. Asked in Spanish from Spanish speaking NA, she shakes her head yes. Also shakes head yes for leg pain. Called office to report incident and that resident was being sent out to the hospital. Called doctor ' s office to report the incident and that the resident was being sent out t the hospital. 911 called. Family was called by another nurse. Leaves out of facility via stretcher. The root cause/ conclusion: Improper positioning during ADL care. On 2/26/19 at 3:46 PM a telephone interview was attempted with NA # 1, who was providing care for Resident # 12 when she fell from bed on 11/29/18, but her telephone number was no longer in service. A telephone interview was conducted on 2/26/19 at 2:15 PM with Nurse # 1 who responded to the resident ' s fall. Nurse # 1 stated when she entered the room she found Resident # 12 lying on the right side of the bed on the floor with her head facing towards the end of the bed with her right leg bent at a weird angle. She stated there were urine and feces on floor and resident. She indicated she was focused on sending the resident out to the hospital for evaluation. The Nurse stated she called EMS, took Resident # 12 ' s vital signs and covered her up. The Nurse did not remember Resident # 12 crying or hollering out in pain. The Nurse stated she believed Resident # 12 had a bowel movement and the NA was cleaning her up at the time of the fall. She stated she did not remember if the head of the bed was up, however the bed was at high level and she lowered the bed for EMS to reach the resident. Review of the local hospital emergency room report dated 11/29/18 read in part, that Resident # 12 presented with a right leg injury. I spoke with the nurse at the nursing home. Apparently the aide was helping her and she fell from her bed onto the floor. She has a history of previous stroke. Review of the X-ray completed on 11/29/18 revealed Resident # 12 had a right distal femur fracture. Review of the general nursing note written by Nurse # 2 dated 11/29/18 at 7:42 PM documented Resident # 12 returned to the facility via emergency medical services on a stretcher at 6:34 PM in no distress. Resident has a [DIAGNOSES REDACTED].) Orders to keep resident ' s leg in an immobilizer, follow up with orthopedics in 7-12 days. An interview was conducted with the RN Unit Manager on 2/26/19 at 2:55 PM. The RN Unit Manager stated Nurse # 1 came and reported to her Resident # 12 had fallen and she was going to send her out to the ER. She stated Nurse # 1 reported to her that the NA was in the room alone, providing care when Resident # 12 fell out of the bed. She stated she brought the NA to the DON ' s office to interview. The NA reported she was providing care, the bed was broken at a 90 % angle and she continued to provide care. When asked if she had checked the bed prior to care the NA revealed she had not and had not gotten any help. The NA reported the head of bed was up and the bed was raised up high to provide incontinent care. The NA reported she gave care to her good side and as she began to roll Resident # 12 onto her right side she flipped out of the bed. The RN Manager stated that Resident # 12 was flaccid on her right side and was a 2 person assist with bed mobility and bathing. She stated staff first tended to Resident # 12 and after she was transported to the ER, staff checked her bed and found it to be working properly. The RN Unit Manger stated staff were in-Serviced to always provide 2 person assist when providing care and to check beds are working properly before providing resident care. Nurse # 1 stated she asked the NA if she attempted to get someone to help her give care, and NA # 1 stated that she did not ask anyone to help her with Resident # 12. An interview was conducted with the Director of Nursing (DON) on 2/26/19 at 1:43 PM. The DON stated after the fall, the NA involved came to report Resident # 12 had a fall. The NA reported the head of the bed was stuck up at a 90 % angle and when she was using a draw sheet the resident flipped out of bed. The NA stated she had not reported the bed was not working to the Maintenance man or nurse. The DON revealed when other staff entered the room to check the bed, it was working fine. She stated the NA was suspended pending their investigation and later terminated. An interview was conducted with the Administrator on 2/28/19 at 2:42 PM. The Administrator stated they discussed Resident # 12 ' s fall and afterwards instructed staff to use 2 person assist with all resident transfers. He stated he would have expected the NA to get help when caring for Resident # 12. The Administrator stated the facility ' s investigation of Resident #12 ' s fall revealed the NA #1 failed to do anything right.

Based on record review, physician, resident and staff interviews, the facility allowed a resident (Resident #168) to disregard 13 of 13 sampled residents' right to be treated with dignity (Resident #39, #43, #68, #71, #78, #79, #81, #105, #129, #131, #143, #172, and #203) as evidenced by vulgar, offensive and disruptive behaviors. The facility also did not maintain dignity for 6 of 6 sampled residents (Resident #44, #79, #83, #105, #122, and #172) who reported facility staff were searching their belongings routinely. Findings included: 1.a.Resident #131 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set (MDS) of 04/06/15 documented Resident #131 had poor decision making skills with moderately impaired cognition. A grievance/concern form dated 04/10/15 noted Resident #131 ' s family was very upset about an incident with Resident #168. The family reported to the social worker (SW #1) that she did not want Resident #168 anywhere around Resident #131. The family reported being worried about her safety and what Resident #168 was doing when she wasn't sitting with Resident #131. The family reported that Resident #168 had offered a stuffed animal to Resident #131 and the family told him not to give it to her but he gave it to her anyway. When Resident #131 started loving on the stuffed animal, Resident #168 remarked " Hey, I gave you that, why don't you give me some sugar like that? " and leaned into Resident #131. Resident #131 was extremely demented and the family felt that Resident #168 disregarded the family's wishes. A note from SW #1 of 05/04/15 at 4:52 PM noted that a grievance had been received from the call center regarding Resident #131. The grievance concerned resident on resident "tormenting" . According to the care line Resident #131's family was unhappy with the way the facility was handling the situation. SW #1 documented she had been made aware of the issue weeks ago and had been in contact with law enforcement, the Ombudsman and the corporate attorney. She documented she had asked the family of Resident #131 to go to law enforcement themselves. SW #1 telephoned the family and suggested that they go to the Magistrate's office and talk to them about the concern. It was documented that the family stated they understood the restrictions the facility had but she feared for Resident #131's safety. SW #1 also documented she assured the family that she was doing the best she could to keep the two residents from interacting. A late entry note from SW #1 indicated on 05/06/15 at 8:07 AM she had telephoned the magistrate's office. SW #1 was told someone from the facility would need to agree to testify for the resident (Resident #131). SW #1 documented that she could find no one who had witnessed any incidents or had firsthand experience. During an interview with Resident #81 on 05/07/15 at 3:45 PM, she stated about a month ago she had witnessed Resident #168 feeling the back of Resident #131's neck and flipping her hair. She stated Resident #131 was not capable of speaking for herself. She didn't report it to anyone. Resident #105 reported during an interview on 05/09/15 at 1:02 PM that he had witnessed Resident #168 twirling Resident #131's wheelchair around until she cried. He stated that Resident #168 was constantly harassing her. During an interview with the social worker #1 (SW #1) on 05/07/15 at 11:20 AM, she stated she had received a grievance from Resident #131's family in regards to Resident #168 harassing Resident #131 in front of the family. She stated the family was concerned about Resident #168 being inappropriate with Resident #131. 