Every finding on record at Mountain View Health Services

Based on interview and record review it was determined that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice. Specifically, for 1 out of 16 residents sampled, the facility did not seek timely emergency care for a resident who was displaying signs and symptoms of a Gastrointestinal (GI) bleed. This was cited at a harm level. Resident identifier 11. Findings included:Resident 11 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included epilepsy, myocardial infarction, chronic kidney disease, congestive heart failure, osteoporosis, and repeated falls. Resident 11's progress notes revealed the following: a. On 3/2/26 at 4:23 AM, the note documented, Per CNA [Certified Nurse Assistant] Res [Resident] is having black tarie [sic] stool. b. On 3/2/26 at 8:36 AM, the note documented, res states she is not feeling well. she states she has had coffee ground emesis and stool. she states she was given pepto bismol last night. advised will get an order for zofran to help with vomiting and when she vomits again to let us know. Wctm [will continue to monitor]. c. On 3/2/26 at 10:03 AM, the note documented, Resident is having severe abdominal discomfort with black tarry stools and claims to have coffee ground emesis her Xarelto and Aspirin were held. Resident was having a hard time getting her medications down this morning so the supplements were held and she was given a Zofran to help with the nausea. d. On 3/2/26 at 12:58 PM, the note documented, Resident was discharged to [name omitted] Hospital at Noon today for a suspected GI bleed. e. On 3/2/26 at 12:00 AM, the provider note documented, Acute Illness with GI Bleeding - Transfer to Emergency Department03/02/2026 03:06 PMASSESSMENT & PLANDifferential diagnosis includes upper gastrointestinal bleeding secondary to anticoagulation therapy, peptic ulcer disease with bleeding, medication-induced gastritis, acute decompensated heart failure with gastrointestinal manifestations, medication toxicity from polypharmacy, acute anemia secondary to blood loss, and potential drug-drug interactions affecting anticoagulation.Possible acute upper gastrointestinal bleeding: Patient presents with coffee ground emesis and melena in the setting of dual antiplatelet and anticoagulant therapy with Xarelto 20 mg [milligrams] daily and aspirin 81 mg daily. This represents a high-risk bleeding scenario requiring immediate emergency evaluation. Patient transferred to emergency department for urgent assessment, laboratory evaluation including complete blood count, comprehensive metabolic panel, coagulation studies, and potential endoscopic intervention. Will coordinate care with emergency department team and await stabilization before return to facility.Acute illness with lethargy: Dramatic change from baseline functional status in this typically active resident who is normally ambulatory and engaged. Current presentation of lethargy and sleeping during daytime hours represents significant clinical deterioration requiring urgent evaluation. Likely secondary to blood loss anemia and hemodynamic compromise from gastrointestinal bleeding.HISTORY OF PRESENT ILLNESS[AGE] year-old female residing in skilled nursing facility presents with acute onset of significant clinical deterioration over the past 24 hours. Nursing staff expressed concern prompting urgent evaluation due to dramatic change from patient's baseline functional status. Patient typically maintains good activity level, spending time in her armchair or ambulating in facility hallways, making current presentation particularly concerning. Patient found reclined in bed sleeping during midday hours, which represents highly unusual behavior pattern for this resident. On evaluation, patient appears lethargic and acutely ill with significant change from baseline mental status and activity level. Patient reports experiencing significant nausea and vomiting over the past day with concerning gastrointestinal symptoms. Most notably, patient describes coffee ground emesis and dark tarry stools consistent with melena, raising immediate concern for upper gastrointestinal bleeding. These symptoms are particularly concerning given patient's current anticoagulation regimen and cardiac history requiring dual therapy for cardiovascular protection. It should be noted that this note was created on 3/2/26 at 10:13 PM and the effective date was 3/2/26 at 12:00 AM. On 7/13/26 at 1:20 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that coffee ground emesis and black tarry stools were a sign of a GI bleed. RN 2 stated that she would respond by obtaining a set of vital signs and then notify the provider. RN 2 stated that she would document all of this information in a progress note. RN 2 stated that if the resident was currently on an anticoagulant and had a history of GI bleed it would warrant further evaluation at the hospital. On 7/15/26 at 9:56 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that coffee ground emesis and black tarry stools was an indication of a GI bleed. The DON stated that staff should notify the provider immediately and document a progress note. The DON reviewed resident 2's progress notes and stated that the notes did not indicate that the provider was notified of resident 2's onset of black tarry stools and coffee ground emesis immediately. It should be noted that resident 2 waited approximately 7.5 hours from the onset of symptoms to her subsequent transfer to the emergency room for evaluation and treatment.

Based on interview and record review it was determined that the facility did not ensure that each resident who was given a psychotropic drug had an adequate indication for use of the medication; that psychotropic drugs received a gradual dose reduction (GDR) and behavioral interventions, unless clinically contraindicated; as needed (PRN) orders for psychotropic drugs were limited to 14 days unless the practitioner documented a clinical rationale to extend beyond 14 days with a duration of use for the order; and PRN orders for antipsychotics were limited to 14 days and were not be renewed unless the attending physician evaluated the resident for the appropriateness of the medication. Specifically, for 4 out of 16 sampled residents, the facility did not document an adequate indication of use for Seroquel; did not have monitoring for hours of sleep with the use of a psychotropic medication for insomnia and did not have monitoring for adverse side effects while taking an anticoagulant; did not have a GDR attempt or a documented clinical contraindication to the GDR for psychotropic medications; and had duplicative medication classes for lorazepam and clonazepam which did not have an evaluation by the physician for the appropriateness of the medications. Resident identifiers: 4, 13, 36, and 41.Findings included:1. Resident 4 was admitted to the facility on [DATE] with diagnoses which included, generalized anxiety disorder, major depressive disorder, and vascular dementia.Resident 4's physician orders included:a. Clonazepam Oral Tablet 1 MG (milligram), Give 1 tablet by mouth one time a day for anxiety. The order was initiated on 5/7/26.b. Seroquel Oral Tablet 50 MG (Quetiapine Fumarate), Give 1 tablet by mouth two times a day for antipsychotic. The order was initiated on 5/7/26. c. Trazodone HCl (hydrochloride) Oral Tablet 50 MG, Give 1 tablet by mouth one time a day for insomnia. The order was initiated on 5/7/26. [It should be noted that hours of sleep were not being monitored for resident 4.]d. Lorazepam Oral Tablet 1 MG, Give 1 mg by mouth one time only for agitation and aggressive behaviors until 5/21/26 at 11:59 PM. This order was initiated on 5/21/26.e. Lorazepam Oral Tablet 1 MG, Give 1 tablet by mouth every 24 hours as needed for agitation. This order was initiated on 5/22/26.f. Lorazepam Oral Tablet 1 MG, Give 1 tablet by mouth every 24 hours as needed for agitation for 14 Days. This order was initiated on 6/25/26 and discontinued on 7/9/26.On 7/15/26 at 9:38 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she ran the psychotropic meeting with the provider. RN 1 stated that resident 4 had as needed lorazepam, but thought it had been discontinued. RN 1 stated that resident 4 had scheduled clonazepam. RN 1 stated that resident 4 had a lot of behaviors and he came to the facility on both medications and this was duplicative therapy. RN 1 stated that resident 4 had not had a psychotropic review because he had not been at the facility for 3 months. RN 1 stated that the pharmacy had reviewed resident 4's medications and they never mentioned anything about his medications. RN 1 stated that resident 4 should have his hours of sleep tracked to see if the insomnia medication was working. RN 1 stated that Seroquel was being given to resident 4 for aggression and it was prescribed prior to his being at the facility. On 7/15/26 at 12:33 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the pharmacist reviewed the medications of residents when they admitted and then every month thereafter. The DON stated that resident 4 was given an as needed order for lorazepam when only nurses were in the facility and he was having behaviors. The DON stated there was not a rationale for resident 4 to be taking both clonazepam and lorazepam. The DON stated that resident 4 was taking Seroquel for vascular dementia, but dementia residents should not be given an antipsychotic. 2. Resident 13 was admitted to the facility on [DATE] with diagnoses which included, mixed receptive-expressive language disorder, generalized muscle weakness, cognitive communication deficit, and dementia.Resident 13's physician orders included hydroxyzine hydrochloride 50 mg tablet, give one tablet by mouth two times a day for anxiety. The order was initiated on 6/17/25.No documentation could be located for a clinical rationale as to why a gradual dose reduction had not been done.On 7/15/26 at 9:36 AM, an interview was conducted with RN 1. RN 1 stated that resident 13 had been on the medication for over a year and there was no documentation regarding a gradual dose reduction or a rationale as to why this was contraindicated. RN 1 stated that gradual dose reductions needed to be done yearly. 3. Resident 41 was admitted to the facility on [DATE] with diagnoses which included cerebral aneurysm, major depressive disorder, insomnia, generalized anxiety disorder, mood disorder, hypertension, and cognitive communication deficit. Resident 41's physician orders included:a. Buspirone Hydrochloride (HCL) Tablet, give 7.5 mg by mouth two times a day for anxiety. The order was initiated on 8/20/25.b. Trazodone HCL Tablet, give 25 mg by mouth one time a day for insomnia. The order was initiated on 4/8/24. On 1/27/26, resident 41's psychotropic drug review documented Trazodone 25 mg for insomnia had a recommendation to maintain the current dose. The Buspirone 7.5 mg for anxiety documented that the behaviors had stabilized and to maintain the current dose. The prior psychotropic review on 10/28/25 had the same recommendations for the same medications and dosages. No documentation could be found for a clinical contraindication to a gradual dose reduction (GDR) for the Trazodone and Buspirone. On 7/14/26 at 9:54 AM, an interview was conducted with the DON. The DON stated they did not have any documentation of a clinical contraindication to the GDR for resident 41's Trazodone and Buspirone. On 7/14/26 10:06 AM, an interview was conducted with RN 1. RN 1 stated that resident 41 did not have a GDR for the Trazodone and Buspirone. 4. Resident 36 was admitted to the facility on [DATE] with diagnoses which included Schizoaffective disorder, urinary tract infection, psychosis and anxiety. Resident 36's physician's orders included:a. On 4/29/23, Cymbalta 30 MG give 2 capsules by mouth one time a day for Depression. b. On 2/9/24, Clonazepam 0.5 MG give 1 tablet by mouth one time a day related to dementia without behavioral disturbance, mood disturbance, and anxiety. A note from the local Behavioral Health provider dated 1/22/26 revealed [Resident 36] is taking two antipsychotic medications as it is needed to keep his psychotic symptoms controlled. This was started while he was in the [state removed] State Hospital and no change is medical [sic] indicated. On 7/15/26 at 9:37 AM, an interview was conducted with RN 1. RN 1 stated that there was a contraindication for Gradual Dose Reduction for resident 36 on 1/22/26. RN 1 was observed to review the contraindication 1/22/26. RN 1 stated the contraindication was for Fanapt and Clozapine the 2 antipsychotics medications. RN 1 stated there was no contraindication for the Clonazepam or Cymbalta. RN 1 stated she asked for the physician to provide a contraindication for all of resident 36's psychotropic medications but that was not provided.

Based on interview and record review it was determined that the facility did not ensure that appropriate information was communicated to the receiving provider that included contact information of the practitioner responsible for the care of the resident, resident representative information, Advance Directive information, all special instructions for ongoing care, comprehensive care plan goals, and all other necessary information for a safe and effective transition of care. Additionally, the facility did not send a copy of the transfer/discharge notice to the State Long-Term Care Ombudsman. Specifically, for 4 out of 16 residents sampled, the facility did not document in the resident's medical record the information sent to the receiving provider and notification to the Ombudsman of the transfer was not made. Resident identifiers: 2, 4, 11, and 41. Findings included:1. Resident 2 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included type 2 diabetes mellitus, fibromyalgia, hypertension, chronic kidney disease, fracture of left femur, history of falling, and chronic pain. On 3/11/26 at 3:35 AM, resident 2's progress note documented, Pt [patient] had unwitnessed fall in room. Loud crash heard from 300 hall, nurse and aide immediately responded, 303 call light then came on, pushed by roommate. Pt states her headphone cord was wrapped around her foot and she tripped. Pt was getting up to go to the bathroom at time of fall. [NAME] was not being used, pt barefoot, no oxygen in place. Pt assessed while sitting on floor. Neuro checks and VS [vital signs] WNL [within normal limits]. No abrasions or bruising noted. Pt lifted to feet by aide and nurse. When standing pt had difficulty ambulating or bearing weight on LLE [left lower extremity]. Pt assisted to bathroom and when sitting down pt c/o [complained of] excruciating pain. At that time, this nurse contacted telehealth. D/t [due to] current clodiprogel order and extreme pain, order given to send pt to ED [emergency department] for further evaluation. EMT [emergency medical technician] contacted, pt transported to [name omitted]. In house provider notified. Pt stated she did not want family notified of event. No documentation could be found in resident 2's medical records of what information was sent to the receiving provider, and no documentation could be found of notification to the Ombudsman of resident 2's transfer. On 7/13/26 at 1:20 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that when they send a resident to the emergency room (ER) they notified the provider, obtained a telephone order to transfer the resident, and notified Emergency Medical Services (EMS). RN 2 stated that they completed the Handy Dandy discharge summary and completed the discharge to hospital checklist. RN 2 stated that they sent a Discharge transfer summary that had all the current medications and a copy of the facesheet. RN 2 stated that she documented in the progress note the resident condition and need to transfer to the hospital, and that the provider, Administrator (ADM) and family were notified. RN 2 stated she did not document in the progress note what information was sent to the receiving provider. 2. Resident 41 was admitted to the facility on [DATE] with diagnoses which included cerebral aneurysm, major depressive disorder, insomnia, generalized anxiety disorder, mood disorder, hypertension, cognitive communication deficit, and history of traumatic fracture. On 7/13/26 at 8:11 AM, an interview was conducted with resident 41. Resident 41 stated that she went to the hospital when she fractured her leg. On 6/1/26 at 6:29 AM, resident 41's progress note documented, During dinner service resident was being assisted out of bed to wheelchair. CNA [Certified Nurse Assistant] reported to nurse that resident stated she was tired and began sitting down. The CNA assisted resident to sitting on floor. Resident was assessed with no reported or found injuries. Resident then told nurse she was having Charlie horses in her leg. On 6/2/26 at 4:37 PM, resident 41's progress note documented, Xray results show a nondisplaced distal femoral fracture. Telehealth called and ordered send to ER for eval [evaluation]. EMS transport to [name omitted]. Medical directorship and family notified. On 6/2/26, a Nurse Discharge Checklist documented that the Medical Doctor (MD), family, and DON (Director of Nursing)/ADM were notified. A discharge summary was completed. The resident was sent with a copy of the discharge summary, facesheet, and Medication Administration Record. The facesheet contained the resident information, payer information, care providers with contact numbers, pharmacy number, diagnoses, and advanced directives. No documentation could be found in resident 41's medical records of notification to the Ombudsman of resident 41's transfer. 3. Resident 11 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included epilepsy, myocardial infarction, chronic kidney disease, congestive heart failure, osteoporosis, and repeated falls.On 3/2/26 at 12:58 PM, resident 11's progress note documented, Resident was discharged to [name omitted] Hospital at Noon today for a suspected Gastrointestinal (GI) bleed. On 3/2/26, the Nurse Discharge Checklist did not have a check mark next to Complete discharge summary or Send Resident with a copy of discharge summary, copy of face sheet and MAR [medication administration record].No documentation could be found in resident 11's medical records of what information was sent to the receiving provider, and no documentation could be found of notification to the Ombudsman of resident 11's transfer. On 7/15/26 at 9:56 AM, an interview was conducted with the DON. The DON stated that they send the facesheet and the order summary with transfers/discharges. The DON stated that if the discharge summary was not checked on the checklist then there was no way to verify that it was done. 4. Resident 4 was admitted to the facility on [DATE] with diagnoses which included, generalized anxiety disorder, major depressive disorder, and vascular dementia. On 6/26/26 at 6:00 AM, resident 4's progress note documented, Resident was found on floor of his room. at 0050 [12:50 AM]. When completing assesment [sic], a scalp hematoma was found with a small half inch abrasion. Doctor was called due to patient being on blood thinners. Doctor ordered patient to be sent to [local hospital] at 0120 [1:20 AM]. No documentation could be found in resident 4's medical records of what information was sent to the receiving provider, and no documentation could be found of notification to the Ombudsman of resident 4's transfer. On 7/6/26 at 11:35 AM, resident 4's progress note documented, pt [patient] tx [transported] to [local hospital] via ems to R/O [rule out] he HEAD INJURY. There was no documentation found of notification to the Ombudsman. On 7/15/26 at 9:23 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that there was a checklist that was created to ensure that the facility staff completed a hospital transfer correctly. On 7/14/26 at 11:48 AM, an interview was conducted with the ADM. The ADM stated that he notified the Ombudsman with transfers and discharges and this was completed at the time of the transfer/discharge. The ADM stated that he filled out the resident discharge form or emergency transfer form and scanned them to the Ombudsman. The ADM stated that he then filed the form in a binder in his office. The ADM stated that he had been providing notification to the Ombudsman as each transfer occurred for the past 6-7 months. The ADM reviewed his notification forms and could not locate any Ombudsman notification for residents 2, 4, 11, and 41. On 7/14/26 at 1:27 PM, an interview was conducted with the ADM. The ADM stated that he misunderstood the regulation and had not notified the Ombudsman of resident 2's transfer to the hospital.

Based on interview and record review it was determined, for 3 of 16 sampled residents, the facility did not develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, a resident did not have a care plan for weight loss and nutrition; another resident did not have a care plan for dementia, wandering and elopements; and another resident did not have a care plan for skin impairment. Resident identifiers: 2, 4 and 36. Findings included:1. Resident 36 was admitted to the facility on [DATE] with diagnoses which included Schizoaffective disorder, diabetes mellitus, hematuria, urinary tract infection, psychosis and anxiety. An annual Minimum Data Set (MDS) dated [DATE] revealed resident 36 was at risk for nutrition and in the care area assessment (CAA) section it was documented that nutrition would be care planned. There was no nutritional care plan located in resident 36's medical record. On 7/15/26 at 3:27 PM, an interview was conducted with the Registered Dietitian (RD). The RD stated she did not complete nutritional care plans. The RD stated she was not aware that the nutrition section of the MDS triggered the CAA and that it was marked that a nutritional care plan would be developed. 2. Resident 2 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included type 2 diabetes mellitus, fibromyalgia, hypertension, chronic kidney disease, fracture of left femur, history of falling, and chronic pain.On 3/31/26, resident 2's physician ordered, Float heels in bed every day and night shift. On 5/30/26, resident 2's physician ordered, Offload L [left] heel, nonblanchable, and boggy. Skin prep daily to L heel. one time a day for nonblanchable/boggy heel. On 6/22/26 at 1:00 AM, resident 2's provider progress note documented, .Ongoing concerns include bilateral foot erythema extending from toes over the dorsum of both feet in lateral regions with no tenderness at affected sites; diabetic neuropathy is a contributing factor to foot care risk. Boggy nonblanchable redness to the left heel has been managed with offloading and Skin-Prep application daily. There was no care plan in resident 2's medical record for skin alterations that addressed the left heel bogginess. On 7/15/26 at 9:54 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she completed the residents; care plans. The DON stated that as issues arise they developed a focus area for it in the care plan. The DON stated that resident 2 should have a care area for the bogginess in the heels and she missed that. The DON stated that resident 2 currently did not have a care plan focus area for skin. 3. Resident 4 was admitted to the facility on [DATE] with diagnoses which included, generalized anxiety disorder, major depressive disorder, and vascular dementia. On 5/9/26 at 12:21 AM, resident 4's progress note documented, On 5/8/26, at 2045 [8:45 PM] the resident was sitting on the couch at 200 hall, three men from the fire department where [sic] in the building to assist with the resident in room [ROOM NUMBER]B. The nurse and two CNA's [Certified Nursing Assistants] where [sic] in room [ROOM NUMBER], after the fire department helped the resident to the bed, they left, but the nurse and cna's remained in the room to reposition the resident. AT 2110 [9:10 PM] the nurse went to [resident 4] room to administer his night time med [medication], he was not in the room. The nurse alerted all CNA's and all started to look for the resident inside the facility, the compound withing [sic] the facility and outside the facility fence with no success. DON was called and another search was performed, the DON called the police. The [local police department] located the resident and returned him to the facility AT 2240 [10:40 PM].On 6/7/26 at 1:33 AM, resident 4's progress note documented, Resident became agitated and repeatedly expressed a desire to leave the facility. Resident approached the exit door and pushed past a CNA who was attempting to close and secure the door. During this event, the resident sustained a skin tear/scrape to the top of the right hand. The area was observed and reported according to facility protocol. Staff attempted verbal redirection and distraction techniques. Resident was temporarily redirected by offering use of the telephone; however, he continued attempts to leave the secured area and repeatedly exited to the outdoor grounds. Staff maintained continuous supervision and followed the resident throughout the grounds to ensure safety. Resident proceeded to the final locked gate on the property and attempted to climb over it. At that time, [name redacted] Director of Nursing [DON], arrived and assumed management of the situation. Multiple redirection and de-escalation interventions were utilized. After approximately two hours of continued monitoring, redirection, and de-escalation efforts, the resident became calm enough to accept assistance into a wheelchair and was safely returned to the memory care unit.A review of resident 4's care plan did not address any goals or interventions for dementia, wandering and exit-seeking behavior, and the elopement. On 7/14/26 at 1:27 PM, an interview was conducted with the DON. The DON stated that she updated care plans with goals and interventions for residents. The DON stated that facility staff did not know that resident 4 was a wandering risk and they just knew to watch him. The DON stated that resident 4 had a care plan for a potential of injury related to dementia and wandering, but no interventions on how to care for resident 4 with his behaviors or exit-seeking behaviors.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible, and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 3 out of 16 sampled residents, the facility failed to implement new or revised interventions after repeated falls. In addition, the locked unit was left without nursing staff supervision for multiple periods of time and a resident was observed on the floor and another resident was observed to urinate on the floor in front of a resident. Additionally, a resident eloped from the facility. Resident identifiers: 4, 13, and 39.Findings included:FALLS:1. Resident 4 was admitted to the facility on [DATE] with diagnoses which included, repeated falls, generalized anxiety disorder, major depressive disorder, and vascular dementia.On 5/7/26 a wandering risk scale assessment was completed and resident 4 scored an 11 which indicated he was at a high risk to wander.On 7/13/26 at 5:42 AM, an observation was made of resident 4. Resident 4's recliner was tipped forward and resident 4 was sitting with his buttocks on the foot rest of his recliner and his lower legs were on the floor. Resident 4 kept stating Help me up. I really hurt my leg. There were no staff members observed on the secured unit. On 7/13/26 at 5:55 AM, the surveyor notified staff that resident 4 was sitting with his buttocks on the foot rest of the recliner and his lower legs were on the floor and resident 4 was asking for help.A review of resident 4's progress notes revealed:a. On 5/11/26 at 2:36 AM, a general note documented, Resident found on floor in room at approximately 1830 [6:30 PM]. Fall was unwitnessed. Resident alert and responsive upon assessment. Assisted to bed with CNA [Certified Nurse Assistant] assistance. Initial head-to-toe assessment completed. No visible injuries noted at time of assessment. Resident denied pain/discomfort during initial assessment. ROM [range of motion] within baseline. Neuro [neurological] checks initiated per protocol. Vital signs: 115/100 (vital signs difficult to capture due to patient unable to take instructions). At approximately 2130 [9:30 PM], resident reported tenderness/pain to posterior head when area was palpated during reassessment. Mild swelling noted. No open area noted. Resident otherwise denied additional pain or symptoms. Provider notified. Supervisor notified. No contacts available to notify. Continued monitoring initiated per protocol. Telehealth notified and order from [name redacted] ordered to transfer to ER [emergency room] s/p [status post] fall with blunt head trauma, warfarin use. Resident stated at initial assessment that he did not hit his head and he had no pain. He explained he fell when trying to pick something up that he had dropped on the floor. Resident educated on use of the call light and using his walker.The interventions for this fall included assessing resident 4's current abilities and risk factors for potential of falls and to keep bed in low position for safety.b. On 5/15/26 at 7:32 PM, a general note documented, res [resident] was found on the floor by nurse and assisted to bed by CNA's. no injury noted.The intervention for this fall included assessing resident to assist physician to determine cause: vital signs, appetite, recent relocation, possible hearing or vision losses, change in LOC (level of consciousness), and medications.c. On 5/21/26 at 5:16 PM, a general note documented, Resident called out and staff found resident on floor in room at approx 1630 [4:30 PM]. Resident laying on his front but states he fell onto his back. Some pain in back and head but is able to move. Neuros started. Medical directorship and resident's girlfriend notified. Resident now in dining room pleasantly talking with staff.There was no intervention for this fall.d. On 5/22/26 at 5:24 PM, a general note documented, Resident was found lying on his left side on the floor in his room in front of his chair. Resident claims to have no pain other than his head on the left side. No impact marks were noted.There was no intervention for this fall.e. On 5/23/26 at 9:39 AM, a health status note documented, At 0725 [7:25 AM], an aid [sic] came to nurse & [and] reported that resident fell in the dinning [sic] room. Unwitnessed fall. Nurse went & check the resident. He told nurse he stood up from WC [wheelchair] without assist & fell. No injury or wound.The intervention for this fall was for resident 4 to use his wheelchair to locomote on unit.f. On 6/7/26 at 1:51 AM, a general note documented, At approximately 2145 [9:45 PM], resident was observed by multiple CNAs standing when he appeared to lose his balance and slowly descend to the floor, landing on his buttocks. Resident had a chair on one side and a handrail on the other side and was observed grasping both during the descent. The fall was witnessed by staff. CNAs assisted the resident from the floor to a chair and immediately notified the nurse. Nursing assessment was completed. No injuries were reported by the resident or observed during assessment. No redness, bruising, swelling, skin tears, or other signs of injury were noted at the time of evaluation. Resident remained at baseline following the incident.There was no intervention implemented for this fall.g. On 6/11/26 at 3:57 AM, a general note documented, Resident was found at aprox [approximately] 2130 [9:30 PM] on floor of his room. Resident could not recollect if he had fallen or sat down on the floor. No injuries were found or reported. Neuros began.There was no intervention implemented after this fall.h. On 6/11/26 at 4:54 PM, a general note documented, Resident was attempting to stand up from his wheelchair after lunch, about 1215 [12:15 PM] and got tangled up in the foot rests and fell in the hallway of Memory Lane. Neuros started and first aid done to his R [right] elbow and knuckle of his R middle finger.There was no intervention implemented after this fall.i. On 6/15/26 at 2:11 AM, a general note documented, Per CNA Res was found on the floor next to his low bed approximately around 0200 [2:00 AM] Neuros restarted.The intervention for this fall was that resident 4 was allowed to crawl on floor to get comfortable.j. On 6/19/26 at 3:40 AM, a general note documented, Aide reported to this nurse that pt was sitting on the floor in front of his w/c in dining room. Aide states she was helping another pt to their seat. In the very short time she completed that task pt had attempted to stand and fell. Likely slid out of w/c or tripped on foot pedals. Pt assessed, no injuries noted. Pt lifted to w/c by this nurse and aide. Pt denied pain at time of fall.There was no intervention implemented after this fall.k. On 6/19/26 at 12:20 PM, a general note documented, Resident had another fall today no injuries were noted. Neuros were continued from the previous fall NP [nurse practitioner] was notified and DON [Director of Nursing] is aware and care plan is being reviewed.The intervention for this fall was to place a mat on the bedside to ensure no injury when rolling on the floor. l. On 6/21/26 at 6:47 AM, a general note documented, CNA informed nurse that resident was found next to his bed sitting on his mat in his room. Resident was assessed throughout the night for any injuries. No injuries reported or found. Vitals at baseline.There were no interventions implemented for this fall.m. On 6/26/26 at 6:00 AM, a general note documented, Resident was found on floor of his room. at 0050 [12:50 AM]. When completing assesment [sic], a scalp hematoma was found with a small half inch abrasion. Doctor was called due to patient being on blood thinners. Doctor ordered patient to be sent to [name redacted] hospital at 0120 [1:20 AM] .The intervention for this fall was to check resident 4 every hour for bathroom assistance.n. On 6/28/26 at 6:44 AM, a general note documented, Resident was found on the mat of his room at 0245 [2:45 AM] hrs [hours]. No injuries. Neuros started. Vitals continued at baseline.There was no intervention implemented after this fall.o. On 6/29/26 at 3:50 AM, a general note documented, Res pressed call light and asked aid [sic] for assistance in getting dressed, after putting on pants Res tried to sit back on bed and fell back with head making contact with the wall.The intervention for this fall was to assist resident 4 in sitting completely or lying down before leaving the room.p. On 7/13/26 at 10:01 AM, a general note documented, Resident was sliding out of his chair this morning. He was found sitting on the foot rest of the chair. Resident was put back into his chair with the help of an aid [sic] and nurse.There was no intervention for this fall.ELOPEMENT:On 5/9/26 at 12:21 AM, a weekly note for resident 4 documented, On 5/8/26, at 2045 [8:45 PM] the resident was sitting on the couch at 200 hall, three men from the fire department where [sic] in the building to assist with the resident in room [ROOM NUMBER]B. The nurse and two CNA's [Certified Nursing Assistants] where [sic] in room [ROOM NUMBER], after the fire department helped the resident to the bed, they left, but the nurse and cna's remained in the room to reposition the resident. AT 2110 [9:10 PM] the nurse went to [resident 4] room to administer his night time med [medication], he was not in the room. The nurse alerted all CNA's and all started to look for the resident inside the facility, the compound withing [sic] the facility and outside the facility fence with no success. DON [Director of Nursing] was called and another search was performed, the DON called the police. The [local police department] located the resident and returned him to the facility AT 2240 [10:40 PM].On 6/7/26 at 1:33 AM, a general note documented, Resident became agitated and repeatedly expressed a desire to leave the facility. Resident approached the exit door and pushed past a CNA who was attempting to close and secure the door. During this event, the resident sustained a skin tear/scrape to the top of the right hand. The area was observed and reported according to facility protocol. Staff attempted verbal redirection and distraction techniques. Resident was temporarily redirected by offering use of the telephone; however, he continued attempts to leave the secured area and repeatedly exited to the outdoor grounds. Staff maintained continuous supervision and followed the resident throughout the grounds to ensure safety. Resident proceeded to the final locked gate on the property and attempted to climb over it. At that time, [name redacted] Director of Nursing (DON), arrived and assumed management of the situation. Multiple redirection and de-escalation interventions were utilized. After approximately two hours of continued monitoring, redirection, and de-escalation efforts, the resident became calm enough to accept assistance into a wheelchair and was safely returned to the memory care unit.On 7/13/26 at 5:58 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 4 fell a lot and always tried to run away from the facility. On 7/14/26 at 12:14 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she was informed by the Business Office Manager that resident 4 was wandering off at his assisted living facility and they wanted to try and have resident 4 not be in the locked memory care unit. RN 1 stated that resident 4 had dementia and eloped when he first arrived at the facility. On 7/14/26 at 1:27 PM, an interview was conducted with the DON. The DON stated that once she received risk management reports after a resident had a fall, she reviewed the care plan and tried to think of interventions to prevent future falls. The DON stated that resident 4 had very poor cognition and scored a high-risk to wander. The DON stated that if she had done the wandering assessment when resident 4 was admitted to the facility, she would have placed him in the locked memory care unit. The DON stated that resident 4 was still actively exit seeking. The DON stated that resident 4 had eloped from the facility and had a near elopement when he was able to get into an employee's vehicle and refused to get out. On 7/14/26 at 2:02 PM, a follow-up interview was conducted with the DON. The DON stated that she updated care plans with fall interventions within 24 hours after the fall. The DON stated that there should be a new intervention after every fall. 2. Resident 13 was admitted to the facility on [DATE] with diagnoses which included, mixed receptive-expressive language disorder, generalized muscle weakness, cognitive communication deficit, and dementia.On 7/13/26 at 5:43 AM, an observation was made of resident 13 laying on the couch in the common area of the locked memory care unit. No staff were observed to be in the common area. At 6:29 AM, an observation was made of resident 13 with his right hand down his pants and his penis in his right hand making rubbing gestures. No staff were observed to be in the common area during this time. At 6:36 AM, an observation was made of resident 13, who continued to have his right hand down his pants and his penis in his right hand making rubbing gestures. No staff were observed to be in the common area during this time. At 6:45 AM, an observation was made of resident 13 rubbing his genital area over his clothes. On 7/13/26 at 6:47 AM, an observation was made of Licensed Practical Nurse (LPN) 1 asking resident 13 if she could get him back into his room if he wanted to pet himself. LPN 1 was observed to tell CNA 2 to keep other residents out of the common area while resident 13 was touching himself. CNA 2 was observed to place a pillow on resident 13's lap. It should be noted that resident 13 did not have the capacity to verbally communicate. On 7/13/26 at 7:09 AM, an observation was made of resident 13 standing in the common area of the locked memory care unit. CNA 2 was observed to be in a resident's room.On 7/13/26 at 7:12 AM, resident 13 walked out into the main hallway and pulled his penis out of his pants and urinated on the floor. Resident 39 was observed to tell resident 13 to stop and he should not be doing that. No staff were observed in the hallway of the memory care unit. On 7/13/26 at 7:13 AM, CNA 2 was observed to take resident 13 into his room to the bathroom and left the puddle of urine on the floor in the hallway. On 7/13/26 at 7:22 AM, an observation was made of CNA 2 cleaning the urine puddle on the floor with towels. A review of resident 13's progress notes revealed:a. On 1/26/26 at 4:33 AM, a general note documented, Per CNA Resident was found on the floor in another res [resident] room and there was urine on the floor.b. On 1/26/26 at 6:08 AM, a general note documented, Patient involved in an incident. Pt was found by Aides in room [ROOM NUMBER], on floor next to door. Pt was unable to describe event. Urine was found by aides on floor next to patient.c. On 5/31/26 at 5:33 PM, a general note documented, Approx 1700 [5:00 PM] CNA passed by resident's room and noticed resident had urinated on the floor. At that moment, resident slipped in the urine and fell onto his low bed on his left side. Did not hit head, no injuries noted, ambulating without difficulty. Medical directorship and family notified.On 7/14/26 at 9:00 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 13 needed help going to the bathroom. CNA 2 stated that resident 13 wandered and would urinate or defecate on the floor in the locked memory care unit. CNA 2 stated that resident 13 had a certain system when he needed to go to the bathroom and resident 13 needed to have constant supervision. CNA 2 stated that resident 13 would touch himself in the genital area when he needed to use the bathroom. On 7/15/26 at 9:17 AM, an interview was conducted with the DON. The DON stated that resident 13 urinated wherever he chose. The DON stated that resident 13 could not communicate and spoke nonsense. The DON stated that resident 13 had scheduled bathroom checks every hour. The DON stated that there were usually signs that resident 13 had to use the bathroom and if the CNA had been watching resident 13 he would not have urinated on the floor. The DON stated that staff had to be on the locked memory care unit at all times. 3. Resident 39 was admitted to the facility on [DATE] with diagnoses which included dementia, Alzheimer's disease, history of falling, and personal history of traumatic brain injury.On 7/13/26 at 5:51 AM, an observation was made of resident 39. Resident 39 was observed to have a scab on the bridge of her nose.A review of resident 39's progress notes revealed:a. On 1/21/26 at 6:30 PM, a general note documented, While receiving a report from the previous shift, the assigned CNA reported that the resident had experienced a fall in the hallway. Nursing staff immediately responded. Upon approaching the resident, nursing staff observed resident leaning on the wall. Blood noted on the wall. The resident was assisted, and a small skin tear was noted to the back of her head, on the right side. The affected area cleansed and pressure was applied. Approximately one hour later, the resident experienced another fall. Per the assigned CNA, the resident attempted to stand independently prior to the fall while she was helping another resident; the resident was found on her behind. MD [medical doctor] was notified and an order was obtained to send her out for further evaluation. Paramedics were called, and the resident was transferred to the hospital.b. On 1/22/26 at 12:23 AM, a general note documented, Resident was sent back to the facility following treatment from the hospital. [Name redacted] the nurse stated that resident was diagnosed with Subdural hematoma. The intervention for these falls were to assess blood pressure to determine if the resident was hypotensive.c. On 1/23/26 at 10:44 PM, a general note documented, Resident had a witnessed fall, she was sitting on the chair next to the CNA [name redacted] she grabbed the CNA's phone and tried to walk faster away from the CNA, she lost her balance and fell, landed on her buttocks.There was no intervention for this fall.d. On 2/16/26 at 5:36 PM, a general note documented, Resident had a witnessed fall in room [ROOM NUMBER] she was searching for something on the ground and tipped over to the right side and hit her head on the wall she may have a little bump forming on the head behind the ear.There was no intervention for this fall.e. On 2/16/26 at 7:32 PM, a general note documented, Pt fell while getting self up from couch in hallway. Hit head, witnessed by aide. On neuros at time of fall. Neuros WNL [within normal limits]. c/o [complaining of] pain LLE [lower left extremity], no injuries noted. Provider notified.The intervention for this fall was resident 39 must have a cane when standing and walking.f. On 3/19/26 at 6:19 PM, a general note documented, Resident fell during smoke break. Unwitnessed while supervising CNA was assisting another resident. [Resident 39] claims she did not hit her head. I performed a neuro assessment, no injuries other than a small abrasion on her L [left] knee noted. There was no intervention for this fall.g. On 4/11/26 at 2:19 PM, a health status note documented, A staff reported resident fell outside during smoke break, but the staff did not see when she fell. Resident denies any unusual s/s [signs and symptoms] including pain. No injury or wound from fall noted.There was no intervention for this fall.h. On 7/7/26 at 5:57 AM, a general note documented, Per CNA Res walked out of her room with her nose bleeding claiming she fell. Neuros started.There was no intervention for this fall.On 7/15/26 at 8:46 AM, an interview was conducted with CNA 3. CNA 3 stated that he had to remind resident 39 to use her cane when walking because she often forgot to use it. CNA 3 stated that resident 39 had fallen several times and he usually would have her sit as much as possible to prevent her from falling. On 7/15/26 at 9:25 AM, an interview was conducted with the DON. The DON stated that resident 39 was a fall risk and her most recent fall resulted in a scraped face. The DON stated that fall interventions were not done after every fall that resident 39 had.