1.b. Resident #78 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set (MDS) assessment of 03/31/15 documented Resident #78 was cognitively intact and independent with decision making. This resident was also included in a list provided by the facility as being alert, oriented and reliable. A note from social worker #1 (SW #1) of 03/11/15 at 2:08 PM noted that the nurse staff scheduler had informed her that Resident #168 was speaking in an inappropriate vulgar manner to another female resident (Resident #78). It was noted that this time staff witnessed this behavior. SW #1 documented that Resident #168 was asking inappropriate sexual questions and the resident (Resident #78) felt uncomfortable and voiced she did not like him talking to her like that. Another note from SW #1 of 03/12/15 at 8:16 AM noted that SW #1 had spoken with Resident #168 about the incident of yesterday with a female resident where he was asking her sexual questions. He denied talking with the female (Resident #78). Resident #78 was interviewed about the incident with Resident #168 on 05/09/15 at 3:00 PM. She was visiting her male friend in his room. Resident #78 stated Resident #168 picked on her and harassed her constantly. She stated she had complained to several staff members including the social workers but no one had done anything because he was still doing it. Resident #78 could not provide any of the staff member's names other than social worker #1 (SW #1). Resident #78 stated Resident #168 would park himself in her doorway and stare at her from the hallway which made her very uncomfortable. She stated she felt that he was invading her rights when he made those horrible sexual comments in front of the other residents. Resident #78 reported there had been one incident with him a few months back where she was so upset she cried from embarrassment about the disrespectful way he treated her. She stated he was making awful vulgar sexual comments that she couldn't repeat about sexual things he thought she and her male friend were doing. Resident #78 stated he yelled it out (the B--- J---) in the hallway in front of the other residents. Her male friend reported that Resident #168 was constantly harassing Resident #78 and staff allowed him to do so. He stated he was present in the hallway that day and he told Resident #168 to stop talking to her like that. He also stated he told Resident #168 if he didn't leave her alone he was calling the police himself since the facility didn't appear to be doing anything to resolve the issue. Resident #78 stated no one had come back to her to ask her any questions about the incident or offer any resolution to the problem she was having with Resident #168. (The male friend did not want to be included in the list of residents but gave permission to share the interview.) 1c. Resident #105 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. He was also identified by the facility to be alert, oriented and reliable. Resident #105 was interviewed on 05/06/15 at 10:30 AM. He stated Resident #168 constantly yelled, cursed and would go into other resident's rooms uninvited. He stated he harassed the female residents in the building and had witnessed him going into other residents' rooms to curse them. He commented that this type of behavior had been going on for over a year now. He stated Resident #168 came into his room about 3 weeks ago and demanded a bag of pork skins that he had seen on top of his refrigerator. Resident #105 stated he told Resident #168 that he couldn't have the bag of skins. He stated that Resident #168 responded that if he wanted it he would take it and he couldn't stop him. As he was talking, tears were coming out of both eyes. Resident #105 stated Resident #168 told him there was nothing he could do about it because he was "stuck" in the bed and couldn't get up to stop him. He reported that he had reported that incident and others concerning Resident #168 to SW #1 on many occasions. When questioned about resolution, he stated SW #1 told him Resident #168 had rights and she couldn't do anything about it. He also stated she told him he didn't have any rights. Resident #105 stated Resident #168 had told him and the other residents as well as staff that he could do whatever he wanted. Resident #105 stated no one would say anything to him. He commented that Resident #168's behaviors were very upsetting for him. He also commented that he couldn't continue to "live like this" going without sleep every single night because of Resident #168's yelling, cursing and playing his television full volume. During another interview with Resident #105, on 05/08/15 at 11:28 AM, he stated he didn't feel that the facility was doing anything to change the way Resident #168 behaved. He stated he had been up every night this week yelling, cursing and playing his television at full volume. He appeared to be angry and frustrated based on his tone stating something had to be done. Resident #105 reported he had complained to SW #1 several times and she always responded that she had spoken with Resident #168 about the issue. Resident #105 commented it was obvious that talking with Resident #168 was not doing anything. He also stated he knew first hand that Resident #168 had been warned by staff to behave when visitors were in the building. He also stated if he capable of behaving when visitors were in the building why couldn't he behave all of the time. 1.d. Resident #203 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. There was no minimum data set (MDS) assessment available for this resident. Resident #203 was identified by the facility as being alert, oriented and reliable. A nurse's note of 05/05/15 at 11:11 AM indicated Resident #203 was alert and oriented x 4. During an interview with Resident #203, on 05/06/15 at 6:00 PM, he stated this was his second admission to the facility. He reported during his last admission there were problems with Resident #168 talking ugly to the other residents in the facility and it was still happening. Resident #203 stated Resident #168 disturbed the residents at night preventing them from sleeping. He reported this past Sunday his family was visiting him. He stated his grandchildren were here and Resident #168 was using M----- F----- along with other "awful" words in front of them. He stated he did not like that type of language to begin with but it was even worse when it was in front of his grandchildren. Resident #203 stated he didn't like that type of language in front of the other residents either. He reported it to be disgusting. When questioned if he had reported it, he responded he had not and that was why he was complaining in hopes someone could do something since the administration at the facility had not. 1.e. Resident #39 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set (MDS) assessment of 04/07/15 noted Resident #39 to be independent with decision making and cognitively intact. She was also identified by the facility as being alert, oriented and reliable. During an interview with Resident #39, on 05/09/15 at 11:45 AM, she stated one night recently she was going to the bathroom and Resident #168 was in the hallway. She stated he started yelling at her from the hallway calling her "d--- f-a-- ". Resident #39 stated she told him to stop calling her names. She stated he continued to roll down the hallway yelling out "d--- f-a- ". She stated she had not reported it to anyone but if he continued to talk to her in that manner or came into her room she would hit him with her reacher. Resident #39 commented that she felt his language was offensive. 1.f. Resident #43 was admitted to the facility 04/30/13. Cumulative [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set (MDS) assessment of 04/02/15 documented Resident #43 as independent with decision making and cognitively intact. He was also identified by the facility as being alert, oriented and reliable. During an interview with Resident #43, on 05/06/15 at 10:50 AM, he stated Resident #168 would go into other resident's rooms uninvited and would take sodas. He stated the management of the facility was well aware of his behaviors. He reported that Resident #168 constantly "picked on" one of the female residents. Resident #43 stated SW #1 had reported to him that the facility was actively seeking placement elsewhere. He stated staff and other residents had complained to him about Resident #168 being loud and disruptive. 1.g. Resident #68 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. The most recent Admission Minimum Data Set (MDS) assessment of 03/05/15 documented that Resident #68 was cognitively intact with independent decision making skills. He was also identified by the facility as being alert, oriented and reliable. During an interview with Resident #68, on 05/07/15 at 9:50 AM, he stated that Resident #168 was the rudest and most disrespectful person he had ever encountered. He stated Resident #168 terrorized the other residents and treated the elderly badly. Resident #68 stated he sits behind the residents and mocks them and makes fun of them. He stated he talked ugly to them calling them names. Resident #68 stated Resident #168 was up all night every night disturbing all of the residents with his television on full volume preventing anyone from getting any sleep. He stated Resident #168 was constantly yelling and cursing and disturbing everyone. Resident #68 stated he had asked the staff to ask Resident #168 to please turn his television down and they responded that it wouldn't do any good to ask him to turn it down because he turned it back up after they left the room. He stated the whole issue with Resident #168 had become a "big joke" with the staff. He was expressing anger with the issue and stated he was fed up. Resident #68 stated he complained to social worker #1 (SW #1) about Resident #168 and was told Resident #168 had rights and was told there was nothing they could do. He commented "what about my rights? " and stated he had rights just as well as Resident #168 did. He reported complaining to the Administrator about 3 weeks ago concerning issues with Resident #168. He stated he had complained again this past Monday about Resident #168 and was told by the Administrator that his "hands were tied." Resident #68 reported that he had complained to the nurses and they did nothing either. He stated that a few weeks ago he had been involved in a grievance with 3 other residents about Resident #168. He stated they wrote down about 15 different issues concerning Resident #168 and took them to SW #1. Resident #68 reported nothing had changed and expressed that it was not "right" that Resident #168 would be allowed to mistreat the other residents and act like he was. He added that the "old folks" in this facility should not have to put up with Resident #168 constantly abusing then and staff doing nothing to stop it. 1.h. Resident #71 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set (MDS) assessment of 04/06/15 documented Resident #71 to be independent with decision making and was cognitively intact. She was also identified by the facility as being alert, oriented and reliable. During an interview with Resident #71, on 05/07/15 at 9:35 AM, she stated Resident #168 was loud. She stated his room was at the other end of the hall and she could hear him in her room. She stated he felt that his constant cursing was offensive. She stated she was afraid of him because of his anger management problems. She had not reported her feelings to anyone. 1.i. Resident #79 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set (MDS) assessment of 04/14/15 noted Resident #79 was cognitively intact with independent decision making skills. Resident #79 was also identified by the facility as being alert, oriented and reliable. During an interview with Resident #79, 05/07/15 at 2:30 PM, she stated Resident #168 "picked on" one of the female residents constantly and she couldn't defend herself. She also stated that he talked very "ugly" to her. She also commented that Resident #168 usually bothered the residents who weren't capable of defending themselves. She stated she had complained to various staff members in the past about Resident #168's behaviors but nothing was ever done so she stopped complaining. 1.j. Resident #81 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment of 04/23/15 documented Resident #81 has being independent with decision making. There were no behaviors noted in this assessment. She was also identified by the facility as being alert, oriented and reliable. During an interview with Resident #81, on 05/07/15 at 3:45 PM, she stated that Resident #168 would come into her room uninvited when she was wearing her night gown. She stated that it bothered her and felt he was mistreating her. She stated she had witnessed Resident #168 bothering a female resident about a month ago. She commented that about a month ago she and some of the other residents had complained to SW #1 about him and SW #1 told her that the facility couldn't do anything about Resident #168. Resident #81 stated if Resident #168 continued to come into her room uninvited she would use her walking stick on him. She also commented she did not like being mistreated. 1.k. Resident #129 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set (MDS) assessment of 03/11/15 documented Resident #129 as being independent with decision making and cognitively intact. She was also identified as being alert, oriented and reliable by the facility. During an interview with Resident #129, on 05/07/15 at 9:35 AM, she stated Resident #168 played his television so loud at night that it kept her awake and she couldn't sleep. She stated she had reported the issue to 2 different nurses but couldn't remember who. She stated Resident #168 would get so angry over things and she was afraid of him. Resident #129 also stated " he cares" her. 1.l. Resident #143 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set (MDS) assessment of 02/15/15 documented Resident #143 as being independent with decision making and cognitively intact. He was also identified by the facility as being alert, oriented and reliable. During an interview with Resident #143, on 05/07/15 at 10:55 AM, he stated because of [MEDICAL CONDITION] he ambulated with 2 hand held walking canes and was very slow. He stated Resident #168 had a habit of "riding" on his heels with his wheelchair. Resident #143 stated about a couple of months ago he was walking in the hall with his canes and Resident #168 came up behind him. He stated Resident #168 used very loud foul language and threatened to "run him over." Resident #143 reported that he was afraid that Resident #168 was going to hurt him. He commented that he had completed a grievance and gave it to the social services department. During another interview with Resident #143, on 05/09/15 at 3:15 PM, he stated there was an on-going problem with Resident #168 telling him he was going to "run him over." He stated that he had been to the social worker to report the issue. During another interview with SW #1, on 05/09/15 at 5:00 PM, she stated as of last evening Resident #168 had been placed on one on one supervision in an attempt to control his behaviors. She was not aware of any issue regarding Resident #143 and denied ever receiving any grievance or complaint from Resident #143. She stated no one had reported anything about Resident #168 trying to "run over" Resident #143. 1.m. Resident #172 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. The most recent Significant Change Minimum Data Set (MDS) assessment of 04/01/15 documented Resident #172 was independent with decision making and cognitively intact. She was also identified by the facility as being alert, oriented and reliable. During an initial interview with Resident #172, on 05/04/15 at 5:41 PM, she stated staff were nice to her but there was one resident (Resident #168) who was disruptive and harassed some of the other residents constantly. She stated one of the female residents was "scared to death" of him. She reported Resident #168 being up at night yelling and cursing in the halls. Resident #172 stated he had his volume too high on his television making it difficult for her to sleep. She also stated a lot of the residents would not go to activities programs because Resident #168 was so disruptive. During the follow-up interview with Resident #172, on 05/07/15 at 2:40 PM, she stated Resident #168 constantly bothered and harassed the other residents. She stated Resident #168 kept everyone up all night using "awful" language, shouting and yelling down the halls. Resident #172 stated she had complained to numerous staff members about his behaviors but no one did anything about it. She commented she was tired of not getting any sleep because of Resident #168's yelling and cursing. Resident #172 stated she and 2 of the other residents had gone to SW #1 to report concerns regarding Resident #168 ' s behaviors and the way he treated the other residents. She stated SW #1 told her she would speak with Resident #168. She stated SW #1 told her Resident #168 had his rights. She