Based on interview and record review, for 3 of 16 sampled residents, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug used without adequate monitoring. Specifically, resident's had blood pressure medications administered when their blood pressure was outside the ordered parameters and another resident was on an anticoagulant without monitoring. Resident identifiers: 4, 36 and 41.Findings included:1. Resident 36 was admitted to the facility on [DATE] with diagnoses which included Schizoaffective disorder, urinary tract infection, psychosis, hypotension and anxiety. On 7/14/26 at 10:00 AM, an interview was conducted with resident 36. Resident 36 stated that his medications made him sleepy but he napped when he needed to. Resident 36's physician's orders revealed the following:a. On 1/27/26, Lisinopril Oral Tablet (Lisinopril), Give 5 mg by mouth one time a day for Hold for Systolic Blood Pressure (SBP) <(less than) 180 or Heart Rate (HR) < 60. b. On 12/13/17, BLOOD PRESSURE PARAMETERS - HOLD Blood Pressure (BP) MEDS AND NOTIFY MD (Medical Doctor) IF SYSTOLIC IS < 110; NOTIFY MD IF SYSTOLIC IS > (greater than) 180 two times a day. Resident 36's June 2026 Medication Administration Record (MAR) revealed on 6/24/26 Lisinopril 5 mg was held with a blood pressure of 120/74. On 6/12/26, Lisinopril 5 mg was administered with a blood pressure of 85/62. Resident 36's July 2026 MAR was reviewed. Lisinopril was administered on 7/4/26 with a blood pressure of 104/73 and on 7/10/26 with a blood pressure of 108/73. On 7/15/26 at 8:31 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated the 2 orders had different parameters and the orders needed to be reviewed by the physician for clarification. RN 1 stated the parameters should probably be to hold Lisinopril if SBP was less than 110 and not less than 180. RN 1 stated the medication should have been held when the blood pressure was less than 110 and it was not held. On 7/15/26 at 8:39 AM, an interview was conducted with the Nurse Practitioner (NP). The NP reviewed the physician's orders and stated the parameters on the Lisinopril medication were wrong. The NP stated the parameters should have been clarified because the two orders were confusing. The NP stated blood pressures should be taken prior to medication being administered and Lisinopril should not be administered if the SBP was less than 110. On 7/15/26 at 8:50 AM, an interview was conducted with the Director of Nursing (DON). The DON stated if the Lisinopril was administered when the SBP was less than 110 then it would be a medication error. The DON stated resident 36 should have not been administered Lisinopril when the SBP was less than 110. On 7/15/26 at 3:18 PM, an interview was conducted with the Pharmacist. The Pharmacist stated all residents medications were reviewed monthly. The Pharmacist stated it was recommended to not have parameters to hold blood pressure medications. The Pharmacist stated she did not review the parameters for blood pressure medications when the dose was less than 5 mg. 2. Resident 41 was admitted to the facility on [DATE] with diagnoses which included cerebral aneurysm, major depressive disorder, insomnia, generalized anxiety disorder, mood disorder, hypertension, and cognitive communication deficit. On 4/9/24, resident 41's physician ordered, Lisinopril Oral Tablet 40 MG (milligrams), give 1 tablet by mouth one time a day. On 4/9/24, resident 41's physician ordered Metoprolol Succinate Oral Capsule ER (extended release) 24 Hour Sprinkle 25 MG, give 1 capsule by mouth one time a day for Hypertension (HTN). On 5/15/24, resident 41's physician ordered BLOOD PRESSURE PARAMETERS HOLD BP MEDS AND NOTIFY MD IF SYSTOLIC IS < [less than] 110; NOTIFY MD IF SYSTOLIC IS > [greater than] 180 every day shift. On 1/15/25, resident 41's physician ordered Hydrochlorothiazide Oral Tablet 12.5 MG, give 1 tablet by mouth one time a day for HTN. Resident 41's June 2026 Medication Administration Record (MAR) documented on 6/24/26 the BP was 106/60 and the Lisinopril, Hydrochlorothiazide, and Metoprolol were administered. It should be noted that per the physician ordered parameters these medications should have been held. On 7/14/26 at 9:10 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that medication should be held for parameters ordered by the physician. RN 1 stated that when medications were held the physician should be notified and it should be documented in the electronic MAR progress note. On 7/14/26 at 9:54 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff should have not administered the Lisinopril, Hydrochlorothiazide, and Metoprolol on 6/24/26 and they should have filled out a medication error form. The DON stated that the staff should have informed the physician that the medication was administered when it should have been held per the parameters and they should have obtained vital signs and monitored the resident's blood pressure afterwards. 3. Resident 4 was admitted to the facility on [DATE] with diagnoses which included, repeated falls, generalized anxiety disorder, major depressive disorder, unspecified atrial fibrillation, and vascular dementia. Resident 4's physician orders initiated on 5/7/26 for Eliquis Oral Tablet 5 MG (Apixaban), Give one tablet by mouth two times daily. Resident 4's June 2026 Medication Administration Record and Treatment Administration Record was reviewed and did not contain monitoring for adverse side effects or excessive bleeding for the use of Eliquis. On 7/15/26 at 9:38 AM, an interview was conducted with RN 1. RN 1 stated that the facility did not monitor the use of Eliquis and residents were only monitored if they were on warfarin. On 7/15/26 at 12:33 PM, an interview was conducted with the DON. The DON stated that the facility only monitored anticoagulant medications that required a weekly blood draw like warfarin or heparin. The DON stated that resident 4 could have a stroke or excessive bleeding while taking Eliquis. On 7/15/26 at 3:18 PM, an interview was conducted with the facility Pharmacist. The Pharmacist stated that Eliquis bleeding monitoring was a nursing standard of care and nursing staff should be monitoring for any type of bleeding risks or issues.

Based on observation and interview it was determined that the facility did not store drugs under proper temperature controls. Specifically, observations were made of multiple medications stored in the refrigerator at improper temperatures. Findings included:On 7/15/26 at 8:21 AM, the medication refrigerator was inspected. The thermometer read 26 degrees Fahrenheit and was verified by Registered Nurse (RN) 1. Observations were made of two multidose vials of insulin and multiple packages of insulin pens for different residents. Additionally, multiple syringes of Lorazepam were present. On 7/15/26 at approximately 9:00 AM, an interview was conducted with the Director of Nursing (DON). The DON was unable to state what the correct temperature range should be for the medication refrigerator and the storage of insulin. The DON stated that the risk of having the temperature at 26 degrees Fahrenheit was that the medication could freeze and it would compromise its integrity. The DON stated that for insulin pens it was not possible to visualize the medication to verify if it was frozen or not. Review of the facility policy for Storage of Medications and Biologicals documented that Medications requiring 'refrigeration' or 'temperatures between 2 [degrees] C [Celcius] (36 degrees F) and 8 degrees C (46 degrees F)' are kept in a refrigerator with a thermometer to allow temperature monitoring.

Based on observation and interview it was determined the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food was stored on the floor in the freezer, food in the refrigerator was past the use by date, food was transported through the hallway uncovered and staff were observed to cross contaminate during meal service. Findings included:1. On 7/13/26 at 6:19 AM, an initial kitchen tour was conducted. The following was observed:a. There was a box of chocolate mighty shakes, a box of spinach, a box of Campbell's soup on the floor in the freezer. There were boxes stacked on top of each of these boxes. b. There was pineapple in a container and a container of applesauce dated to use by 7/4/26. 2. On 7/15/26 at 1:13 PM, a follow up kitchen tour was conducted. The following was observed: a. A bag labeled mushrooms was dated 7/9, corn dated 7/9, canned cherries with no label dated 7/9 and tomato paste dated 7/11. b. The Dietary Manager (DM) was observed in the kitchen with half of her hair covered with a hair net. On 7/15/26 at 1:20 PM, an interview was conducted with [NAME] 1. [NAME] 1 stated all hair needed to be covered in a hair net when in the kitchen. On 7/15/26 at 1:30 PM, an interview was conducted with the Dietary Manager (DM). The DM stated the food that was outdated in the refrigerator and needed to be thrown out. The DM stated food was good in the refrigerator for 7 days. The DM stated food deliveries were on Monday, Tuesday and Saturday, so the food should have been put on shelves in the freezer on Saturday. The DON stated hair nets needed to cover all of the staff's hair and no hair should be poking out of the hair net. The DM stated hair nets were to be worn the entire shift. 3. On 7/13/26 breakfast service was observed in the locked memory care unit. The following were observed:a. At 7:41 AM, [NAME] 1 donned gloves without performing hand hygiene and began to touch multiple surfaces on her food cart. With the same gloved hands, [NAME] 1 tore a french toast into pieces.b. At 7:43 AM, with the same gloved hands, [NAME] 1 was observed to tear a french toast into pieces and to pick up a syrup bottle and pour syrup over the toast pieces.c. At 7:45 AM, with the same gloved hands, [NAME] 1 touched the center of the plate and then began tearing up pieces of french toast and placed them on the plate. The cook was observed to pour syrup over the french toast pieces. 4. On 7/14/26 lunch service was observed in the locked memory care unit. The following were observed:a. At 11:40 AM, [NAME] 1 performed hand hygiene and donned gloves. [NAME] 1 then began to uncover all of the food and pulled back the aluminum foil covers.b. At 11:41 AM, [NAME] 1 touched chopped turkey on the plate with her gloved hands and picked up a muffin with her gloved hands.c. At 11:44 AM, with the same gloved hands, [NAME] 1 placed her gloved thumb in the potatoes.d. At 11:45 AM, with the same gloved hands, [NAME] 1 touched beans with her fingers and pushed them to the side of the plate. On 7/14/26 at 11:50 AM, an interview was conducted with [NAME] 1. [NAME] 1 stated that she used hand sanitizer when she removed her gloves. [NAME] 1 stated that she changed her gloves when she left the unit or an area.On 7/15/26 at 10:58 AM, an interview was conducted with the DM. The DM stated that staff should perform hand hygiene and wear gloves when serving food. The DM stated that gloves should be changed pretty often and if food was touched.

Based on interview and record review the facility failed to ensure clinical records were complete, accurate, and documented in accordance with accepted professional standards for 2 of 16 sampled residents. Specifically, there was incomplete documentation regarding residents behavioral health. Resident identifiers: 4 and 5.Findings include:1. Resident 5 was admitted to the facility on [DATE] with diagnoses which included Type II Diabetes Mellitus, Morbid Obesity, Mood Disorder, Major Depressive Disorder, Atrial Flutter, Hyperlipidemia, Hyperkalemia, Generalized Edema, and Stage 3B Chronic Kidney Disease. Resident 5's Quarterly Minimum Data Set (MDS) dated [DATE], which indicated had a Brief Interview for Mental Status (BIMS) score of 9 (cognitively impaired), required substantial-to-maximum assistance from staff for transfers and bed mobility, and experienced frequent bowel and bladder incontinence.Resident 5's progress notes and Certified Nursing Assistant (CNA) administration logs revealed intermittent placeholder entries stating: Demonstrating new behavior - see Aide for details.A review of the clinical record showed no detailed progress notes, behavior monitoring logs, or specific qualitative descriptions explaining what behavior occurred, the triggers, the severity, or the interventions attempted by staff during these occurrences.On 7/14/16 at 12:08 PM, an interview was conducted with the Director of Nursing (DON), who acknowledged that resident 5 exhibited significant behavioral manifestations related to his mood disorder and depression. When asked why these specific behaviors were not detailed in the medical record progress notes or behavior tracking logs, the facility DON stated that staff intentionally avoid documenting specific behavioral details to avoid generating formal incident reports. The facility DON confirmed the facility's documentation practice by stating: We want to document the behavior but not be too specific. The facility DON acknowledged that Certified Nursing Assistants (CNAs) did not enter necessary clinical descriptions and agreed that staff required education on documenting accurate clinical details.2. Resident 4 was admitted to the facility on [DATE] with diagnoses which included, repeated falls, generalized anxiety disorder, major depressive disorder, and vascular dementia.Resident 4's progress notes revealed:a. On 5/21/26 at 9:59 PM, a general note documented, Demonstrating new behavior - see Aide for details.b. On 5/22/26 at 2:21 AM, a general note documented, Demonstrating new behavior - see Aide for details.c. On 5/27/26 at 9:59 PM, a general note documented, Demonstrating new behavior - see Aide for details.d. On 6/27/26 at 9:59 PM, a general note documented, Demonstrating new behavior - see Aide for details.On 7/15/26 at 7:34 AM, an interview was conducted with CNA 3. CNA 3 stated that he did not know what demonstrating a new behavior meant in the charting. CNA 3 stated that he just charted aggression or rejection of care.On 7/15/26 at 8:54 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that she believed that new behavior might mean that the behavior the resident was exhibiting was different than normal, but she would not know what the new behavior was.

Based on interview and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain, implement, and monitor effective corrective action plans to prevent the recurrence of deficient practices. Specifically, after being cited for non-compliance during the January 2026 survey, the QAA committee discontinued monthly oversight after only two to three months, prematurely returning to a quarterly schedule.This failure to maintain continuous, systematic QAA oversight resulted in repeat deficient practices identified during the July 2026 survey regarding clinical record accuracy, medication availability, and physician notification.Findings included:During the prior health survey completed in January 2026, the facility was cited for deficient practices impacting resident care and operational compliance.During the health survey completed on 7/15/26, the survey team identified repeat non-compliance for deficiencies F656, F689, F770 and F880 that were cited on the previous survey 1/8/26. On 7/15/26 at 3:02 PM, an interview was conducted with the facility Administrator regarding the facility's QAPI and QAA processes. The Administrator confirmed that following the recertification survey on 1/8/26, the facility temporarily increased monitoring by conducting monthly QAPI meetings and audits for 2-3 months. The facility Administrator stated that once facility leadership determined they were back in compliance, they discontinued the increased monitoring and reverted back to quarterly QAPI meetings while continuing routine audit.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment. Specifically, for 1 out of 16 sampled residents, personal protective equipment (PPE) was not worn for high contact care for residents on Enhanced Barrier Precautions (EBP). Additionally, multiple observations were made of resident drinks and meals being delivered throughout the locked memory care unit while uncovered during transport. Resident identifier: 4.Findings included:EBP:1. Resident 4 was admitted to the facility on [DATE] with diagnoses which included, pressure ulcer of heel stage 2, type 2 diabetes mellitus with other skin ulcer, non-pressure chronic ulcer of foot and lower leg, and unspecified open wound of right foot.On 7/13/26 at 5:42 AM, an observation was made of resident 4. Resident 4 had bilateral bandages to lower extremities. No signage for EBP or PPE was available for staff use.On 7/14/26 at 7:36 AM, an observation was made of resident 4 being transferred into his wheelchair from the recliner. No PPE was observed to be used.On 7/14/26 at 2:47 PM, an observation was made of resident 4 being transferred into his recliner from the wheelchair. No PPE was observed to be used.On 7/15/26 at 7:18 AM, an observation was made of resident 4 getting out of bed with the assistance of Certified Nursing Assistant (CNA) 3. CNA 3 was not wearing PPE.Resident 4's physician orders revealed:a Lower left extremity: clean with wound cleanser, apply silver collagen, cover with a superabsorbent dressing. This order was initiated on 5/10/26.b. Left heel: clean with wound cleanser, apply silver collagen and cover with a superabsorbent dressing. Change daily and as needed. This order was initiated on 6/21/26.c. Left second toe: clean with wound cleanser or normal saline and cover. This order was initiated on 7/10/26.d. Left dorsal foot abrasion: clean with wound cleanser or normal saline and cover with superabsorbent dressing. This order was initiated on 7/12/26.e. Left lateral foot: clean with wound cleanser or normal saline and cover with superabsorbent dressing. This order was initiated on 7/12/26.[It should be noted that no order for EBP was located in resident 4's medical record.]On 7/13/26 at 11:29 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 4 had some leg wounds and that resident 4's legs were wrapped. CNA 2 stated that resident 4 was not on EBP.On 7/14/26 at 1:27 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that EBP was required if a resident had an open wound or urinary catheter. The DON stated PPE that was required by staff to wear included a gown, mask, and gloves.The DON stated that anytime staff had any interaction with the resident such as performing cares or transferring they would be required to wear PPE. The DON stated that resident 4 should have EBP. DINING:2. On 7/13/26 breakfast service was observed in the locked memory care unit. The following were observed:a. At 7:41 AM, the cook donned gloves without performing hand hygiene.b. At 7:46 AM, CNA 2 walked an uncovered plate of food down the hall from the common area into room [ROOM NUMBER].c. At 7:47 AM, CNA 2 removed her gloves and did not perform hand hygiene. CNA 2 donned new gloves and walked an uncovered plate of food across the hall to a resident's room. CNA 2 was observed to discard her gloves and apply new gloves without performing hand hygiene.d. At 7:48 AM, CNA 2 was observed to walk uncovered cups of milk and orange juice to room [ROOM NUMBER].3. On 7/13/26 breakfast service was observed in the 200 and 300 hallway. The following were observed:a. On 7/13/26 at 8:20 AM, an observation was made of a gallon of milk being transported through the 200 hallway to the dining room with it being uncapped.b. On 7/13/26 at 8:21 AM, an observation was made of [NAME] 1 placing food on a plate for a resident by the nurses station. The meal tray was transported to room [ROOM NUMBER] with apple juice and hot cereal uncovered. 4. On 7/14/26 at 11:48 AM, an observation was made of CNA 4 walking an uncovered plate of food down the hall to room [ROOM NUMBER]. On 7/14/26 at 1:27 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff should be performing hand hygiene before they apply gloves and after they remove them.On 7/15/26 at 10:58 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that staff should perform hand hygiene and wear gloves when serving food. The DM stated that gloves should be changed pretty often and if food was touched. The DM stated that all meals should be covered.

Based on interview it was determined that the facility did not ensure that the individual financial record was available to the resident through quarterly statements upon request. Specifically, for 1 out of 16 residents, the facility did not provide the resident with a quarterly statement of their personal funds account. Resident identifier: 1. Findings included:Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included paranoid schizophrenia, major depressive disorder, mood disorder, psychosis, post-traumatic stress disorder, heart failure, type 2 diabetes mellitus, and hypertension. On 7/13/26 at 8:27 AM, an interview was conducted with resident 1. Resident 1 stated that the facility managed her money and she was able to obtain funds when she needed them. Resident 1 stated that she had not received any statements of her personal funds account. On 7/15/26 at 12:00 PM, an interview was conducted with the Business Office Manager (BOM). The BOM stated that resident 1 had a personal funds account with the facility. The BOM stated that she provided resident 1 statements but not regularly and probably every 6 months. The BOM stated that resident 1 usually withdrew all her money each month which was $45. The BOM stated that she did not provide quarterly statements to the residents and she did not have any evidence that the residents received a statement. The BOM stated that she usually provided the residents with statements when the accountant came to balance the books and that was approximately every 6 months.

Based on interview and record review, the facility failed to consult the resident's physician when there was a need to alter treatment significantly. Specifically, for 1 of 16 sampled residents, a resident's physician was not notified when diabetic medication was unavailable for administration. Resident identifier: 45.Findings include:Resident 45 was admitted to the facility on [DATE] with diagnoses which included Diabetes Mellitus (DM), Epilepsy, Peripheral Vascular Disease, and Acquired Absence of Right Leg Above Knee.Resident 45's physician orders initiated 5/30/26 revealed metFORMIN HCl Oral Tablet 500 MG (milligrams): Give 1 tablet by mouth 2 times a day for DM (Arise and HS).Resident 45's May 2026 Medication Administration Record (MAR) revealed on 5/30/26 at 7:09 AM Metformin 500 mg was not administered. Registered Nurse (RN) 2 documented cannot find. On 5/31/26 at 9:06 AM, RN 1 noted that Metformin 500 mg was not available, pharmacy states they will send today, medical directorship notified. While the medical director/physician was notified on May 31, 2026, no retroactive or timely notification was documented for the original omission on May 30, 2026.Further review of the clinical record, which included nursing progress notes, eMAR administration logs, and physician communication forms, revealed no documentation indicating that RN 2 or any facility staff notified the attending physician that the morning dose of Metformin was omitted due to unavailability.On 7/14/26, an interview was conducted with the Director of Nursing (DON). The DON stated that facility standard practice required licensed nursing staff to immediately contact the pharmacy and notify the attending physician whenever an ordered medication was unavailable or could not be administered, and to document that notification in the resident's clinical record.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately to the State Survey Agency (SSA). Specifically, for 1 out of 16 sampled residents, a resident eloped from the facility and this elopement was not reported to the SSA. Resident identifier: 4.Findings included:Resident 4 was admitted to the facility on [DATE] with diagnoses which included generalized anxiety disorder, major depressive disorder, and vascular dementia.On 5/7/26 a wandering risk scale assessment was conducted on resident 4. Resident 4 scored an 11 which indicated that resident 4 had a high risk to wander.On 5/9/26 at 12:21 AM, a weekly note documented, On 5/8/26, at 2045 [8:45 PM] the resident was sitting on the couch at 200 hall, three men from the fire department where in the building to assist with the resident in room [ROOM NUMBER]B. The nurse and two CNA's [Certified Nursing Assistants] where [sic] in room [ROOM NUMBER], after the fire department helped the resident to the bed, they left, but the nurse and cna's remained in the room to reposition the resident. AT 2110 [9:10 PM] the nurse went to [resident 4's] room to administer his night time med [medication], he was not in the room. The nurse alerted all CNA's and all started to look for the resident inside the facility, the compound withing [sic] the facility and outside the facility fence with no success. DON [Director of Nursing] was called and another search was performed, the DON called the police. The [local police department] located the resident and returned him to the facility at 2240 [10:40 PM]. A full head to toe assessment was performed, no issues found, resident stated he didn't fall or get hurt. vital signs were taken and they are within range.On 7/14/26 at 3:04 PM, an interview was conducted with the Administrator (ADM). The ADM stated that resident 4 had eloped from the facility. The ADM stated that he was not involved with the elopement because he was out of town and assumed that it was reported. The ADM stated that when he heard that resident 4 had eloped the DON was covering for him and he did not think to ask her about reporting to the SSA. The ADM stated that resident 4 was located by the police department and he was unsure how long resident 4 was gone from the facility.

Based on interview and record review it was determined, for 1 of 16 sampled residents, that the facility did not ensure each resident maintained acceptable parameters of nutritional status, such as usual body weight. Specifically, a resident was not provided interventions when he experienced weight loss. Resident identifier: 36. Findings included:Resident 36 was admitted to the facility on [DATE] with diagnoses which included Schizoaffective disorder, diabetes mellitus (DM), hematuria, urinary tract infection (UTI), psychosis and anxiety. On 7/14/26 at 9:58 AM, an interview was conducted with resident 36. Resident 36 stated he did not think he had lost much weight but lately he had not been eating a lot. Resident 36 stated he had not experienced any change except he was not as hungry. Resident 36 stated there were snacks in the vending machines but he had to pay for those himself. Resident 36 stated it would be nice to have a snack before bed. Resident 36's weights were as follows: [Note: All weights were in pounds.]a. On 2/1/26 was 171.4b. On 3/1/26 was 174.6c. On 4/5/26 was 167.6d. On 5/8/26 was 172.8e. On 6/5/26 was 169.8f. On 6/19/26 was 165.2g. On 7/10/26 was 166.0An annual Minimum Data Set (MDS) dated [DATE] revealed resident 36 was at risk for nutrition and the care area assessment revealed that nutrition would be care planned. There was no nutritional care plan located in resident 36's medical record. A Skin and Weight assessment dated [DATE] revealed Eating fair to good. very self directed with meal choices and intake. Weight down 4% x [times] one week. Wt [weight] down 4% X 1 week, recently dx'd [diagnosed] with UTI, chronic for resident. Will cont [continue] current poc [plan of care] and f/u [follow up].There were no meal percentages located in resident 36's medical record. Resident 36's diet order dated 2/24/26 revealed reduced concentrated sweets, regular texture, regular consistency and fortified for DM. There were no orders located for snacks or supplements. On 7/15/26 at 10:59 AM, an interview was conducted with the Dietary Manager (DM). The DM stated the nurses completed the mini nutritional assessment and she was not sure what was done with the information from the assessment. The DM stated the Registered Dietitian (RD) attended the skin and weight meetings every Friday. The DM stated Certified Nursing Assistants (CNA) obtained weights every Sunday and reweights were done throughout the week for the skin and weight meeting on Fridays. The DM stated the Director of Nursing (DON), RD and herself attended the meetings. The DM stated if a weight had more than a 2% change in a week they were discussed in the meeting. The DM stated she did not know the last time resident 36 was discussed but resident 36 had recently had a UTI. On 7/15/26 at 1:36 PM, a follow up interview was conducted with the DM. The DM stated residents were offered snacks at 10:00 AM and 2:00 PM if they had physician ordered snacks. The DM stated all residents were offered a snack at night. The DM stated resident 36 did not have ordered snacks. On 7/15/26 at 3:27 PM, an interview was conducted with the RD. The RD stated she attended skin and week meetings weekly with the DON and DM. The RD stated she made notes in the Skin and Weight assessment. The RD stated the DM completed the first half of the assessment to determine what the problem was and then the team filled out the rest and a form that was provided to the physician to sign. The RD stated resident 36 frequently got UTI's and his weight would decrease and then it came right back up. The RD stated staff offered him health shakes, med pass, ensure, boost or high protein snacks between meals but there was no documentation of snacks being offered. The RD stated meal percentages were not tracked because the DM was really good about knowing the residents and how much they eat.

Based on interview and record review it was determined that the facility did not ensure that a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Specifically, for 2 out of 16 sampled residents the facility was unable to demonstrate development and implementation of interventions for managing residents' dementia with behavioral disturbances. Resident identifier: 4 and 13.Findings included:1. Resident 4 was admitted to the facility on [DATE] with diagnoses which included, generalized anxiety disorder, major depressive disorder, and vascular dementia.On 7/13/26 at 5:42 AM, an observation was made of resident 4. Resident 4's recliner was tipped forward and resident 4 was sitting with his buttocks on the foot rest of his recliner and his lower legs were on the floor. Resident 4 kept stating Help me up. I really hurt my leg. There were no staff members observed on the secured unit. On 7/13/26 at 5:55 AM, the surveyor notified staff that resident 4 was sitting with his buttocks on the foot rest of the recliner and his lower legs were on the floor and resident 4 was asking for help.On 7/13/26 at 11:24 AM, an observation was made of resident 4 sleeping in his bed. On 7/13/26 at 12:26 PM, an observation was made of resident 4 sleeping in his bed. Resident 4 did not eat lunch.On 7/14/26 at 6:58 AM, an observation was made of resident 4 sleeping in his recliner. On 7/14/26 at 9:13 AM, an observation was made of resident 4 sleeping in his bed.Resident 4's physician orders included:a. Buspirone HCl (Hydrochloride) Oral Tablet 15 MG (milligram), Give one tablet by mouth two times daily. This order was initiated on 5/7/26.b. Clonazepam Oral Tablet 1 MG, Give one tablet by mouth one time a day for anxiety. This order was initiated on 5/7/26.c. Fluoxetine HCl Oral Capsule 40 MG, Give one capsule by mouth two times a day for anxiety. This order was initiated on 5/7/26.d. Seroquel Oral Tablet 50 MG (Quetiapine Fumarate), Give one tablet by mouth two times a day for antipsychotic. This order was initiated on 5/7/26. e. Trazodone HCl Oral Tablet 50 MG, Give one tablet by mouth one time a day for insomnia. This order was initiated on 5/7/26.f. Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium), Give 250 mg by mouth every 24 hours as needed for sundowning at bedtime as needed. This order was initiated on 5/13/26 and was administered on 5/18/26 at 7:18 PM, 5/21/26 at 2:00 PM, 5/25/26 at 6:35 PM, 6/1/26 at 7:58 PM, 6/3/26 at 7:05 PM, 6/6/26 at 6:44 PM, and 6/7/26 at 7:34 PM. g. Lorazepam Oral Tablet 1 MG, Give 1 mg by mouth one time only for agitation and aggressive behaviors. This order was initiated and completed on 5/21/26 at 11:00 PM.h. Lorazepam Oral Tablet 1 MG, Give one tablet by mouth every 24 hours as needed for agitation. This order was initiated on 5/22/26 and was administered on 6/1/26 at 9:11 PM, 6/7/26 at 9:32 AM, 6/11/26 at 8:12 AM, 6/13/26 at 11:15 AM, 6/14/26 at 4:45 AM, 6/15/26 at 7:22 AM, 6/16/26 at 7:40 AM, 6/17/26 at 9:09 AM and 5:15 PM, 6/18/26 at 7:16 PM, 6/19/26 at 6:45 AM, 6/21/26 at 1:30 PM, 6/24/26 at 7:08 AM, and 6/25/26 at 7:50 AM. [It should be noted that this medication was not given every 24 hours as the directions specified,]i. Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium), Give one tablet by mouth one time a day related to generalized anxiety disorder. This order was initiated on 6/8/26 and administered on 6/8/26, 6/9/26, 6/11/26, 6/12/26, 6/13/26, and 6/14/26. j. Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium), Give one tablet by mouth two times a day for agitation. This order was initiated on 6/15/26 and administered once on 6/15/26 and twice a day from 6/16/26 through 6/30/26, and 7/1/26.k. Lorazepam Oral Tablet 1 MG, Give one tablet by mouth every 24 hours as needed for agitation for 14 days. This order was initiated on 6/25/26 and ended on 7/9/26. This was administered on 6/29/26 at 9:10 PM, 6/30/26 at 10:54 AM, and 7/4/26 at 11:30 AM. l. Depakote ER (Extended release) Oral Tablet Extended Release 24 Hour 500 MG (Divalproex Sodium), Give one tablet by mouth one time a day for agitation. This order was initiated on 7/1/26 and administered on 7/1/26, 7/2/26 X 2 and 7/3/26. [It should be noted that this medication was given twice on 7//2/26.] m. Valproic Acid Oral Solution 500 MG/10 ML (milliliter) (Valproate Sodium), Give 10 mL by mouth one time a day for behaviors. This order was initiated on 7/3/26. This medication was given in the evenings on 7/3/26, 7/5/26, 7/6/26, 7/7/26, 7/8/26, 7/9/26, 7/10/26, 7/11/26, and 7/13/26. n. Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium), Give 5 mL by mouth one time a day for behaviors. This order was initiated on 7/4/26. This medication was administered in the morning on 7/4/26, 7/5/26, 7/7/26, 7/8/26, 7/9/26, 7/10/26, 7/11/26, 7/12/26, and 7/13/26.o. Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium), Give 10 mL by mouth one time a day related to unspecified dementia. This order was initiated on 7/12/26 and discontinued on 7/12/26.p. Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium), Give 5 mL by mouth one time a day related to vascular dementia. This order was not administered to resident 4. Resident 4's care plan did not address any focus, goals, or interventions for dementia. Resident 4's Treatment Administration Record (TAR) revealed that antianxiety target behavior was repeated concerns and the antipsychotic target behavior was distressing delusions. A review of the June 2026 TAR revealed that resident 4 did not have repeated concerns on 6/22/26, 6/25/26, and 6/26/26. Resident 4 had distressing delusions on 6/6/26, 6/7/26, 6/14/26, 6/15/26, 6/16/26, 6/17/26, 6/18/26, 6/19/26, 6/20/26, 6/21/26, 6/22/26, 6/23/26, 6/24/26, 6/27/26, 6/28/26, and 6/29/26.On 7/14/26 at 9:25 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that resident 4 sun downs in the afternoon and can become fidgety, agitated and tended to wander. RN 2 stated that she thought some of resident 4's agitation was because he was not able to smoke anymore. On 7/14/26 at 1:27 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 4 had poor cognition and dementia. The DON stated that when resident 4 arrived at the facility he was able to smoke independently, but that he was unable to smoke at all anymore due to his exit-seeking behaviors and being unable to hold his cigarette. The DON stated that she was in charge of care plans and dementia should be included. On 7/15/26 at 11:55 AM, a follow-up interview was conducted with the DON. The DON stated that dementia interventions were located on the care plan and resident 4 did not have a care plan regarding his behaviors or dementia diagnosis.2. Resident 13 was admitted to the facility on [DATE] with diagnoses which included, mixed receptive-expressive language disorder, generalized muscle weakness, cognitive communication deficit, and dementia.On 7/13/26 at 5:43 AM, an observation was made of resident 13. Resident 13 was observed to be laying on the couch in the common area of the locked memory care unit. No staff were observed to be in the locked memory care unit.On 7/13/26 at 6:29 AM, an observation was made of resident 13 with his right hand down his pants and his penis in his right hand. No staff were observed to be in the common area during this time. On 7/13/26 at 6:36 AM, an observation was made of resident 13. Resident 13 continued to have his right hand down his pants and his penis in his right hand. No staff were observed to be in the common area during this time.On 7/13/26 at 6:45 AM, an observation was made of resident 13. Resident 13 was observed to be rubbing his genital area over his clothes. On 7/13/26 at 6:47 AM, an observation was made of Licensed Practical Nurse (LPN) 1 asking resident 13 if she could get him back into his room if he wanted to pet himself. LPN 1 was observed to tell CNA 2 to keep other residents out of the common area while resident 13 was touching himself. CNA 2 was observed to place a pillow on resident 13's lap. On 7/13/26 at 7:12 AM, resident 13 walked out into the main hallway and pulled his penis out of his pants and urinated on the floor.On 7/13/26 at 9:23 AM, an observation was made of resident 13 sleeping in a dining room chair.On 7/13/26 at 11:25 AM, an observation was made of resident 13 sleeping in a dining room chair.On 7/14/26 at 7:00 AM, an observation was made of resident 13 sitting and rocking back and forth in a dining room chair. No staff were present in the unit hallway or the dining area.On 7/14/26 at 2:35 AM, an observation was made of resident 13 sitting in the hallway on the couch picking his skin on his right arm. No staff were present in the unit hallway or the dining area. On 7/15/26 at 7:19 AM, an observation was made of resident 13 sleeping in bed. On 7/15/26 at 7:41 AM, an observation was made of Certified Nursing Assistant (CNA) 3 delivering breakfast to resident 13. Resident 13 was still sleeping in bed. On 7/15/26 at 8:45 AM, an observation was made of CNA 3 discarding resident 13's breakfast that was untouched and resident 13 still sleeping in bed.Resident 13's care plan had a focus area initiated on 5/29/25 which documented, The resident has impaired cognitive function/dementia or impaired thought processes. Interventions included, engage the resident in simple, structured activities that avoid overly demanding tasks; keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion; and provide a program of activities that accommodates the resident's abilities.Resident 13's care plan had a focus area initiated on 5/18/26 which documented, Resident has an altered thought process impairment. He is sometimes understood and sometimes understands. He can by [sic] short tempered and has delusions. Interventions for this included, short 1x1 visits to check n [sic] leisure needs and socializes 2x weekly; resident will participate in independent activities of interest daily such as watch socialize, walks, look at weekend packet; resident will participate in diversion activities PRN [as needed]; when resident gets annoyed try to help him calm down. If this does not work have him leave and return when he feels less annoyed; watch for things that tend to annoy resident and try to avoid when possible; and help resident to obtain recreation supplies as they are requested.On 7/14/26 at 9:00 AM, an interview was conducted with CNA 4. CNA 4 stated that resident 13 required assistance with eating because he would often fall asleep. CNA 4 stated that resident 13 often wandered and would urinate or defecate on the floor anywhere in the locked memory care unit. On 7/15/26 at 8:48 AM, an interview was conducted with CNA 3. CNA 3 stated that resident 13 did not know where the restroom was and resident 13 would urinate on the floor if he was not taken to the bathroom every hour. CNA 3 stated that resident 13 would often get up and pace around the hallway. On 7/15/26 at 10:14 AM, an interview was conducted with CNA 2. CNA 2 stated that she was taught to redirect residents that were overly sad or having freak outs. CNA 2 stated that she was taught to just remain calm with the resident. CNA 2 stated she did not remember exactly what she learned in training, but thought that there was an in-service a few months ago. On 7/15/26 at 10:18 AM, an interview was conducted with RN 1. RN 1 stated that during some staff meetings they have had dementia focused training and were taught ways to redirect residents with dementia. RN 1 stated that dementia behaviors had to be care planned and that any psychotropic medications the resident might be taking should be included on the care plan along with interventions to deal with certain behaviors. On 7/15/26 at 11:25 AM, an interview was conducted with the Activities Director (AD). The AD stated that she had difficulty with finding activities that resident 13 could do. The AD stated that resident 13's wife visited daily and he would get tired after those visits so she left him alone. The AD stated that she tried to visit with resident 13 once a week for a few minutes. The AD stated that resident 4 had been very difficult to visit with because he was on medications that made him very sleepy and he was sleeping a lot. The AD stated that resident 4 was coming out of the locked memory care unit to play bingo, but he became a flight risk and having him come off the unit was difficult. The AD stated that resident 4 slept through the coffee social that occurred this week. The AD stated that resident 4 was fairly new to the facility and she was still trying to get to know him.