commented so did she and she felt that no one cared about her rights because nothing had changed. Resident #172 stated no one listened to her complaints and Resident #168 was allowed to do whatever he wanted. She stated staff didn't say anything to him when he was acting out. She reported that Resident #168 "bothered" and "tormented" one of the confused female residents and was constantly calling her names. She stated she shouldn't have to "be shut up in her room" because of him and his behaviors. Resident #172 commented she was tired and frustrated with not being allowed to get a good night's sleep because of Resident #168. Resident #168 was admitted to the facility on [DATE] and re-admitted on [DATE]. Cumulative [DIAGNOSES REDACTED]. A "contract to enhance POSITIVE behaviors" , signed by Resident #168 on 12/17/14, noted that the goal was that Resident #168 would treat all residents and staff members with kindness. The objective for this goal was that Resident #168 would use nice words when speaking to residents. Another goal indicated that Resident #168 was to stay in his room and his space. The objective for this goal was that Resident #168 would learn to respect the privacy of the other residents by not going into their rooms. The most recent Quarterly Minimum Data Set (MDS) assessment of 02/16/15 noted Resident #168 to be cognitively intact with independent decision making skills. He had verbal behavior symptoms exhibited 1 to 3 days during the assessment period. Resident #168's care plan of 02/23/15 identified problems with: . Exhibits behaviors of verbal aggression as evidenced by calling residents names. Interventions included approach him in a calm friendly manner, develop a behavior plan if needed. Another intervention was to identify triggers and reduce exposure to them. Maintain a consistent routine as possible was also included as an intervention. . Exhibits disruptive/demanding behaviors as evidenced by cursing at staff and picking arguments with his roommate. Interventions included to approach in a calm friendly manner, document interventions and responses, identify behavior triggers and reduce exposure to them, maintain consistent routine and work with resident to develop a behavior contract if necessary. Information provided by the facility of 04/10/15 indicated that the corporate Regulatory Affairs Specialist had provided recommendations for dealing with Resident #168. The recommendations included: .Reach out to the ombudsman for assistance with placement .Contact local police to have them talk with Resident #168 regarding behaviors .Continue search for alterative placement .If able to locate safe discharge to let the specialist know A note from SW #1 of 04/14/15 at 4:00 PM noted that a meeting had been held with Resident #168, 2 police officers and the social worker. It was documented that the police spoke with Resident #168 about his behaviors and how his behaviors were unacceptable. The police officers also told Resident #168 that these behaviors could be punishable by law if anyone felt the need to press charges. The police officers also explained to Resident #168 The physician's orders [REDACTED].#168 was [MEDICATION NAME] milligrams (a sleep aid) at bedtime as needed, [MEDICATION NAME] 30 milligrams daily (an antidepressant), [MEDICATION NAME] 250 milligrams at bedtime (a mood stabilizer) and [MEDICATION NAME] 5 mg every 8 hours as needed (an antianxiety medication). An interview was conducted with Nurse #6 on 05/07/15 at 9:30 AM. She stated she worked on Resident #168's hall and was familiar with him and his behaviors. She stated he was angry, aggressive and disrespectful to the other residents. Nurse #6 stated she had been in his room on several occasions and asked him to turn his television volume down and he would get very angry with her but he would turn it down. She stated but as soon as she left out of the room he would turn it back up. Nurse #6 stated she had told him to not go into other resident's rooms and to respect their privacy as well as respect them as individuals. She stated some of the residents had complained to her about Resident #168 and she advised them to talk with the social workers. Resident #168 was interviewed on 05/07/15 at 10:45 AM. Resident #168 reported that some of the residents had complained about the volume of his television and he would turn it down. Resident #168 stated the staff employed at the facility was too young to work with elderly residents including himself. He stated he was - years old and wasn't going to have any young staff member telling him what to do with his television because the television was his. He denied being disruptive and disrespectful to the other residents in the facility. It was apparent that he was beginning to get agitated as he was taking his gloves off and putting them back on during the interview and was not maintaining eye contact. He was also becoming argumentative. Resident #168 also stated no one was going to tell him what to do. He denied going into other resident's rooms uninvited. He reported that at times he wasn't able to sleep at night and would go to the break room for a while but he would go back to his room. When questioned about being loud and keeping the other residents awake, he responded "you could hear a pin drop" on night shift. Resident #168 reported the facility staff had telephoned the police about him and they came out to the facility. He reported that he was not afraid of the police officers. Resident #168 stated that routinely when he was self-propelling his wheelchair down the hallways there were several residents who parked their wheelchairs in the hallways. He reported that he expected them to move out of his way because they could see him coming and he shouldn't have to say anything to pass through. When questioned about being considerate of others when he needed to pass them, he responded "why should I have to say excuse me?" Resident #168 stated he did not know what his rights were here at the facility and ended the conversation saying it was time for a smoke break. A follow-up interview was not conducted due to the apparent agitation and defensiveness displayed during this interview. During an interview with the social worker #1 (SW #1) on 05/07/15 at 11:20 AM, she stated she had spoken with Resident #168 on multiple occasions about the rights of the residents. She stated talking with him was nonproductive and he continued with the unacceptable behaviors. SW #1 stated she had lots of incidents too numerous to go over individually regarding Resident #168. She reported that she had spoken with him on almost a daily basis in regards to the huge list of unacceptable behaviors that he exhibited. SW #1 reported that she had contacted the Ombudsman for advice. When questioned about the safety of the residents in the facility she responded that the police had been out to the facility to speak with Resident #168 and gave him a verbal warning. She commented the behaviors were unchanged. SW #1 stated he had a signed behavior contract but there were no consequences if he broke the contract. She reported the only consequence was a 30 day notice for discharge but thus far she had not been able to find suitable placement for Resident #168. She commented that no one at the facility could do anything with him or his behaviors. SW #1 stated she could not provide a safe and orderly discharge so he would continue to be there until she found an appropriate placement. A telephone interview was conducted with the Ombudsman on 05/07/15 at 3:03 PM. She stated the facility telephoned her about a month ago asking if she could come out and brainstorm with them on some issues at the facility. She stated they expressed no urgency with the request. The Ombudsman stated she came out last week and met with SW #1. She stated she advised them to call the police each time incidents occurred. She stated SW #1 told her she had not been able to find a suitable place for him to be discharged to. The Ombudsman commented that the facility had not imposed any consequences for his unacceptable behaviors and he was doing whatever he wanted whenever he wanted and no one had done anything to stop him. During an interview with the nurse staff scheduler, on 05/07/15 at 4:00 PM, she stated Resident #168 had been a problem for the facility for a while. She stated he was constantly making inappropriate comments to the other residents. She stated she had witnessed incidents and had reported them to the social services department. During an interview with Nurse #4, on 05/07/15 at 4:40 PM, she stated she worked third shift and there was one resident who disrupted the entire hall. She stated Resident #168 made inappropriate verbal sexual comments to the residents. She stated she had overheard some of the other residents talking about his behaviors and constant verbal abusive manners. When questioned if she reported it or talked with them about it, she responded she had not. She did state she passed it on to the oncoming nurses. Nurse #4 stated she had spoken with him numerous times about his inappropriate behaviors toward the other residents but he paid no attention to what she was saying and continued doing the same things. She commented that when she spoke with him about his behaviors he told her no one could kick him out of the building. Nurse #1 was interviewed on 05/07/15 at 5:15 PM. She was identified as working third shift on Resident #168's hall. Nurse #1 reported that she was very familiar with Resident #168 and his behaviors. She reported that he frequently told staff that he could do whatever he wanted and no one could stop him. Nurse #1 stated it didn't do any good to say anything to him because there were no consequences for his unacceptable behaviors. She stated there was chaos wherever he would go in the building. Nurse #1 reported him as being belligerent with the other

Based on staff interview and record review the facility failed to 1) utilize its quality assurance (QA) process to resolve kitchen sanitation/cleanliness issues which were cited as deficient practice in multiple surveys and which were addressed in the facility's current QA action plan to correct problems with pest control in the facility. The facility was previously required to develop plans of correction for kitchen sanitation citations received during the 2012, 2013, and 2014 annual recertification surveys and during a 2014 complaint investigation. The facility developed a plan of correction for a pest control citation received during a 2015 complaint investigation. 2) utilize its QA process to resolve dignity issues which were cited as deficient practice during January 2015 and March 2015 complaint surveys. Findings included: 1. This tag is cross referenced to: F371: Based on observation and staff interview the facility failed to clean the face of a wall fan blowing into the dish machine area where sanitized kitchenware was unloaded, failed to air dry and remove food particles from kitchenware before stacking it in storage, failed to monitor wash/rinse gauges during the operation of the dish machine, failed to clean walls/corners/floors in the kitchen, and failed to label and date opened food items. F469: Based on observation, resident interview, family interview, staff interview, and record review the facility failed to eradicate and contain common household pests in resident care areas, and failed to maintain cleanliness in the kitchen which was identified as the possible cause of a bug infestation. At 2:28 PM on 05/07/15 the district food service manager stated the facility had been without a dietary manager for approximately four months so she tried to assist the facility one or two days a week. She reported she did not conduct kitchen sanitation audits since she was in the building on a limited basis. She commented she thought the dietary employees were keeping up with the daily cleaning tasks, but there might be problems with more routine cleaning tasks such as the cleaning of walls, ovens, and baseboards. Review of the kitchen's daily cleaning schedule for May 2015 revealed through 05/07/15 18 assignments had not been initialed off as being completed. At 2:35 PM on 05/07/15 the lead cook, helping to supervise the dietary staff in the absence of a dietary manager, stated she was not told that conducting sanitation audits was a part of her job responsibilities. At 2:43 PM on 05/08/15 the administrator stated the purpose of a QA program was to identify areas of resident care that the facility needed to improve upon, develop interventions to facilitate the improvement, utilize an audit process to evaluate the effectiveness of the interventions, and revise the proposed interventions or incorporate the successful interventions into system changes to prevent the problems from reoccurring. According to the administrator, there was not a current QA action plan in place for F371, but kitchen sanitation was the key intervention in a current QA action plan for pest control. He explained he thought kitchen sanitation issues were resolved after each survey through development and implementation of a plan of correction. The administrator commented on-going routine kitchen sanitation inspections were necessary to make sure kitchen sanitation issues remained resolved. He reported he had not done any kitchen sanitation audits himself since the summer of 2014. He stated, however, maintenance was supposed to be completing weekly pest control audits in the kitchen since this was the area of the building identified as the main source of roach infestation during a 2015 complaint investigation. Review of weekly pest control audits, completed by the maintenance department in the kitchen, revealed generally less live roaches were being found, but during the week of 04/13/15 through 04/17/15 audits documented, "noticed a little more insect activity." The audits documented a couple of issues in the kitchen over the past month which may have contributed to the return of roaches in the kitchen such as boxes on the floors for prolonged periods of time and dirty, sticky kitchen floors. At 10:53 AM on 05/09/15 the facility's registered dietitian stated that completing kitchen sanitation audits were not part of her job responsibilities. 2. This tag is cross referenced to: F241: Based on record review, physician, resident and staff interviews, the facility allowed a resident (Resident #168) to disregard 13 of 13 sampled residents' right to be treated with dignity (Resident #39, #43, #68, #71, #78, #79, #81, #105, #129, #131, #143, #172, and #203) as evidenced by vulgar, offensive, and disruptive behaviors. The facility also did not maintain dignity for 6 of 6 sampled residents (Resident #44, #79, #83, #105, #122, and #172) who reported facility staff were searching their belongings routinely. At 2:43 PM on 05/08/15 the administrator stated the purpose of a QA program was to identify areas of resident care that the facility needed to improve upon, develop interventions to facilitate the improvement, utilize an audit process to evaluate the effectiveness of the interventions, and revise the proposed interventions or incorporate the successful interventions into system changes to prevent the problems from reoccurring.

Based on record review, physician interview, resident and staff interviews, the facility administration did not follow through on verbal and written concerns of 1 resident (Resident #168) who exhibited disrespectful, bullying behavior for 13 of 13 residents (Resident #39, #43, #68, #71, #78, #79, #81, #105, #129, #131, #143, #172, and #203) and the bullying behavior continued. The facility's administration also did not maintain a respectful/dignified environment for 6 of 6 sampled residents (Resident #) who reported staff searching their belongings regularly. Findings included: This tag is cross referenced to F166. Based on record review, resident and staff interviews, the facility did not follow-up on grievances expressed by 3 of 3 sampled residents (Resident #68, #105 and #172) regarding disruptive behaviors by another resident (Resident #168). This tag is cross referenced to F223. Based on record review, resident and staff interviews, the facility allowed a resident (Resident #168) to verbally harass and torment 1 of 1 sampled residents (Resident #131). The facility also allowed Resident #168 to physically abuse 1 of 1 sampled residents (Resident #131). This tag is cross referenced to F241. Based on record review, physician, resident and staff interviews, the facility allowed a resident (Resident #168) to disregard 13 of 13 sampled residents' right to be treated with dignity (Resident #39, #43, #68, #71, #78, #79, #81, #105, #129, #131, #143, #172, and #203) as evidenced by vulgar, offensive and disruptive behaviors. The facility also did not maintain dignity for 6 of 6 sampled residents (Resident #44, #79, #83, #105, #122, and #172) who reported facility staff were searching their belongings routinely.