Based on record review and interview, the facility failed to ensure pharmaceutical services were provided to timely obtain, maintain, and supply ordered prescription medications/ Specifically, 1 of 16 sampled residents, the facility failed to ensure that a prescribed antidiabetic medication was available for scheduled administration and the medication was not administered. Resident identifier 45.Findings include:Resident 45 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus (DM), Phantom Limb Syndrome with pain, Epilepsy, Peripheral Vascular Disease, and Acquired Absence of Right Leg Above Knee.Resident 45's physician orders revealed an order initiated prior to May 30, 2026 for metFORMIN HCl Oral Tablet 500 MG (milligrams): Give 1 tablet by mouth 2 times a day for DM (Arise and HS).Resident 45's electronic Medication Administration Record (eMAR) revealed an entry by Registered Nurse (RN) 2, dated 5/30/26 at 7:09 AM, for the scheduled morning dose of Metformin 500 mg with the accompanying documentation: cannot find.The eMAR revealed an administration note by RN 1, dated 5/31/26 at 9:06 AM, for the scheduled morning Metformin dose which stated: not available, pharmacy states they will send today, medical directorship notified. On 7/14/26, an interview was conducted with the Director of Nursing, who confirmed that the facility failed to ensure pharmaceutical services were provided to timely obtain, maintain, and supply ordered prescription medications for Resident 45.

Based on interview and record review, for 2 of 16 sampled residents, the facility did not ensure each resident's medications were reviewed by a licensed pharmacist. In addition, the pharmacist must report any irregularities to the attending physician and the facility's Medical Director or Director of Nursing (DON), and these reports must be acted upon. Specifically, for 2 of 16 residents sampled, the pharmacist did not report irregularities when a resident had contradicting physician ordered parameters for administering blood pressure medications. In addition, the pharmacist did not report when another resident had duplicate medication therapy, did not have monitoring for anticoagulant medication and did not have an appropriate diagnosis for Seroquel. Resident identifiers: 4 and 36. Findings included:1. Resident 36 was admitted to the facility on [DATE] with diagnoses which included Schizoaffective disorder, urinary tract infection, hypotension, psychosis, and anxiety. Resident 36's pharmacy reviews were conducted monthly with no irregularities found from January 2026 through July 2026. Physician's orders revealed the two contradicting orders. 1. Started on 1/27/26, Lisinopril Oral Tablet (Lisinopril), Give 5 mg by mouth one time a day for Hold for systolic blood pressure (SBP) < (less than) 180 or Heart rate <60. 2. Started on 12/13/17, BLOOD PRESSURE PARAMETERS - HOLD Blood Pressure (BP) MEDS AND NOTIFY MD (Medical Doctor) IF SYSTOLIC IS < 110; NOTIFY MD IF SYSTOLIC IS > (greater than) 180 two times a day. On 7/15/26 at 8:50 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the pharmacy reviewed all residents medications monthly but she was not sure what they actually reviewed. The DON stated the pharmacist looked at a lot of stuff. The DON stated she was not sure why the contradicting parameters for blood pressure medications were not caught by the pharmacist. On 7/15/26 at 3:18 PM, a telephone interview was conducted with the pharmacist. The pharmacist stated medications were reviewed monthly. The pharmacist stated it was recommended to not have parameters because the medication could be used for something different. The pharmacist stated that parameters were not on the pharmacists radar when the blood pressure medication was less than 5 mg. 2. Resident 4 was admitted to the facility on [DATE] with diagnoses which included, repeated falls, generalized anxiety disorder, major depressive disorder, and vascular dementia.Resident 4's physician orders included:a. Clonazepam Oral Tablet 1 MG (milligram), Give 1 tablet by mouth one time a day for anxiety. The order was initiated on 5/7/26.b. Eliquis Oral Tablet 5 MG (Apixaban), Give 1 tablet by mouth two times a day related to Unspecified Atrial Fibrillation. The order was initiated on 5/7/26. [It should be noted that resident 4 was not being monitored for any adverse side effects.]c. Seroquel Oral Tablet 50 MG (Quetiapine Fumarate), Give 1 tablet by mouth two times a day for antipsychotic. The order was initiated on 5/7/26. [It should be noted that there was not an appropriate diagnosis for the use of this medication.]d. Trazodone HCl (hydrochloride) Oral Tablet 50 MG, Give 1 tablet by mouth one time a day for insomnia. The order was initiated on 5/7/26. [It should be noted that hours of sleep were not being monitored for resident 4.]e. Lorazepam Oral Tablet 1 MG, Give 1 mg by mouth one time only for Agitation and aggressive behaviors until 05/21/2026 23:59. This order was initiated on 5/21/26.f. Lorazepam Oral Tablet 1 MG, Give 1 tablet by mouth every 24 hours as needed for agitation. This order was initiated on 5/22/26.g. Lorazepam Oral Tablet 1 MG, Give 1 tablet by mouth every 24 hours as needed for agitation for 14 Days. This order was initiated on 6/25/26 and discontinued on 7/9/26.Resident 4's medications were reviewed by the pharmacist on 5/30/26 and 6/24/26. There were no irregularities identified by the pharmacist. On 7/15/26 at 9:38 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 4 had as needed lorazepam, but thought the medication was discontinued. RN 1 stated that resident 4 had scheduled clonazepam. RN 1 stated that resident 4 had a lot of behaviors and he came to the facility on both medications and this was duplicative therapy. RN 1 stated that resident 4 had not had a psychotropic review because he had not been at the facility for 3 months. RN 1 stated that the pharmacy had reviewed resident 4's medications and they never mentioned anything about his medications. RN 1 stated that resident 4 should have his hours of sleep tracked to see if the insomnia medication was working. RN 1 stated that Seroquel was being given to resident 4 for aggression and it was prescribed prior to his being at the facility. On 7/15/26 at 12:33 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the pharmacist reviewed the medications of residents when they admit and then every month thereafter. The DON stated that resident 4 was given an as needed order for lorazepam when only nurses were in the facility and he was having behaviors. The DON stated there was not a rationale for resident 4 to be taking both clonazepam and lorazepam. The DON stated that resident 4 was not being monitored for any adverse side effects for the Eliquis because the facility does not monitor anticoagulants unless it was warfarin or heparin. The DON stated that because Eliquis was not being monitored resident 4 could have a stroke or excessive bleeding. The DON stated that resident 4 was taking Seroquel for vascular dementia, but dementia residents should not be given an antipsychotic. On 7/15/26 at 3:18 PM, an interview was conducted with the facility Pharmacist. The facility Pharmacist stated that she started working for the facility 2 weeks ago. The Pharmacist stated that she was not sure why resident 4 would be taking clonazepam and lorazepam, but possibly because clonazepam was long-acting and lorazepam was short acting. The Pharmacist stated that lorazepam and clonazepam should not be taken together or within several hours of each other. The Pharmacist stated that she did not know why resident 4 was taking Seroquel because he did not have an appropriate diagnosis for the use of an antipsychotic. The Pharmacist stated that resident 4 should have his hours of sleep tracked if resident 4 was taking medication for insomnia. The Pharmacist stated that it was a nursing standard of care to monitor for side effects and increased risk of bleeding when using Eliquis. The Pharmacist stated that she had not reviewed the medical record of resident 4.

Based on interview and record review, for 1 of 16 sampled residents, the facility did not provide or obtain timely laboratory services to meet the needs of its residents. Specifically, a resident had a physician's order to obtain a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP) and a Clozaril level. Resident identifier: 36. Findings included:Resident 36 was admitted to the facility on [DATE] with diagnoses which included Schizoaffective disorder, urinary tract infection, psychosis, and anxiety. A physician's order dated 11/1/25 revealed Please order CBC, CMP, and Clozarilone time a day every 30 day(s) for lab levels. There were no laboratory results for February 2026. On 7/15/26 at 10:16 AM, an interview was conducted with the Director of Nursing (DON). The DON stated she was unable to find the results for February 2026 CBC, CMP and Clozapine. The DON stated she signed an audit but was not sure how the labs were missed.

Based on interview and record review it was determined that the facility did not file in the resident's clinical record signed and dated reports of radiologic and other diagnostic services. Specifically, for 1 of 16 sampled residents, the facility did not file an x-ray result in the resident's medical records. Resident identifier: 41. Findings included:Resident 41 was admitted to the facility on [DATE] with diagnoses which included cerebral aneurysm, major depressive disorder, and history of traumatic fracture.On 7/13/26 at 8:11 AM, an interview was conducted with resident 41. Resident 41 stated that she went to the hospital when she fractured her leg. On 6/2/26 at 4:37 PM, resident 41's progress note documented, Xray results show a nondisplaced distal femoral fracture. Telehealth called and ordered send to ER [emergency room] for eval [evaluation]. EMS [emergency medical services] transport to [name omitted]. Medical directorship and family notified.Results for the x-ray obtained on 6/2/26 were not found in resident 41's electronic medical records or hard chart. On 7/15/26 at 8:41 AM, an interview was conducted with the Director of Nursing (DON). The DON stated she conducted a weekly audit of labs and diagnostics but missed that resident 41's x-ray results were not in the medical record. The DON stated that they had received the results and the physician had reviewed them but they were not located in resident 41's medical record. The DON stated that she printed the results from the portal yesterday.

Based on observation, interview, and record review it was determined, for 13 of 24 sampled residents, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to sanitize the blood glucose meters according to manufacturer requirements. This was determined to have resulted at an immediate jeopardy level. In addition, the facility had not updated their COVID-19 policy and procedures according to the latest guideline. Resident identifier: 1, 3, 6, 10, 11, 13, 14, 16, 22, 24, 35, 36 and 43. NOTICE On 1/7/26 at 2:30 PM, an Immediate Jeopardy was identified and notice was given verbally and in writing to the Administrator (ADM) and the Director of Nursing (DON) regarding the facility not sanitizing the blood glucose meters according to manufacturer requirements to prevent the transmission of bloodborne pathogens. On 1/8/26, the ADM provided a written abatement plan for the removal of the Immediate Jeopardy effective on 1/8/26 at 2:00 PM. The following is a summary of the plan: Correction of deficient practice: current glucometers that were in use were discarded immediately and replaced with new, sanitized devices. Systemic changes including the following: infection control policy and procedures, specifically Blood Sampling (Finger Sticks) Policy updated to include manufacturer recommendations for cleaning and disinfecting procedures. All nursing staff will be trained by the Director of Nursing on the updated policy for disinfecting the glucometer after each use to ensure Infection Prevention standards are being met. Nurses not available to sign the in-service book will have the new policy and procedure sent to them via text message and will respond that they understand the new process and will physically sign the in-service book for their next shift in the building. Staff training and education: all licensed nursing staff will receive immediate re-education on: infection control principles; blood and glucose monitoring procedures; and proper cleaning and disinfecting of glucometers. Staff competency evaluations were completed and documented. Audits to ensure compliance: Infection Preventionist or designee will conduct: weekly random audits for 5 weeks; monthly random audits thereafter; all results of audits will be reported to the Administrator and Quality Assurance and Performance Improvement (QAPI) team. Audits will include: observation of glucose testing and a review of cleaning and sanitizing practices. The Medical Director has been notified of the potential risk of exposure to other residents. The facility will continue to monitor for signs and symptoms of any new illness. The facility will follow recommendations from the Medical Director. The facility alleged abatement of the Immediate Jeopardy as of 1/8/26 at 2:00 PM. On 1/8/26, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 1/8/26 at 2:00 PM. Findings included: IMMEDIATE JEOPARDY On 1/7/26 at 8:45 AM, an interview was conducted with LPN (Licensed Practical Nurse) 1. LPN 1 stated that each medication cart contained one [NAME] Quintet AC Glucose Meter, which was used for all blood glucose checks. LPN 1 reported disinfecting the blood glucose meter with alcohol prep pads before and after each use. An observation was made of the alcohol prep pad, which contained 70% isopropyl alcohol. No CaviWipes were observed on the south medication cart. On 1/7/26 at 1:13 PM, an interview was conducted with LPN 2. LPN 2 stated that each medication cart had one [NAME] Quintet AC Glucose Meter, which was used for all blood glucose checks. LPN 2 stated they disinfected the blood glucose meter with alcohol prep pads following each use. No CaviWipes were observed on the north medication cart. According to the [NAME] Quintet AC Glucose Meter Owner's Manual, Indirect transmission of Human Immunodeficiency (HIV), Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) during the delivery of healthcare services has been increasingly reported. Persons using blood glucose monitoring systems have been identified as one risk group due to sharing.blood glucose meters. The manual further instructed The meter MUST be cleaned and disinfected after use on each patient. The following disinfecting wipe can be used to clean and disinfect the meter. CAVIWIPES DISINFECTING TOWELETTES (EPA# 46781-8) . It should be noted that according to the manufacturer's Safety Data Sheet, CaviWipes contained 17.20% of Isopropanol, 1 – 5% of 2-Butoxyethanol, and 0.28% of Benzethonium Chloride. The manual also stated the cleaning procedure is to remove dust, blood and body fluid from the surface and should be performed whenever the meter is visibly dirty. The disinfecting procedure is necessary to kill pathogens such as HIV, HBV and HCV on the device. The manual revealed the following cleaning and disinfecting procedures: Wipe the entire surface of the meter with CaviWipe thoroughly to clean any possible dirt dust, blood, and other body fluids, take another CaviWipe and wipe the meter thoroughly again, allow the surface to remain wet for 2 minutes, and allow to air dry. On 1/7/26 at 1:14 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility had a glucometer in each medication cart that was shared between residents. The DON stated the nurses used alcohol wipes to sanitize the glucometers after each use. The DON stated the facility did not have CaviWipes available because they had been flushed down the toilet and caused plumbing issues. The DON stated she used CaviWipes at the hospital and she liked them because of their drying time. The DON stated she was not aware of the manufacturer requirements to use CaviWipes to sanitize the glucometer. All diabetic residents' medical records were reviewed to determine who was receiving scheduled blood glucose checks and their diagnoses. There were 13 residents in the facility with orders for blood glucose checks. 1. Resident 3 was admitted to the facility on [DATE] with diagnoses which included chronic HCV. It should be noted that HCV is a bloodborne pathogen. Resident 3's medical record was reviewed on 1/7/26. Resident 3 had physician's orders dated 3/26/23 for blood sugar checks twice daily. 2. Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic viral Hepatitis C, type 2 diabetes mellitus, paranoid schizophrenia, and major depressive disorder. Resident 1's medical record was reviewed on 1/7/26. A physician's order dated 3/13/22 revealed blood sugar check every week on Wednesdays related to type 2 diabetes mellitus without complications. 3. Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included type 2 diabetes mellitus, takotsubo syndrome and schizoaffective disorder. Resident 14's medical record was reviewed on 1/7/26. A physician's order dated 2/9/2020 revealed to check blood glucose every evening related to type 2 diabetes mellitus. 4. Resident 10 was admitted to the facility on [DATE] with diagnoses which included Huntington's disease, type 2 diabetes mellitus and bipolar disorder. Resident 10's medical record was reviewed on 1/7/26. A physician's order dated 5/29/21 revealed to check blood sugars every week and notify the physician if less than 60 or over 400. The blood sugar was to be done every Friday. 5. Resident 11 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus with hyperglycemia, Alzheimer's disease and muscle weakness. Resident 11's medical record was reviewed on 1/7/26. A physician's order dated 7/14/25 revealed to check blood sugars every morning related to type 2 diabetes with hyperglycemia. 6. Resident 13 was admitted to the facility on [DATE] with diagnoses which included hypercapnia, Schizoaffective disorder and type 2 diabetes mellitus. Resident 13's medical record was reviewed on 1/7/26. A physician's order dated 11/10/25 revealed to check blood glucose daily every morning for type 2 diabetes. 7. Resident 6 was admitted to the facility on [DATE] with diagnoses which included dementia, type 1 diabetes mellitus and anxiety disorder. Resident 6's medical record was reviewed on 1/7/26. A physician's order dated 7/25/23 revealed blood checks before and after meals and at bedtime. 8. Resident 43 was admitted to the facility on [DATE] and readmitted on [DATE] which included diabetes mellitus due to underlying condition with other diabetic neurological complications, bacteremia and generalized anxiety. Resident 43's medical record was reviewed on 1/7/26. A physician's order dated 12/24/25 revealed blood glucose check twice daily for diabetes mellitus. 9. Resident 16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosed which included severe sepsis, type 2 diabetes mellitus and schizoaffective disorder. Resident 16's medical record was reviewed on 1/7/26. A physician's order dated 8/24/23 revealed blood sugar checks twice daily related to type 2 diabetes mellitus. 10. Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included vascular dementia, type 2 diabetes mellitus and chronic kidney disease. Resident 22's medical record was reviewed on 1/7/26. A physician's order dated 1/5/25 revealed to check blood sugars twice daily. 11. Resident 24 was admitted to the 2/22/22 with diagnoses which included history of COVID-19, cerebral infarction and type 2 diabetes mellitus. Resident 24's medical record was reviewed on 1/7/26. A physician's order dated 11/14/24 revealed blood sugar checks every Friday for diabetes mellitus. 12. Resident 35 was admitted to the facility on [DATE] with diagnoses which included type 1 diabetes mellitus, schizophrenia and major depressive disorder. Resident 35's medical record was reviewed on 1/7/26. A physician's order dated 8/19/22 revealed to check blood sugar before meals and at bed time. 13. Resident 36 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus and cerebral aneurysm. Resident 36's medical record was reviewed on 1/7/26. A physician's order dated 8/3/25 revealed blood sugar checks twice daily for blood sugar checks. POTENTIAL FOR HARM On 1/5/26, the infection control policy and procedure was requested during entrance. The following was provided with a revision date of August 2014: Coronavirus 2019, Prevention and Control Policy Statement This facility follows current guidelines and recommendations for the prevention and control of Coronavirus 2019 (COVID-19). Prevention: There are currently no vaccines to prevent COVID-19. On 1/8/26 at 1:30 PM, an interview was conducted with the DON. The DON stated there must be a more updated infection control policy and procedure because it had to have been updated after 2014. The DON stated this was not updated because there was a vaccine available. On 1/8/26 at 1:40 PM, an interview was conducted with the Administrator and the Business Office Manager (BOM) who stated there was a more updated policy and they were not sure where that one was. The DON was interviewed as well and stated that was the policy and procedure in the infection control binder.