Based on record review, resident and staff interviews, the facility did not investigate allegations of abuse and did not protect 1 of 1 sampled residents (Resident #131) from on-going verbal and/or physical abuse by a cognitively intact resident (Resident #168). Findings included: The facility's Abuse prohibition policy, revised on 07/01/09, noted that abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish and included verbal, sexual, physical, and mental abuse. It was noted that if suspected abuse was resident to resident, the resident who had in any way threatened another would be removed from the setting or situation. It was also noted that upon receiving information concerning a report of suspected or alleged abuse an immediate and thorough investigation was to be done. It was further noted that the facility would take whatever steps necessary to prevent further incidents. Resident #131 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set (MDS) assessment of 04/06/15 documented Resident #131 had poor decision making skills with moderately impaired cognition. A "GRIEVANCE/CONCERN FORM" dated 04/10/15 noted that the family of Resident #131 reported to social worker #1 (SW #1) that she did not want Resident #168 anywhere around Resident #131. The family reported being worried about her safety and what Resident #168 was doing when she wasn't sitting with Resident #131. The family reported that Resident #168 had offered a stuffed animal to Resident #131 and the family told him not to give it to her but he gave it to her anyway. When Resident #131 started loving on the stuffed animal, Resident #168 remarked "Hey, I gave you that, why don't you give me some sugar like that? " and leaned into Resident #131. It was also noted that the family told Resident #168 that Resident #131 didn't give kisses to anyone. It was noted that Resident #131 was extremely demented and the family felt that Resident #168 disregarded the family's wishes. A note from social worker #1 (SW #1) of 05/04/15 at 4:52 PM indicated that a grievance had been received from the call center regarding Resident #131. The grievance concerned resident on resident "tormenting" . SW #1 documented that she had been made aware of the issue weeks ago and had been in contact with law enforcement, the Ombudsman and the corporate attorney. She documented she had asked the family of Resident #131 to go to law enforcement themselves. SW #1 telephoned the family and suggested that they go to the Magistrate's office and talk to them about the concern. It was documented that the family stated they understood the restrictions the facility had but she feared for Resident #131's safety. SW #1 assured the family that she was doing the best she could to keep the two residents from interacting. Resident #105 was interviewed on 05/06/15 at 10:30 AM. He stated Resident #168 constantly harassed the female residents in the building including Resident #131. During an interview with Resident #172, on 05/04/15 at 5:41 PM, she stated Resident #168 constantly harassed Resident #131. She stated Resident #131 was "scared to death" of Resident #168. Resident #172 stated she had witnessed Resident #168 "tormenting" Resident #131 and calling her "ugly" names. During an interview with SW #1, on 05/07/15 at 11:20 AM, she stated she had received a grievance a few weeks ago from Resident #131's family in regards to Resident #168 harassing Resident #131 in front of the family. She commented the family was concerned about Resident #168 being inappropriate with Resident #131. During another interview with Resident #172, on 05/07/15 at 2:40PM, she stated she along with 2 other residents had written a long list of concerns in a grievance that they had given to SW #1. She stated one of the reasons they prepared the grievance was because of the way Resident #168 was harassing and tormenting Resident #131 and the other residents. She also stated Resident #168 constantly called Resident #131 "ugly" names. During an interview with Resident #79, on 05/07/15 at 2:30 PM, she stated Resident #168 "picked on" Resident #131 constantly and that Resident #168 talked very "ugly" to her. She stated Resident #131 couldn't defend herself. Resident #79 also stated that Resident #168 usually bothered the residents who weren't capable of defending themselves. She commented that she had complained to various staff members in the past but nothing was ever done so she stopped complaining. The nurse staff scheduler was interviewed on 05/07/15 at 4:00 PM. She stated she had heard Resident #168 make inappropriate comments to Resident #131 and had reported it to social services. Nurse #1 was interviewed on 05/0715 at 5:15 PM. She stated Resident #168 was belligerent with the residents and harassed the residents who weren't capable of defending themselves. She stated she had reported issues to administration in the past but nothing was done so she stopped. Resident #105 was interviewed again on 05/09/15 at 1:02PM. He stated he had witnessed Resident #168 spinning Resident #131's wheelchair around and around in a circle until she cried. He also stated Resident #168 was constantly abusing her. He stated he had reported it to SW #1. Resident #68 was interviewed on 05/07/15 at 9:50 AM. He stated Resident #168 made fun of the "old folks" , called them names and mocked them. He was not able to provide any residents names other than Resident #131 but he had witnessed these behaviors. Resident #68 stated Resident #168 constantly picked on Resident #131. He stated that Resident #168 would point at Resident #131 calling her ugly names. He stated he had complained about his behaviors to staff and administration but staff did nothing and the behaviors continued. The Administrator was interviewed on 05/08/15 at 12:00 PM. He stated he had been made aware of the incident regarding Resident #131 where Resident #168 had been seen spinning her around in her wheelchair. He stated SW #1 had been handling the issues regarding Resident #168 and Resident #131. He added that the facility investigated any resident to resident altercation that was brought to their attention. SW #1 was interviewed on 05/09/15 at 4:45 PM. She stated the issue regarding Resident #131's wheelchair was mentioned third party while talking with 2 other residents concerning a grievance they had brought to her concerning behaviors exhibited by Resident #168 toward the other residents. She stated the 2 residents gave no specific information other than Resident #168 had been observed twirling Resident #131 around in her wheelchair and that Resident #168 was harassing her. SW #1 stated she had spoken with some of the staff and no one was able to provide her with any information. She stated in order to investigate the issue she needed to know when it occurred and who witnessed it. When questioned about investigating the issues with Resident #131 as abuse, she responded that she felt it was a resident to resident confrontation and did not see it as an abuse situation. SW #1 reported she had been talking with Resident #168 about his behaviors toward Resident #131 as well as the other residents but the behaviors were unchanged. During an interview with the Director of Nurses (DON), on 05/09/15 at 5:00 PM, she denied awareness of the issue with Resident #131's wheelchair and Resident #168. She stated SW #1 was handling those issues.