Based on interview and record review, the facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility. Specifically, for 1 out of 3 sampled residents, a resident was not readmitted after being transferred to the hospital. Resident identifier: 1.Findings included:Resident 1 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, hypertensive heart and chronic kidney disease without heart failure, with state 5 chronic kidney disease, or end state renal disease, major depressive disorder, and anxiety disorder.Resident 1's medical record was reviewed.On 4/11/25 at 5:18 PM, a General Note documented . Resident was transported by a transport service around 1500 [3:00 PM], family was not present. Resident seems to know where she is at but not why she is alert and oriented x3 [person, place, and time]. Resident needs assistance with ADLs [activities of daily living] and transfers due to the risk for falls. Physician was notified and meds [medications] were brought in by hospice nurse.On 4/11/25 at 11:39 PM, a General Note documented a late entry Resident seen at the nurse's station very agitated and upset because she wants to go home. She purposely tipped over a chair at the nurse station out of anger. This nurse Tried to redirect and educate resident about safety of not doing that. Resident was taking [sic] to her room to get ready for bed. This nurse stepped out to get the CNA [Certified Nursing Assistant] to help with resident ADLs. While she was in there less than 5 minutes a loud repetitive banging was heard. Resident managed to get her W/C [wheelchair] foot Peddle's [sic] off and was hitting her side table with it. This nurse called Admin [Administrator] [name redacted] to report resident's behavior. While on the phone a CNA [name redacted] was able to retrieve the food peddle [sic] from the resident. She let go and he took it out of the room. [Name redacted] DON [Director of Nursing] was called and notified. This nurse was instructed to call the residents Hospice nurse. Hospice was called and [name redacted] and [name redated] was notified. Hospice nurse called the Dr [doctor] to get order for medication IM [intramuscular]. Several times DON and Hospice nurse was called and spoke with. Hospice nurse said she got order for Haldol IM but wasn't sure if it would be here before tomorrow. Resident settled down a bit but then said to this nurse and Both CNA at the nurse station 'Do you want to watch the picture show?' Not understanding what she meant, the resident threw the tissue box and then started to take things off the medication cart. At one point was touching the sharps container. Resident was pulled away from the med [medication] cart and CNA put med cart behind the dining room double doors. This nurse was on the phone with [name redacted] DON and instructed to call 911 to have the Resident sent to the emergency room to be evaluated and treated. [Name redacted] was going to call the Hospice nurse and inform her that we are sending resident out. This nurse called resident's SON [name redacted] tonotify [sic] him of resident's behavior that resident was being sent to [name of hospital redacted] for evaluation and treatment. Resident was picked up by EMS [Emergency Medical Services] and Report given.The April 2025 Medication Administration Record (MAR) was reviewed. On 4/11/25, resident 1 received an evening dose of lorazepam 0.5 milligrams (mg) and methadone 2.5 mg.On 4/11/25 at 12:45 PM, a physician's order documented Haloperidol Lactate Oral Concentrate 2 MG/ML [milliliter] (Haloperidol Lactate) Give 0.5 ml by mouth every 1 hours as needed for psychosis. It should be noted that there were no doses administered to resident 1 according to the MAR.On 4/11/25 at 1:00 PM, a physician's order documented LORazepam Oral Concentrate 2 MG/ML (Lorazepam) Give 0.25 ml by mouth every 2 hours as needed for anxiety. It should be noted that there were no doses administered to resident 1 according to the MAR.The facility Transfer/Discharge Report documented that resident 1 was transferred to an acute care hospital on 4/12/25 at 1:00 AM.On 4/12/25 at 6:33 AM, a Police Department (PD) Incident Report documented Narrative [name of PD redacted] was called by [city name redacted] Fire who was having an issue with returning a medical patient from [name of hospital redacted] to [name of Long Term Care (LTC) facility redacted] after treatment. On arrival the doors were locked, [city name redacted] Fire had their patient in their ambulance for over an hour while they tried to find a resolution. We made several attempts by knocking or calling into the facility and staff refused to communicate. I was able to speak to the Director of Nursing for the facility and explain our concerns. She contacted the Director of the Facility as well as the Hospice Nurse for the patient who all responded to the situation. As a result I and the [city name redacted] Fire Department determined the best place for the patient is not at the facility at this time. She was transported back to [name of hospital redacted] By [name of city redacted] Fire and her Hospice Nurse notified so they can make other arrangements. This case needs to be reviewed for any concerns involving the staff at [name of LTC facility redacted].On 4/12/25, the Emergency Department Provider Report documented Medical Decision Making Discussion: This is a [AGE] year-old female who presents to the emergency department via EMS. This patient was discharged from the emergency department a couple of hours previously. She was sent here by her skilled nursing facility when she reportedly was combative and not taking her medications as prescribed. The patient was evaluated here in the emergency department, was given Haldol. She was completely cooperative here in the emergency department during her previous stay, was discharged back skilled nursing facility. She returns now to the emergency department without any medical complaints. According to EMS, when they got back to the skilled, nursing would not take the patient back into the facility. Reportedly, the police were called, staff at the skilled nursing facility would not even open for the police. They called 911 on the police and the EMS who were trying to get into the building reporting that they were trying to break into the skilled nursing facility. We made attempts here from the emergency department to get in contact with the skilled nursing facility. Eventually, we were able to speak with the director of nursing from the skilled nursing facility. After discussing the patient's treatment here tonight, she was reporting that they would be willing to take the patient back into the facility. I also made contact with the patient's POA [power of attorney] who is her daughter [name redacted]. I discussed with her that the skilled nursing facility was having some difficulty with leading the patient back into the facility. She reportedly has contact information for an administrator there and will attempt to make contact with them. However, we received multiple calls back from EMS, they waited at the skilled nursing facility for several hours trying to get the patient back into the facility. Eventually, police and EMS made the determination that they felt it would be safer for the patient to come back here to the emergency department. Reportedly, the patient's hospice nurse has been called and she will come here to the emergency department to try to get the patient placed into a different skilled nursing facility.On 4/12/25, the Ombudsman received a personal rights violation. The complainant was the emergency room nurse that was on duty. Patient was transported to [name of hospital redacted] from facility with a complaint of abdominal pain and a 'verbal altercation with staff' per EMS and patient not want to take medication that is prescribed. After medical screening exam from emergency physician, patient was medically cleared by physician, primary RN [Registered Nurse] administered Haldol and discharged from ED [Emergency Department]. EMS was called for patient transport. EMS arrived at approximately 0030 [12:30 AM] 4/12/25. Patient left with EMS. Patient was cooperative and pleasant with ED staff throughout stay in ED. At 0057 [12:57 AM], EMS called ED and reports facility is refusing to take patient back. Requested EMS staff to talk with facility staff members to request to speak with administrator on call. Multiple calls back and forth with EMS, with reports of the LPN [Licensed Practical Nurse] at facility cursing at EMS, refusing to take patient, and locking EMS and patient outside of facility and recording EMS and patient on personal cell phones. EMS also reported patient had to urinate but staff would not allow patient back into facility, resulting in patient soiling herself when a restroom was very close by per EMS. EMS also reported to [hospital name redacted] that staff at [LTC facility name redacted] stated if the patient was accepted back then they would be calling in for their upcoming shift the following evening. POA of patient notified of incidents by ED physician. To add, police were requested to facility, to which the officer reportedly knocked on doors of facility alongside EMS, and staff members proceeded to call police on the police on scene. Multiple communications with [city name redated] Fire EMS and [hospital name redacted] were made, resulting in a 3 hour long delay, in which patient eventually had to be transported back to [name of hospital redacted] ED due to continuous refusal of patient to facility.On 11/12/25 at 10:27 AM, an interview was conducted with the DON. The DON stated that she received a call from the nurse that a resident was acting erratically, banging things, and throwing things. The DON stated she instructed the nurse to call hospice to get emergency medications to the facility. The DON stated it was relayed back to the nurse that hospice would order the medication but it might not get to the facility for three hours. The DON stated the nurse called her back again and stated that resident 1 was hitting her bedside table. The DON stated she instructed the nurse to call 911 and inform hospice. The DON stated at around 1:00 AM, resident 1 had come back to the facility and the DON called the hospice nurse to be at the facility because the staff did not feel safe with resident 1. The DON stated when she arrived at the facility the hospice nurse had not arrived yet. The DON stated the fire department and police were at the facility and we got the issue resolved and resident 1 went back to the hospital. The DON stated that her staff did not feel safe with resident 1 coming back to the facility and the police and fire department did not feel safe leaving resident 1 at the facility. The DON stated the staff did not do an assessment on resident 1 and the Medical Director (MD) did not assess resident 1 to determine a safe discharge. The DON stated it was 1:00 AM, in the morning. The DON stated resident 1 was technically not their resident because resident 1 was a respite. The DON stated the MD was notified technically to state that resident 1 was no longer at the facility. The DON stated that staff did not allow the police and fire department into the building because staff did not feel safe with the people attempting to get into the building. The DON stated that staff were advised by herself to let the police and fire department into the building and that was not done. The DON stated the situation was not handled the way she would have wanted it to be handled. The DON stated she had asked for certain things from staff and that did not happen. The DON stated that resident 1 took the brunt of it and we have a reputation with the fire department now that we were trying to overcome. The DON stated that hospice would bring in the resident medications and an emergency kit (ekit) and the hospice for resident 1 did not have anything ordered. The DON stated that she will now enter in all the orders and she was working with the pharmacy to get an ekit. The DON stated a nurse to nurse form was not completed for resident 1.On 11/12/25 at 10:43 AM, an interview was conducted with LPN 1. LPN 1 stated that the staff were told not to let resident 1 back in the building by the DON. LPN 1 stated that herself and the two CNAs had to write a report of what had happened. LPN 1 stated that residen 1 was brought back to the facility so fast that the staff were questioning if the hospital did anything. LPN 1 stated the police and ambulance staff were banging on the facility door. LPN 1 stated the Administrator and DON showed up to the facility. LPN 1 stated it was very scary because resident 1 was really mad and banging things. LPN 1 stated that resident 1 was going around the nurses station and knocking things on the floor. LPN 1 stated the police were banging on the door and that was very scary so she called 911.On 11/12/25 at 11:06 AM, an interview was conducted with the Administrator (ADM). The ADM stated that usually as a respite the hospice would deliver their ekit and the ekit never showed up for resident 1. The ADM stated that after the family signed the admission packet the family said good luck on the way out of resident 1's room. The ADM stated resident 1 was not their resident because she was respite. The ADM stated the facility was paid room and board for a hospice resident at the facility for a respite. The ADM stated the staff would administer medications but the hospice would bring in the medications. The ADM stated resident 1 had escalated and the nurse called him to tell him resident 1 was running around the nurses station and the staff had boxed themselves into the nurses station with the medication carts to protect themselves. The ADM stated the staff called 911 when resident 1 started swinging the wc foot rest. The ADM stated that paperwork was sent with EMS. The ADM stated when resident 1 returned to the facility the nurse was reluctant to take resident 1 back because resident 1 was treated for something different at the hospital. The ADM stated the police were demanding that we bring resident 1 back in the facility. The ADM stated the police sergeant, EMS. and fire department were at the facility when he arrived. The ADM stated at the end of everything the hospice nurse showed up. The ADM stated after speaking with the nurse he realized there was a communication break down. The ADM stated that resident 1 was not super reasonable and the nurse did not want to bring her back in the facility. The ADM stated they agreed to bring resident 1 back in and that was when the fire department decided not to leave resident 1.