Based on record review, resident and staff interviews, the facility allowed a resident (Resident #168) to verbally harass and torment 1 of 1 sampled residents (Resident #131). The facility also allowed Resident #168 to physically abuse 1 of 1 sampled residents (Resident #131). Findings included: Resident #131 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set (MDS) assessment of 04/061/15 documented Resident #131 had poor decision making skills with moderately impaired cognition. A "GRIEVANCE/CONCERN FORM" dated 04/10/15 noted that Resident #131's family reported to SW #1 that she did not want Resident #168 anywhere around Resident #131. The family reported being worried about her safety and what Resident #168 was doing when she wasn't sitting with Resident #131. The family reported that Resident #168 had offered a stuffed animal to Resident #131 and the family told him not to give it to her but he gave it to her anyway. When Resident #131 started loving on the stuffed animal, Resident #168 remarked "Hey, I gave you that, why don't you give me some sugar like that?" and leaned into Resident #131. It was documented that the family told Resident #168 Resident #131 didn't give kisses to anyone. It was noted that Resident #131 was extremely demented and the family felt that Resident #168 disregarded the family's wishes. A note from SW #1 of 05/04/15 at 4:52 PM indicated that a grievance had been received from the call center regarding Resident #131. The grievance concerned resident on resident "tormenting" . SW #1 documented that she had been made aware of the issue weeks ago and had been in contact with law enforcement, the Ombudsman and the corporate attorney. She documented she had asked the family of Resident #131 to go to law enforcement themselves. SW #1 telephoned the family and suggested that they go to the Magistrate's office and talk to them about the concern. It was documented that the family stated they understood the restrictions the facility had but she feared for Resident #131's safety. SW #1 assured the family that she was doing the best she could to keep the two residents from interacting. Resident #105 was interviewed on 05/06/15 at 10:30 AM. He stated Resident #168 constantly harassed the female residents in the building including Resident #131. During an interview with Resident #43, on 05/06/15 at 10:50 AM, he stated Resident #168 "picked on "Resident #131 constantly. He stated he cursed and harassed her as well as other residents. He reported staff were very aware of his behaviors. During an interview with Resident #172, on 05/04/15 at 5:41 PM, she stated Resident #168 was disruptive and harassed Resident #131 constantly. She stated Resident #131 was "scared to death" of Resident #168. Resident #172 stated she had witnessed Resident #168 "tormenting" Resident #131 and calling her ugly names. She commented that staff allowed the behavior and said nothing to him. During an interview with social worker #1 (SW #1), on 05/07/15 at 11:20 AM, she stated she had received a grievance a few weeks ago from Resident #131's family in regards to Resident #168 harassing Resident #131 in front of the family. She commented the family was concerned about Resident #168 being inappropriate with Resident #131. SW #1 remarked the only consequence for Resident #168's behavior was a 30 day discharge but she had not been able to locate a suitable location thus far. During an interview with Resident #79, on 05/07/15 at 2:30 PM, she stated Resident #168 "picked on" Resident #131 constantly and that Resident #168 talked very "ugly" to her. She stated Resident #131 couldn't defend herself. Resident #79 also stated that Resident #168 usually bothered the residents who weren't capable of defending themselves. She commented that she had complained to various staff members in the past but nothing was ever done so she stopped complaining. The nurse staff scheduler was interviewed on 05/07/15 at 4:00 PM. She stated she had heard Resident #168 make inappropriate comments to Resident #131 and had reported it to social services. Resident #105 was interviewed again on 05/09/15 at 1:02PM. He stated he had witnessed Resident #168 spinning Resident #131's wheelchair around and around in a circle until she cried. He also stated Resident #168 was constantly abusing her. He stated he had reported it to social worker #1 (SW #1). Resident #68 was interviewed on 05/07/15 at 9:50 AM. He stated Resident #168 made fun of the "old folks", called them names and mocked them. He was not able to provide any residents names other than Resident #131 but he had witnessed these behaviors. Resident #68 stated Resident #168 constantly picked on Resident #131. He stated that Resident #168 would point at Resident #131 calling her ugly names. He stated he had complained about his behaviors to staff and administration but staff did nothing and the behaviors continued. Resident #68 reported that he had signed a grievance form that was compiled by some of the other residents concerning Resident #168's behaviors regarding some of the residents including Resident #131.

Based on observations, staff interviews and record reviews, the facility failed to cover the indwelling urinary catheter collection system for 2 of 3 sampled residents (Residents # 2 and # 3) reviewed for indwelling urinary catheters. Findings included: 1. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS), dated [DATE], identified the use of the indwelling urinary catheter. Review of the 3/3/15 care plan developed for the indwelling urinary catheter did not include an intervention to keep the collection system covered for privacy. On 3/25/15 at 10:20 AM, Resident #2 ' s urinary catheter collection system was observed hanging from the side of the bed facing the door and was clearly visualized from the hall. There was no privacy bag covering the collection system. An observation was made on 3/25/15 at 3:05 PM. The indwelling urinary catheter bag was easily visualized from the hall and was not covered for privacy. On 3/26/15 at 8:20 AM, Resident #2 ' s indwelling urinary catheter collection system remained uncovered and visible from the hall. An observation made on 3/26/15 at 11:35 AM revealed the indwelling urinary catheter collection system was not covered and was easily visualized from the hall. On 3/26/15 at 11:28 AM, Nursing Assistant (NA) #1 was interviewed. She stated she had been taught to provide privacy bags for urinary collection systems. She stated she had only worked a short time in the facility and was not aware if the facility provided privacy bags. The NA acknowledged Resident #2 ' s indwelling urinary catheter collection system was not covered for privacy. The Treatment Nurse was interviewed on 3/26/15 at 11:47 AM. The nurse stated both nurses and NAs were taught to cover the urinary catheter collection system for privacy. She stated the facility offered a collection system that provided privacy and also offered bags in which the collection system could be placed. The nurse stated she had just noticed there was no cover on Resident #2 ' s urinary catheter collection system. On 3/26/15 at 3:00 PM the Director of Nursing was interviewed. She stated urinary catheter collection systems should be covered at all times. The DON added privacy bags were provided by the facility. 2. Resident #3 was admitted on [DATE] with Parkinson ' s disease and wounds requiring an indwelling urinary catheter. Review of Resident #3 ' s Minimum Data Set (MDS), dated [DATE], captured the use of the indwelling urinary catheter and identified the resident had 2, Stage IV pressure ulcers. An observation was made on 3/25/15 at 10: 13 AM. Resident #3 was in bed. The urinary collection system was hanging on the side of the bed and easily visible from the hall. There was no privacy bag covering the collection system. Observations were made on 3/25/15 at 2:30 PM. Resident #3 ' s urinary catheter collection system remained uncovered and visible from the hallway. On 3/.26/15 at 8:20 AM, the urinary catheter collection system remained uncovered. The system was easily visualized from the hall. During an observation of catheter care on 3/26/15 at 2:10 PM, it was noted the urinary catheter collection system had been covered Nursing Assistant (NA) #2 was interviewed on 3/26/15 at 2:45 PM. She stated she had cared for Resident #3 on 3/25/15 and 3/26/15. She acknowledged the urinary catheter collection system had not been covered either day. The NA added she could not remember the last time the system had been covered. NA #2 stated she knew the system was supposed to be covered, but she did not tell the nurse it was not because she had not been specifically instructed to notify the nurse. The NA added while the system was now covered, she had not been the one to cover it and did not know who had covered the collection system.