Based on interview and record review, the facility did not ensure that 2 of 30 sample residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, ongoing monitoring for changes in condition were not provided after one resident experienced ongoing emesis and abdmoninal pain, and a second resident had a deep vein thrombosis. The findings for resident 46 were determined to have resulted in immediate jeopardy for resident 46. Resident identifiers: 46 and 298. NOTICE On [DATE] at 3:00 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to provide residents quality of care to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This notice was given verbally and in writing to the facility Administrator (ADM), and the Business Office Manager (BOM) regarding resident 46. On [DATE], the facility ADM provided the following written abatement plan for the removal of the Immediate Jeopardy effective on [DATE] at 11:00 AM: Updated Mountain View Health Services Immediate Jeopardy Removal Plan Date Submitted [DATE] We called and spoke with The Chief Clinical Officer (CCO) of an independent consulting organization as required by UDHHS (Utah Department of Health and Human Services) on [DATE] at approximately 3:05pm regarding the executing an agreement. On [DATE], Mountain View Health Services entered into an agreement with the consulting organization. On [DATE] consultant(s) with the consulting organization will be onsite at the facility. F 684 Quality of Care (Communication) 1. On [DATE] the community management team implemented a morning Standup meeting with Nursing to get report from previous day's activities/concerns. If changes in condition are noted from communication notes DON (Director of Nursing) or ADON (Assistant Director of Nursing) will verify MD (Medical Director) team had been notified and if notification has not been made will do so at that time. When in-person visits are conducted, the consultants will attend morning meetings. In addition, when offsite, the consultants will participate in random morning meetings to review and listen to the process to ensure compliance is achieved. 2. On [DATE] the nursing team implemented a new shift communication form that will be relayed at shift change with oncoming nurse for concerns/follow-up items still pending at shift change. All forms will be left in the drawer at nurse's station so management can review relevant items at the next morning standup meeting and follow up accordingly. In addition, the consultants will provide training on this process [DATE]. 3. On [DATE] a new CNA (Certified Nursing Assistant) communication program/sheets implemented as a way for CNAs to communicate with oncoming shift and report to nurse. Sheets will be collected daily and reviewed during the daily standup meeting with department managers. The consultants will provide education and training on this process [DATE]. 4. On [DATE] nursing implemented a new Communication and Follow-Up book that will remain at the nursing station. The book is a duplicate copy book with highlights and follow-up items from the previous day. The original will be removed and reviewed at daily manager Standup meeting. The consultants will provide education and training on this process [DATE]. 5. On [DATE] communication improvements made between the building and MD team by adding the DON and Administrator have both been added to the secure messaging app between the MD group and Facility. Areas of concern or issues that arise will be addressed in the manager stand-up meeting. 6. On [DATE] representatives from the consulting organization reviewed and assessed the facility's policies and procedures regarding changes in resident condition. The consultants provided the community with a change of condition policy to adopt. The consultants provided education and training on [DATE] [and][DATE] with licensed nursing and nursing assistants. The review with licensed nurses addressed expectations for ongoing assessments of each resident's condition, what constitutes a change in condition, expectations for the communication of changed (sic) in resident condition, and ongoing monitoring of residents experiencing a change in condition. On [DATE] facility in coordination with the consulting organization, the consultants will complete record reviews of all residents for the last 30 days to ensure no resident has experienced a change in condition not previously identified. Any findings of change of condition will be reported to the resident's attending physician and the resident's representative. This information will be communicated with the DON and Administrator at the manager stand-up meeting. The consultants ongoing for the next 30 days will review daily progress notes (M-F) (Monday through Friday) to ensure documented changes of condition are timely identified and action steps are taken with resident changes of condition. Mountain View Health Services has implemented this plan to remove the conditions that constituted immediate jeopardy, and the immediate jeopardy was removed on [DATE]. On [DATE], while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on [DATE] at 11:00 AM. Findings include: 1. Resident 46 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia and hemiparesis, chronic obstructive pyelonephritis, severe sepsis without shock, aspiration pneumonitis, acute kidney failure, supraventricular tachycardia, and bipolar disorder. Resident 46's medical record was reviewed from [DATE] through [DATE]. A History and Physical for resident 46 dated [DATE] documented that resident 46 presented to the local emergency room after facility staff observed resident 46 to have some coffee-ground looking emesis and acute hypoxic respiratory failure. The hospital physician documented that resident 46 had a history of deep vein thromboses and was currently receiving a blood-thinning medication. Resident 46 was diagnosed with sepsis with acute hypoxic respiratory failure and a gastrointestinal bleed at that time. Progress notes for resident 46 revealed the following entries: a. On [DATE], resident 46 was seen by Nurse Practitioner (NP) 2. NP doumented that resident 46 . s a [AGE] year-old male with a history of CVA (cerebrovascular accident), COPD (chronic obstructive pulmonary disease) and multiple previous hospitalization s. Today patient was seen for his recertification visit. He was resting in his bed and appeared comfortable, no signs of distress. Patient reports he is doing fine. He is eating well, sleeping good, no issues with bowels or bladder, no anxiety or depression, no uncontrolled pain, anxiety or depression. He denied any current issues or concerns. Floor staff reports he is doing well. NP 2 did not document any acute health concerns upon assessment of resident 46. b. On [DATE] at 9:30 PM, Registered Nurse (RN) 2 documented that there was a New order for Rocephin 1 Gm (gram) IM (Intramuscular) tonight, Sat (Saturday) [and] Sun (Sunday). for possible cholecystitis. Zofran 4 mg (milligrams) SL (sublingual) q (every) 6 hrs (hours). prn (as needed) N/V (nausea/vomiting). Schedule Tylenol 650 mg TID (three times a day) c (?) 3 days for abdominal pain. Stat (immediate) ultrasound of abdomen RUQ (right upper quadrant) and LLQ (left lower quadrant). No documentation was included in the note to indicate what occurred to prompt staff to contact the physician. c. On [DATE] at 6:15 AM, RN 2 documented, Resident was heard by nurse urping (sic) up fluid. I went into his room and his roommate said he kept doing this. I checked him over and he had some brown- black fluid on the left side of his mouth. I told him not to swallow the fluid and to cough it into an emesis basin which I [NAME] (sic) to him. His VS (vital signs) were taken. T (temperature) 98.1, P (pulse) 112, R (respirations) 16 B/P (blood pressure) ,d+[DATE] and 02 (oxygen) sats (saturations) 94% on room air. I could hear bowel sounds in upper quadrant but minimal in lower quads. He stated that his pain was above his right navel and below it. Fluid brought up was a dark brownish color. MD PA (Physician Assistant) notified at 2200 (10:00 PM) with Rocephin, Zofran and scheduled Tylenol order. See MAR (Medication Administration Recrod) and progress noted (sic). Also a stat (immediate) ultrasound was ordered. Call was made to [name of contracted radiology provider] this AM (morning) and they stated that they donot (sic) do ultrasounds on the weekends. MD to be notified by day nurse, which was agreed in report this AM. [Note: The facility had been performing weekly vital signs on Resident 46. Per facility documentation, on [DATE], Resident 46's blood pressure was ,d+[DATE] and his pulse was 67. Per the facility's vital sign records for Resident 46, between [DATE] and [DATE], Resident 46's blood pressure was generally consistent with the reading obtained on [DATE]. Resident 46's pulse had ranged from 58 to 85.] Although the order for a stat ultrasound for resident 46 was documented to be received at 9:30 PM on [DATE], the facility nurse did not document attempts to have the stat ultrasound performed until 6:15 AM on [DATE]; eight hours and 45 minutes later. Upon receiving notification from the contracted radiology provider that the company did not perform ultrasound tests on the weekend, there were no facility records to document that RN 2 contacted resident 46's physician. [Note: Review of the written telephone order revealed that RN 2 documented she had obtained the order for the Rocpehin and stat ultrasound from NP 1.] d. On [DATE] at 12:50 PM, RN 3 documented that resident 46 . has vomitted (sic) once this shift, it was a light brown color. He has requested more prune juice, but I denied that request and explained that we want to see why his vomit is brown. [Resident 46] had been laying in his vomit all night, we got him up to the shower and changed his bedding. His entire left arm, side of torso, and hip are very red. Cleaned well and put on hydrocortisone cream and barrier cream. Texted pic (picture) to provider of his inflamed skin. RN 3 did not document whether she had informed resident 46's physician of the ongoing brown emesis that resident 46 was experiencing. In addition, RN 3 did not document any indication that she was aware of the stat ultrasound order, or what the status was in obtaining the ultrasound. e. On [DATE] at 10:54 PM, Licensed Practical Nurse (LPN) 3 documented Order noted for ultrasound of Abdomen, [name of contracted radiology provider] notified and is scheduled for Monday [DATE]. No indication was made in the note by LPN 3 that he had contacted resident 46's physician regarding the delay in obtaining the stat ultrasound. f. On [DATE] at 10:10 AM, RN 4 documented that resident 46 had an . Ultrasound scheduled for tomorrow r/t (related to) vomiting and abdominal pain. g. On [DATE] at 4:36 PM, RN 4 documented that resident 46 had a Small amount of dark brown emesis early this morning. No other episodes this shift. h. On [DATE] NP 3 documented that he spoke with resident 46 face to face for approximately 17 minutes, and that they discussed resident 46's medical conditions and his code status. NP 3 also documented that . Patient has cholecystitis and was started on on (sic) Rocephin on [DATE], we will continue to monitor patient closely to determine if antibiotic treatment has been effective. NP 3 documented that resident 46 was experiencing Right upper quadrant/right lower quadrant pain, but did not document any follow up he did with facility staff regarding the ultrasound order. NP 3 did not document any assessment with regard to resident 46's nausea or vomiting. i. On [DATE] at 10:21 PM, RN 5 documented, Res (resident) currently on ABX (antibiotics) IM, (2nd dose) Medication was administered per MD orders. Res tolerated procedure well, there has been no ASE (adverse side effects) observed or reported. Fluids encouraged. RN 5 did not document any assessment with regard to resident 46's abdominal pain, nausea or vomiting. [Note: This note was entered as a late entry on [DATE] at 8:24 AM.] j. On [DATE], at 11:00 AM, RN 4 documented that the contracted radiology provider . cannot ultrasound until [DATE]. Medical directorship notified and ordered to have ultrasound done at [name of local hospital]. Scheduled with [name of local hospital] [DATE] at 0900 (9:00 AM) check in 0845 (8:45 AM). NPO (nothing by mouth) 8hrs (hours) prior to procedure. Medical directorship notified. No emesis on this shift and no reports of emesis on night shift. Resident states he does still have abdominal pain but is able to eat. k. On [DATE] at 8:25 PM, RN 5 documented that resident 46, . continues on ABX IM, (final dose) Medication was administered per MD orders. Res tolerated procedure well, there has been no ASE observed or reported. Res instructed to move RUE (right upper extremity) often to decrease stiffening in the muscle/pain. Fluids encouraged. RN 5 did not document any assessment with regard to resident 46's abdominal pain, nausea or vomiting. [Note: This note was entered as a late entry on [DATE] at 8:28 AM.] l. On [DATE] at 3:00 AM, RN 5 documented, CNA (Certified Nursing Assistant) completed rounds at 12:30am at which time resident was A&O (alert and oriented), brief was changed, resident was talking with staff. CNA started rounds at 02:30 (2:30 AM) upon entering residents' room, CNA exited notified nurse via radio to come down to res room. This nurse immediately went down, performed a quick assessment w/ (with) visual observation. Res had no pulse, eyes open, pale/ash color. No heart sounds. resident feet and hands cold with modeling. (02:45) (2:45 AM) Res was upright HOB (head of bed) ,d+[DATE]-degree, emesis was observed down L (left) side of resident's shirt. There had been no emesis throughout this shift or reported from day shift, resident had no complaints after dinner, other than some abdominal pain, Tylenol offered, res declined. Res took all medication w/o (without) difficulty. Res was scheduled for an abdominal ultrasound this morning at 08:45 (8:45 AM). Appt (appointment) has been cancelled. Facility CNA provided post-mortem care, and reported resident continued to excrete emesis from mouth. Res has emergency contacted listed, who since has passed away. [Name of mortuary] was contacted. Body was received from this facility at 05:45 am (5:45 AM). MD, DON (Director of Nursing) and administrator notified. On [DATE] at 1:45 PM, a telephone interview was conducted the an employee of the contract radiology provider (CRP 1). CRP 1 stated that their company did not receive notification of the ultrasound order for resident 46 until [DATE] at 9:50 PM. [Note: This was approximately 24 hours after the ultrasound order had been given to facility staff.] CRP 1 stated that the order was not called in to their comapny as a stat order. On [DATE] at 5:00 PM, a telephone interview was conducted with CNA 7. CNA 7 stated that a week prior to resident 46's death, she only worked with resident 46 on one shift. CNA 7 stated that during that one shift, she observed resident 46 to be covered in throw up. CNA 7 stated that resident 46 obviously wasn't feeling good. On [DATE] at 5:27 PM, a telephone interview was conducted with CNA 5. CNA 5 stated that she had noticed resident 46 vomiting during one of her shifts the week prior to resident 46's death. CNA 5 stated that she had notified the DON. CNA 5 stated that she observed resident 46's vomit to be watery . because he couldn't keep [his food] down. CNA 5 stated that resident 46 was obviously not feeling food. CNA 5 stated that resident 46 was vomiting so much that his shirt was covered in throw up when she checked on the resident. On [DATE] at 7:17 PM, a telephone interview was conducted with CNA 6. CNA 6 stated that she had worked with resident 46 on [DATE] and [DATE]. CNA 6 stated that resident 46 was complaining about abdominal pain during her shifts. CNA 6 stated that resident 46 had been throwing up and did not get out of bed during her shifts. CNA 6 stated that a bunch of us had to go in and clean him up after the resident had vomited. CNA 6 stated that she observed resident 46's emesis and it wasn't normal throw up . it looked black and like chunky and liquids at the same time. It was black and dark brown. CNA 6 stated that other staff reported to her that resident 46 had been constantly throwing up all day on one of the days she worked with him, I wanna say he threw up both nights but it was worse the next night. They said they wanted to get him an ultrasound and they were waiting but they wanted to get the ultrasound first before they sent him out. On [DATE] at 6:25 PM, a telephone interview was conducted with CNA 4. CNA 4 stated that during the last week of resident 46's life, resident 46 was very sick and he was throwing up for two days. CNA 4 stated that on [DATE], he observed resident 46 while the resident was being weighed. CNA 4 stated that this was the last time he had seen resident 46 and that the resident didn't look really good. He was very pale, and his eyes were sunken in. CNA 4 stated that other staff had reported to him that resident 46 was vomiting a dark liquid and that the resident's health was getting worse and he wasn't feeling well. On [DATE] at 5:39 PM, a telephone interview was conducted with LPN 3. When asked about the note that LPN 3 entered on [DATE], LPN 3 stated that the facility had been having problems with predictability of services with the contracted radiology provider since at least [DATE]. LPN 3 stated the the contracted radiology provider kept putting off coming in to the facility to perform resident 46's ultrasound after it was ordered on [DATE]. LPN 3 stated that he was unsure why there was an order for an ultrasound, or if resident 46 was experiencing a change in condition during the week prior to the resident's death. On [DATE] at 3:55 PM, a telephone interview was conducted with RN 4. RN 4 stated that she worked on Sunday, [DATE], and was aware that resident 46 was supposed to have an abdominal ultrasound completed, but that the contracted radioligy company did not provide ultrasounds on the weekends. RN 4 stated that she did not work on Monday [DATE], and thought that the ultrasound would be completed that day. RN 4 stated that when she returned to work on [DATE], the ultrasound had not been completed so she contacted the contracted radiology company. RN 4 stated that the radiology company told her that they did not have resident 46 on their schedule, and that the earliest they could perform the ultrasound would be on [DATE]. RN 4 stated that she then contacted the on-call provider for further instruction. RN 4 stated that the on-call provider instructed her to schedule the ultrasound at a local hospital. RN 4 stated that the Medical Director was in the facility on [DATE], and she had informed the Medical Director about the delay in getting an ultrasound for resident 46. RN 4 stated that during her shift on [DATE], resident 46 was vomiting at times, although she did not observe the emesis produced. RN 4 stated that staff reported to her that resident 46's emesis was brown or dark brown. RN 4 stated that on [DATE], resident 46 reported he was still experiencing abdominal pain, but did not pinpoint the exact location of the pain. RN 4 reported that on [DATE], resident 46 received a shower, and had consumed at least part of his meals. RN 4 stated that she also worked as the ADON, and that she did not report resident 46's change in condition or delay in obtaining the ultrasound to the DON because we don't have office hours, we just work the floor when we are there. On [DATE] at 2:10 PM, a telephone interview was conducted with RN 5. RN 5 stated that when she arrived for her scheduled night shift on the evening of Monday [DATE], she was not given any information about resident 46's condition during the nurse to nurse report. RN 5 stated that there had been a lack of communication between shifts and that she had been unaware of the stat ultrasound order or that resident 46 had been vomiting. RN 5 stated that she was aware that resident 46 was scheduled for an ultrasound at some point, but it was so long out . that bothered me. RN 5 stated she texted the physician on call on [DATE] because she was worried about the delay because there was a patient in the unit (memory care unit) that died after waiting a long time for treatment. [Note: This was identifed to be resident 298, who has a finding below.] RN 5 stated that the following day, on [DATE], the physician gave an order to schedule the ultrasound with the local hospital. RN 5 stated that at times, the physician on call did not respond timely during the evening and night hours. RN 5 stated that she had been resident 46's assigned nurse on the evening of [DATE]. RN 5 stated that at approximately 12:40 AM on the morning of [DATE], a CNA checked on resident 46 as part of his rounds. RN 5 stated that at that time, the CNA left the resident's room and signaled to the nurse who was at the nurses station that the resident had passed away. RN 5 stated that she then went to resident 46's room to visualize the resident. RN 5 stated that when she saw resident 46, there was no emesis on the resident, but that while providing post mortem care, the CNA reported that emesis came out of resident 46's mouth. RN 5 stated that after resident 46's death, she had reviewed the resident's medical record and realized the resident had been vomiting for a few days. RN 5 stated it was at that time, she discovered that resident 46 had been vomiting, and I didn't see much of an intervention from the facility. RN 5 stated that the lack of communication is concerning because it could have been a different outcome. had I known. Resident 46 stated that the facility has a 24 hour report, but she did not have access to it, and I have to depend on what the nurse tells me during shift change. RN 5 also stated that there was no system of communication between CNAs and nurses. RN 5 stated that for example, she has heard CNAs discussing a resident who had experienced diarrhea, and she told the CNAs they should be reporting those types of things to the nurse on duty also. On [DATE] at 6:32 PM, a telephone interview was conducted with RN 3. RN 3 stated that she had been assigned to resident 46 for one shift after the facility received an order for the resident to have a stat ultrasound on [DATE]. RN 3 stated that when she came on shift on the morning of Saturday, [DATE], resident 36 had been throwing up throughout the night, so I went to give Zofran. RN 3 stated that staff had been texting the physician in an attempt to get the ordered ultrasound completed, because the contract radiology company would not complete the ultrasound on a weekend. RN 3 stated that the contract radiology company would not complete the ultrasound until Monday, [DATE]. RN 3 stated that when she spoke with resident 46 during her shift, the resident reported that he was in pain and was requesting prune juice. RN 3 stated that she did not provide resident 46 with any prune juice, because resident 46's emesis was a brown color and I was trying to determine if it was brown because of blood or prune juice. RN 3 stated that the resident's emesis looked like prune juice, but did not have anything that looked like coffee grounds. RN 3 stated that resident 46 repeatedly asked for prune juice because he did not feel he was having bowel movements. RN 3 stated that resident 46 had actually had a bowel movement during her shift that she observed, and stated it was huge, and yellowy brown in color and didn't look like it had blood in it. RN 3 stated that she had spoken with LPN 3, who was also working that day, about resident 46's vomiting. RN 3 stated that LPN 3 told her that she should notify the physician, but RN 3 told LPN 3 that RN 5 had already contacted the physician, so LPN 3 told RN 3 to wait and see what the doctor wants to do. RN 3 stated that she texted the physcian during her shift because resident 46 had vomited during the evening of [DATE] and night shift hadn't cleaned him up well so he had gotten red on that left side. RN 3 stated that she did not notify the physician about the resident vomiting, only the redness on the resident's skin. RN 3 stated that the physician's response was we will keep an eye on it, and did not provide any new orders. RN 3 stated that the physician did not say anything about the ultrasound. RN 3 stated that she did not realize the ultrasound order had been written as a stat order. On [DATE] at 3:15 PM, an interview was conducted with the DON. The DON stated that she was aware that resident 46 was vomiting during the last week of the resident's life, but could not recall how she received that information. The DON stated that no one had spoken to her about resident 46 and his change of condition. The DON stated that we should have at least sent him to the ER (emergency room ) to get evaluated if the stat order was written. The DON stated that they did complete 24 hour reports, but she was unable to locate any of them. On [DATE] at 11:17 AM, a telephone interview was conducted with NP 3. NP 3 stated that his first day at the facility was on [DATE], the same day he saw and evaluated resident 46 for the first time. NP 3 stated that he was unable to comment on the resident, because he could not locate the resident in the electronic health record system he was using. On [DATE] at 11:31 AM, a telephone interview was conducted with NP 2. NP 2 stated that she had visited with resident 46 on [DATE], and he was his normal self. NP 2 stated that sometime after that visit, the resident had starting vomiting, and staff had contacted the other provider who was on call the night of [DATE]. NP 2 stated she was unsure who evaluated and provided the Rocephin prescription for resident 46 on [DATE], and was unable to determine that. On [DATE] at 12:08 PM, a second interview was conducted with NP 2. NP 2 stated that she was unaware if any previous issues had occurred with the contracted radiology provider. NP 2 stated that other buildings just figure it out how to get the resident in sooner when they received an order to get a stat ultrasound. NP 2 stated she did not think the facility staff accurately communicated resident 46's change of condition to her. When asked if NP 2 was aware that resident 46 had a history of gastrointestinal bleeds, NP 2 stated, No. If I would have known that I would have sent him out to the local hospital. NP 2 stated that the facility was not uploading all of residents' information into the electronic health records, so if she was working from home on a day that the facility staff contacted her, she would not have all of the residents' information available to her. NP 2 stated that other facilities had a 24 hour nursing report to refer to, and a dedicated DON she could speak with, but that at this facility she had to speak with every nurse to obtain information about the residents. On [DATE] at 1:32 PM, a telephone interview was conducted with NP 1. NP 1 stated that she evaluated approximately 150 patients each week and did not recall if she had evaluated resident 46. NP 1 stated that her company did not document anything when an on-call provider was contacted about a specific resident. NP 1 stated that she did not recall if she had written the Rocephin prescription for resident 46 on [DATE]. NP 1 stated that she did not recall why or how she had evaluated resident 46 to diagnose him with cholecystitis. NP 1 stated that typically if she suspected a resident had cholecystitis, she would have the facility start Rocephin injections to control the infection until the ultrasound could be performed. NP 1 stated that if she wrote something as a stat order, she expected it to be done within an hour or two. NP 1 stated that she did not receive any other phone calls from the facility regarding resident 46, nor was she notified that the ultrasound could not be performed on the weekend. NP 1 stated that if the resident did not stabilize or have a reduction in symptoms after receiving the Rocephin injections, then the facility should have sent the resident out to the hospital for further evaluation. NP 1 further stated, I would have expected a phone call back to know that so I could send him out or continue to monitor his symptoms. NP 1 stated that cholecystitis typically responded well to Rocephin. NP 1 stated that had she known about resident 46's ongoing symptoms after receiving the Rocephin, she would have sent him to the hospital no question because his condition has changed. [Cross refer to F776] 50200 2. Resident 298 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, essential hypertension, benign prostatic hyperplasia without lower urinary symptoms, acute kidney failure, weakness, and anxiety disorder. Resident 298's medical record was reviewed on [DATE]. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 298 had a Brief Interview for Mental Status (BIMS) score of 13. A BIMS score of 13 to 15 would suggest intact cognition. A review of resident 298's paper medical chart revealed an order dated [DATE], for a right lower extremity ultrasound to rule out a DVT [deep vein thrombosis]. A review of resident 298's progress notes revealed: a. On [DATE] at 3:22 PM, a health status noted documented, PT [patient] APPT [appointment] C [with] MDR [medical doctor] WAS CANCELLED PER ADMIN [administration] HIS RLE [right lower extremity] IS QUITE A BIT BIGGER THAN PRIOR TO RECENT HOSPITAL STAY. ,D [sic] WAS INT [sic] TO SEE PT AND HE ORDERED THAT HE SEES HIA [sic] ORTHO ASAP [as soon as possible] AND A U/S [ultrasound] TO RLE TO R/O [rule out] DVT SO THIS RN [registered nurse] CALLED TO SET UP MOBILE EXAM WHEN I DID THE [sic] SAID IT WOULD BE DONE UNTIL [DATE]TH WHICH THAT IS THE [NAME] [sic] DAY THT [sic] HIS APPT WAS RESCHEDULED FOR SO I BUT IT THE MD PHONE THIS INFO MAYBE HE WANTED US TO TAKE PT INTO HOSPITAL FOR EXAM. PT IS ALERT ORIENTED TO TIME AND ABLE TO FEED SELF. ABX [antibiotics] GIVEN AS PER 0RDER [sic] INCISION IS CLEAN DRY ANDEDGES [sic] ARE WELL AOPROXAMATED [sic]. WCTM [will continue to monitor]. b. On [DATE] at 2:54 PM, a health status note documented, Resident had a f/t [sic] appointment with [hospital name redacted] for his r [right] hip. An xray was done. Then he went to see his surgeon [name redacted] for f/u [follow up]. New orders are WBAT [weight bearing as tolerated], PT/OT [physical therapy/occupational therapy] to strength, ambulate and balance. Has anterior hip precautions. Anticoagulated for 2 more weeks from other. COntinue [sic] any chronic meds [medications] otherwise. F/U in 6 weeks with xrays to right hip. (around the [DATE] or 1st week of August) c. On [DATE] at 4:22 PM, a health status note documented, [name redacted] in for US of RLE. Patient was out on an appointment and I told [name redacted] that they made the appoinment [sic] in the afternoon as he had am [sic] appointments. The rep for [name redacted] took the number and said she would call back and come back if he was available. I told her that it had to be done. No calls were returned from [name redacted]. [TRUNCATED]