Based on staff interview and record review the facility failed to make changes in the treatment of [REDACTED].#1) with pressure ulcers. Findings included: A [DATE] hospital discharge summary documented, "...she (Resident #1) has a known history of decubitus ulcer with underlying osteo[DIAGNOSES REDACTED] of the sacral bone in the past. She was completely noncompliant with her antibiotics...." Resident #1 was admitted to the facility on [DATE], readmitted to the facility on [DATE], and expired in the facility on [DATE]. The resident's documented [DIAGNOSES REDACTED]. A [DATE] admission nursing assessment documented Resident #1 had a stage II pressure ulcer on her sacrum, and there was pain associated with this wound. A [DATE] interdisciplinary progress note documented, "Wound round completed, sacral stage II wound assessed. Area was present on admission, measures 3.5 x 1.3 x 0.3 cm (centimeters). Wound bed is greater than (symbol used) 50 [MEDICATION NAME] tissue with macerated wound edges, surrounding tissue healthy. Minimal amount of serosanguineous drainage with no odor. Pt. (patient) does not complain of (symbol used) pain. Will start daily dressing changes with [MEDICATION NAME] as per protocol. Has wound clinic appointment [DATE]. A [DATE] physician progress notes [REDACTED]." Resident #1's [DATE] admission minimum data set (MDS) documented her cognition was intact, and she had a stage II pressure ulcer. Record review revealed Resident #1 was hospitalized from [DATE] until [DATE]. A [DATE] physician progress notes [REDACTED]." The facility did not assess the resident's wound after [DATE] until [DATE]. On [DATE] the sacral pressure ulcer remained a stage II wound measuring 3.0 x 0.5 x less than 0.1 cm. Record review revealed Resident #1's first wound clinic appointment was [DATE]. Comparison between wound clinic recommendations and treatment administration records (TARs) revealed the facility followed wound clinic recommendations until [DATE] when Resident #1's physician assistant (PA) ordered the sacral wound treatment of [REDACTED]. Record review revealed members of Resident #1's primary physician team signed off on wound clinic recommendations made on [DATE], [DATE], [DATE], and [DATE], but the facility did not provide the recommended wound treatments. The facility continued to provide [MEDICATION NAME] Ag with border gauze daily through [DATE]. The wound clinic's treatment recommendations were for Iodosorb gel with xtrasorb foam dressing every three days on [DATE], zinc oxide/[MEDICATION NAME] Ag/xtrasorb/[MEDICATION NAME] or medipane every three days on [DATE], [MEDICATION NAME] or Promagran/zinc oxide/foam/tape or [MEDICATION NAME] every three days on [DATE], and skin prep and sensicare to the periwound/[MEDICATION NAME] or Promagran to the wound bed/xtrasorb foam dressing every three days on [DATE]. Review of the Skin Integrity Reports revealed Resident #1's sacral pressure ulcer was not assessed between [DATE] and [DATE]. Resident #1's [DATE] quarterly MDS documented her cognition was moderately impaired, and she had a stage II pressure ulcer. On [DATE] the facility began to follow the treatment recommendations made by the wound clinic on [DATE] and [DATE] for skin prep and sensicare to the periwound/[MEDICATION NAME] or Promagran to the wound bed/xtrasorb foam dressing every three days. On [DATE] "Resident has actual skin breakdown related to incontinence, vascular disease, limited mobility, refuses incontinent care at times; resident has a pressure ulcer on her sacrum" was identified as a problem on the resident's care plan. Interventions to this problem included "Provide wound treatment as ordered", "Weekly skin assessment by licensed nurse", and "Weekly wound assessment to include measurements and description of wound status." Resident #1's Skin Integrity Report documented on [DATE] her sacral wound had declined to a stage III pressure ulcer measuring 1.8 x 1.5 x 0.3 cm with 75% [MEDICATION NAME] tissue and 25% slough in the wound bed. Review of the Skin Integrity Reports revealed Resident #1's sacral pressure ulcer was not assessed between [DATE] and [DATE]. [DATE] and [DATE] the wound clinic recommended continuing its [DATE] and [DATE] recommendations for the treatment of [REDACTED]. These recommendations were signed off on by Resident #1's primary physician team. "Change dressing every other day or as needed for excessive drainage. Review of Resident #1's May and [DATE] TARs revealed the facility continue to change the dressing to the sacral pressure ulcer every three days. A [DATE] physician progress notes [REDACTED]. May d/c (discontinue) wound clinic and continue current care and monitoring with staff." Resident #1's Skin Integrity Report documented on [DATE] the resident had a stage II sacral pressure ulcer measuring 1.0 x 0.6 x 0.2 cm with greater than 75% granulation tissue in the wound bed. Record review revealed no further assessments of the resident's sacral pressure ulcer until she expired in the facility on [DATE]. At 4:12 PM on [DATE] the director of nursing (DON) stated per facility protocol pressure ulcers were to be measure and assessed weekly. She also reported when members of the primary physician team signed off on consult recommendations, the facility was supposed to follow them. The DON commented she could not explain why the facility did not follow wound clinic recommendations for treatment of [REDACTED]. The DON stated these recommendations should have been followed by the facility since all of them were signed off on by the resident's primary physician team. At 4:20 PM on [DATE] Unit Manager #1 stated wounds were to be measured and assessed weekly. She reported this was important to capture any decline in the wounds quickly and react by possibly changing treatments/frequencies and increasing nutrition interventions to promote healing. She explained she was the only unit manager in the facility for a long period of time, and she did the best she could, but was not always able to assess wounds/pressure ulcers weekly per facility protocol. According to this unit manager, when members of the primary physician team signed off on consult recommendations, the facility was supposed to follow them.

Based on observation, record review and staff interview, the facility failed to provide pressure ulcer treatment as recommended by the wound clinic and ordered by the primary physician team for 1 of 3 sampled residents (Resident #12) with pressure ulcers. Findings included: Resident #12 was re-admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Resident #12's Quarterly Minimum Data Set ((MDS) dated [DATE] showed Resident #12 had a stage 4 pressure ulcer. Resident #12 was cognitively aware. Review of the wound clinic orders dated 09/24/14, and ordered by the primary physician team on 09/26/14, showed an order for [REDACTED]. The treatment was to be done every 72 hours. Review of Resident #12's September Treatment Administration Record (TAR) for 09/26/14 showed an order for [REDACTED]. The TAR showed an "X" in the Tuesday, Thursday, Saturday and Sunday boxes designating the treatment should not be done on those days. Review of the October TAR showed an "X" in each Tuesday, Thursday, Saturday and Sunday box again designating that the treatment not be done on those days. In an observation of Resident #12's treatment on 10/01/14 at 12:00 PM the dressing which was dated 09/29/14 was removed. The wound was soaked with acetic acid for 10 minutes and the iodine based gel was applied and covered with a dressing dated 10/01/14. In an interview on 10/01/14 at 4:20 PM the Treatment Nurse stated the order for Resident #12's treatment had been entered so she could perform the treatment during her normal work week. She stated the facility staff had the capability to order the treatment for [REDACTED]. In a telephone interview on 10/02/14 at 9:05 AM the wound clinic physician stated it was his expectation that his orders be followed as written. He indicated his orders were written based on consistency and timing and it was important they be followed. In an interview on 10/02/14 at 7:45 PM the Director of Nursing Services (DNS) stated the nurse who input the order into the computer knew the treatment nurse was here during the week and changed the order so the treatment nurse could do the dressing changes. She stated it was her expectation that orders for treatments be transcribed and performed as ordered by the physician.