Based on interview and record review, the facility did not ensure for 2 of 30 sample residents that radiology and other diagnostic services were provided to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. Specifically, residents were not provided with ultrasounds as ordered by the physician. This resulted in a finding of Immediate Jeopardy for resident 46. Resident identifiers: 46 and 298. NOTICE On [DATE] at 3:00 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to provide residents with radiology and other diagnostic services to meet the needs of the residents. This notice was given verbally and in writing to the facility Administrator (ADM), and the Business Office Manager (BOM) regarding resident 46. On [DATE], the facility ADM provided the following written abatement plan for the removal of the Immediate Jeopardy effective on [DATE] at 11:00 AM: Updated Mountain View Health Services Immediate Jeopardy Removal Plan Date Submitted [DATE] We called and spoke with The Chief Clinical Officer (CCO) of an independent consulting organization as required by UDHHS (Utah Department of Health and Human Services) on [DATE] at approximately 3:05pm regarding the executing an agreement. On [DATE], Mountain View Health Services entered into an agreement with the consulting organization. On [DATE] consultant(s) with the consulting organization will be onsite at the facility. F 776 Radiology and Other Diagnostic Services 1. Facility executed a contract [DATE] with a new Imaging Vendor for all radiological and diagnostic services. The Imaging Vendor has started service [DATE] and nursing staff has been trained on new vendor and process to obtain services from said vendor. Processes for obtaining services from imaging vendor were evaluated by the contracting organization on [DATE] 2. [DATE], facility has completed a 100% audit of all facility residents' appointments and orders in the last 3 months to ensure all residents radiological and diagnostic needs and physician referrals have been followed up on. Audit did not identify any outstanding orders or concerns 3. In-serviced all Nurses on new procedures for Obtaining Radiological Services for residents was conducted on [DATE]. Nurses not available to sign the in-service book will have the new procedures sent to them via messaging and will respond that they understand the new process and will physically sign the in-service book on their next shift in the building. 4. On [DATE] representatives with the consulting organization will review and assess the facility policies and procedures regarding radiology and other diagnostic services, policies and procedures will be developed. * The facility shall ensure radiology and other diagnostic services are available to meet the needs of the facility residents, including timeliness, accuracy and communication of results. * Facility policies shall ensure expectations for terms such as Stat, immediate, urgent or other qualifiers associated with radiology and other diagnostic tests. * The review shall address procedures or processes for obtaining radiology and other diagnostic tests, communicated to the radiology or other diagnostic test provider/supplier/vendor, action to take when a radiology or other diagnostic test providers/supplier/vendor is unable to provide the specified service, and communication of the results. 5. Policy changes for Radiology and Diagnostic Service orders as seen below. * The community has contracted with [name of radiology provider]. The physician will identify, and order diagnostic testing based on resident assessment and needs. * The community will obtain a physician order in the event a resident assessment would warrant radiology/diagnostic testing. * If a resident requires immediate diagnostic testing, the licensed nurse will order a STAT diagnostic test. STAT diagnostic testing will be completed per [name of radiology provider]within four (4) hours. * If the diagnostic testing is not completed with four (4) [hours], the licensed nurse will notify the physician for further orders. * If the residents condition worsens, the nurse will notify the physician and resident will be sent out via 911 for further evaluation and treatment. * Once routine or STAT diagnostic testing is completed, the physician will be notified of the results and the results will be placed in the resident's medical record. Mountain View Health Services has implemented this plan to remove the conditions that constituted immediate jeopardy, and the immediate jeopardy was removed on [DATE]. On [DATE], while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on [DATE] at 11:00 AM. Findings include: 1. Resident 46 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia and hemiparesis, chronic obstructive pyelonephritis, severe sepsis without shock, aspiration pneumonitis, acute kidney failure, supraventricular tachycardia, and bipolar disorder. Resident 46's medical record was reviewed from [DATE] through [DATE]. A History and Physical for resident 46 dated [DATE] documented that resident 46 presented to the local emergency room after facility staff observed resident 46 to have some coffee-ground looking emesis and acute hypoxic respiratory failure. The hospital physician documented that resident 46 had a history of deep vein thromboses and was currently receiving a blood-thinning medication. Resident 46 was diagnosed with sepsis with acute hypoxic respiratory failure and a gastrointestinal bleed at that time. Progress notes for resident 46 revealed the following entries: a. On [DATE], resident 46 was seen by Nurse Practitioner (NP) 2. NP doumented that resident 46 . s a [AGE] year-old male with a history of CVA (cerebrovascular accident), COPD (chronic obstructive pulmonary disease) and multiple previous hospitalization s. Today patient was seen for his recertification visit. He was resting in his bed and appeared comfortable, no signs of distress. Patient reports he is doing fine. He is eating well, sleeping good, no issues with bowels or bladder, no anxiety or depression, no uncontrolled pain, anxiety or depression. He denied any current issues or concerns. Floor staff reports he is doing well. NP 2 did not document any acute health concerns upon assessment of resident 46. b. On [DATE] at 9:30 PM, Registered Nurse (RN) 2 documented that there was a New order for Rocephin 1 Gm (gram) IM (Intramuscular) tonight, Sat (Saturday) [and] Sun (Sunday). for possible cholecystitis. Zofran 4 mg (milligrams) SL (sublingual) q (every) 6 hrs (hours). prn (as needed) N/V (nausea/vomiting). Schedule Tylenol 650 mg TID (three times a day) c (?) 3 days for abdominal pain. Stat (immediate) ultrasound of abdomen RUQ (right upper quadrant) and LLQ (left lower quadrant). No documentation was included in the note to indicate what occurred to prompt staff to contact the physician. c. On [DATE] at 6:15 AM, RN 2 documented, Resident was heard by nurse urping (sic) up fluid. I went into his room and his roommate said he kept doing this. I checked him over and he had some brown- black fluid on the left side of his mouth. I told him not to swallow the fluid and to cough it into an emesis basin which I [NAME] (sic) to him. His VS (vital signs) were taken. T (temperature) 98.1, P (pulse) 112, R (respirations) 16 B/P (blood pressure) ,d+[DATE] and 02 (oxygen) sats (saturations) 94% on room air. I could hear bowel sounds in upper quadrant but minimal in lower quads. He stated that his pain was above his right navel and below it. Fluid brought up was a dark brownish color. MD PA (Physician Assistant) notified at 2200 (10:00 PM) with Rocephin, Zofran and scheduled Tylenol order. See MAR (Medication Administration Recrod) and progress noted (sic). Also a stat (immediate) ultrasound was ordered. Call was made to [name of contracted radiology provider] this AM (morning) and they stated that they donot (sic) do ultrasounds on the weekends. MD to be notified by day nurse, which was agreed in report this AM. [Note: The facility had been performing weekly vital signs on Resident 46. Per facility documentation, on [DATE], Resident 46's blood pressure was ,d+[DATE] and his pulse was 67. Per the facility's vital sign records for Resident 46, between [DATE] and [DATE], Resident 46's blood pressure was generally consistent with the reading obtained on [DATE]. Resident 46's pulse had ranged from 58 to 85.] Although the order for a stat ultrasound for resident 46 was documented to be received at 9:30 PM on [DATE], the facility nurse did not document attempts to have the stat ultrasound performed until 6:15 AM on [DATE]; eight hours and 45 minutes later. Upon receiving notification from the contracted radiology provider that the company did not perform ultrasound tests on the weekend, there were no facility records to document that RN 2 contacted resident 46's physician. [Note: Review of the written telephone order revealed that RN 2 documented she had obtained the order for the Rocpehin and stat ultrasound from NP 1.] d. On [DATE] at 12:50 PM, RN 3 documented that resident 46 . has vomitted (sic) once this shift, it was a light brown color. He has requested more prune juice, but I denied that request and explained that we want to see why his vomit is brown. [Resident 46] had been laying in his vomit all night, we got him up to the shower and changed his bedding. His entire left arm, side of torso, and hip are very red. Cleaned well and put on hydrocortisone cream and barrier cream. Texted pic (picture) to provider of his inflamed skin. RN 3 did not document whether she had informed resident 46's physician of the ongoing brown emesis that resident 46 was experiencing. In addition, RN 3 did not document any indication that she was aware of the stat ultrasound order, or what the status was in obtaining the ultrasound. e. On [DATE] at 10:54 PM, Licensed Practical Nurse (LPN) 3 documented Order noted for ultrasound of Abdomen, [name of contracted radiology provider] notified and is scheduled for Monday [DATE]. No indication was made in the note by LPN 3 that he had contacted resident 46's physician regarding the delay in obtaining the stat ultrasound. f. On [DATE] at 10:10 AM, RN 4 documented that resident 46 had an . Ultrasound scheduled for tomorrow r/t (related to) vomiting and abdominal pain. g. On [DATE] at 4:36 PM, RN 4 documented that resident 46 had a Small amount of dark brown emesis early this morning. No other episodes this shift. h. On [DATE] NP 3 documented that he spoke with resident 46 face to face for approximately 17 minutes, and that they discussed resident 46's medical conditions and his code status. NP 3 also documented that . Patient has cholecystitis and was started on on (sic) Rocephin on [DATE], we will continue to monitor patient closely to determine if antibiotic treatment has been effective. NP 3 documented that resident 46 was experiencing Right upper quadrant/right lower quadrant pain, but did not document any follow up he did with facility staff regarding the ultrasound order. NP 3 did not document any assessment with regard to resident 46's nausea or vomiting. i. On [DATE] at 10:21 PM, RN 5 documented, Res (resident) currently on ABX (antibiotics) IM, (2nd dose) Medication was administered per MD orders. Res tolerated procedure well, there has been no ASE (adverse side effects) observed or reported. Fluids encouraged. RN 5 did not document any assessment with regard to resident 46's abdominal pain, nausea or vomiting. [Note: This note was entered as a late entry on [DATE] at 8:24 AM.] j. On [DATE], at 11:00 AM, RN 4 documented that the contracted radiology provider . cannot ultrasound until [DATE]. Medical directorship notified and ordered to have ultrasound done at [name of local hospital]. Scheduled with [name of local hospital] [DATE] at 0900 (9:00 AM) check in 0845 (8:45 AM). NPO (nothing by mouth) 8hrs (hours) prior to procedure. Medical directorship notified. No emesis on this shift and no reports of emesis on night shift. Resident states he does still have abdominal pain but is able to eat. k. On [DATE] at 8:25 PM, RN 5 documented that resident 46, . continues on ABX IM, (final dose) Medication was administered per MD orders. Res tolerated procedure well, there has been no ASE observed or reported. Res instructed to move RUE (right upper extremity) often to decrease stiffening in the muscle/pain. Fluids encouraged. RN 5 did not document any assessment with regard to resident 46's abdominal pain, nausea or vomiting. [Note: This note was entered as a late entry on [DATE] at 8:28 AM.] l. On [DATE] at 3:00 AM, RN 5 documented, CNA (Certified Nursing Assistant) completed rounds at 12:30am at which time resident was A&O (alert and oriented), brief was changed, resident was talking with staff. CNA started rounds at 02:30 (2:30 AM) upon entering residents' room, CNA exited notified nurse via radio to come down to res room. This nurse immediately went down, performed a quick assessment w/ (with) visual observation. Res had no pulse, eyes open, pale/ash color. No heart sounds. resident feet and hands cold with modeling. (02:45) (2:45 AM) Res was upright HOB (head of bed) ,d+[DATE]-degree, emesis was observed down L (left) side of resident's shirt. There had been no emesis throughout this shift or reported from day shift, resident had no complaints after dinner, other than some abdominal pain, Tylenol offered, res declined. Res took all medication w/o (without) difficulty. Res was scheduled for an abdominal ultrasound this morning at 08:45 (8:45 AM). Appt (appointment) has been cancelled. Facility CNA provided post-mortem care, and reported resident continued to excrete emesis from mouth. Res has emergency contacted listed, who since has passed away. [Name of mortuary] was contacted. Body was received from this facility at 05:45 am (5:45 AM). MD, DON (Director of Nursing) and administrator notified. On [DATE] at 1:45 PM, a telephone interview was conducted the an employee of the contract radiology provider (CRP 1). CRP 1 stated that their company did not receive notification of the ultrasound order for resident 46 until [DATE] at 9:50 PM. [Note: This was approximately 24 hours after the ultrasound order had been given to facility staff.] CRP 1 stated that the order was not called in to their comapny as a stat order. On [DATE] at 5:00 PM, a telephone interview was conducted with CNA 7. CNA 7 stated that a week prior to resident 46's death, she only worked with resident 46 on one shift. CNA 7 stated that during that one shift, she observed resident 46 to be covered in throw up. CNA 7 stated that resident 46 obviously wasn't feeling good. On [DATE] at 5:27 PM, a telephone interview was conducted with CNA 5. CNA 5 stated that she had noticed resident 46 vomiting during one of her shifts the week prior to resident 46's death. CNA 5 stated that she had notified the DON. CNA 5 stated that she observed resident 46's vomit to be watery . because he couldn't keep [his food] down. CNA 5 stated that resident 46 was obviously not feeling food. CNA 5 stated that resident 46 was vomiting so much that his shirt was covered in throw up when she checked on the resident. On [DATE] at 7:17 PM, a telephone interview was conducted with CNA 6. CNA 6 stated that she had worked with resident 46 on [DATE] and [DATE]. CNA 6 stated that resident 46 was complaining about abdominal pain during her shifts. CNA 6 stated that resident 46 had been throwing up and did not get out of bed during her shifts. CNA 6 stated that a bunch of us had to go in and clean him up after the resident had vomited. CNA 6 stated that she observed resident 46's emesis and it wasn't normal throw up . it looked black and like chunky and liquids at the same time. It was black and dark brown. CNA 6 stated that other staff reported to her that resident 46 had been constantly throwing up all day on one of the days she worked with him, I wanna say he threw up both nights but it was worse the next night. They said they wanted to get him an ultrasound and they were waiting but they wanted to get the ultrasound first before they sent him out. On [DATE] at 6:25 PM, a telephone interview was conducted with CNA 4. CNA 4 stated that during the last week of resident 46's life, resident 46 was very sick and he was throwing up for two days. CNA 4 stated that on [DATE], he observed resident 46 while the resident was being weighed. CNA 4 stated that this was the last time he had seen resident 46 and that the resident didn't look really good. He was very pale, and his eyes were sunken in. CNA 4 stated that other staff had reported to him that resident 46 was vomiting a dark liquid and that the resident's health was getting worse and he wasn't feeling well. On [DATE] at 5:39 PM, a telephone interview was conducted with LPN 3. When asked about the note that LPN 3 entered on [DATE], LPN 3 stated that the facility had been having problems with predictability of services with the contracted radiology provider since at least [DATE]. LPN 3 stated the the contracted radiology provider kept putting off coming in to the facility to perform resident 46's ultrasound after it was ordered on [DATE]. LPN 3 stated that he was unsure why there was an order for an ultrasound, or if resident 46 was experiencing a change in condition during the week prior to the resident's death. On [DATE] at 3:55 PM, a telephone interview was conducted with RN 4. RN 4 stated that she worked on Sunday, [DATE], and was aware that resident 46 was supposed to have an abdominal ultrasound completed, but that the contracted radioligy company did not provide ultrasounds on the weekends. RN 4 stated that she did not work on Monday [DATE], and thought that the ultrasound would be completed that day. RN 4 stated that when she returned to work on [DATE], the ultrasound had not been completed so she contacted the contracted radiology company. RN 4 stated that the radiology company told her that they did not have resident 46 on their schedule, and that the earliest they could perform the ultrasound would be on [DATE]. RN 4 stated that she then contacted the on-call provider for further instruction. RN 4 stated that the on-call provider instructed her to schedule the ultrasound at a local hospital. RN 4 stated that the Medical Director was in the facility on [DATE], and she had informed the Medical Director about the delay in getting an ultrasound for resident 46. RN 4 stated that during her shift on [DATE], resident 46 was vomiting at times, although she did not observe the emesis produced. RN 4 stated that staff reported to her that resident 46's emesis was brown or dark brown. RN 4 stated that on [DATE], resident 46 reported he was still experiencing abdominal pain, but did not pinpoint the exact location of the pain. RN 4 reported that on [DATE], resident 46 received a shower, and had consumed at least part of his meals. RN 4 stated that she also worked as the ADON, and that she did not report resident 46's change in condition or delay in obtaining the ultrasound to the DON because we don't have office hours, we just work the floor when we are there. On [DATE] at 2:10 PM, a telephone interview was conducted with RN 5. RN 5 stated that when she arrived for her scheduled night shift on the evening of Monday [DATE], she was not given any information about resident 46's condition during the nurse to nurse report. RN 5 stated that there had been a lack of communication between shifts and that she had been unaware of the stat ultrasound order or that resident 46 had been vomiting. RN 5 stated that she was aware that resident 46 was scheduled for an ultrasound at some point, but it was so long out . that bothered me. RN 5 stated she texted the physician on call on [DATE] because she was worried about the delay because there was a patient in the unit (memory care unit) that died after waiting a long time for treatment. [Note: This was identifed to be resident 298, who has a finding below.] RN 5 stated that the following day, on [DATE], the physician gave an order to schedule the ultrasound with the local hospital. RN 5 stated that at times, the physician on call did not respond timely during the evening and night hours. RN 5 stated that she had been resident 46's assigned nurse on the evening of [DATE]. RN 5 stated that at approximately 12:40 AM on the morning of [DATE], a CNA checked on resident 46 as part of his rounds. RN 5 stated that at that time, the CNA left the resident's room and signaled to the nurse who was at the nurses station that the resident had passed away. RN 5 stated that she then went to resident 46's room to visualize the resident. RN 5 stated that when she saw resident 46, there was no emesis on the resident, but that while providing post mortem care, the CNA reported that emesis came out of resident 46's mouth. RN 5 stated that after resident 46's death, she had reviewed the resident's medical record and realized the resident had been vomiting for a few days. RN 5 stated it was at that time, she discovered that resident 46 had been vomiting, and I didn't see much of an intervention from the facility. RN 5 stated that the lack of communication is concerning because it could have been a different outcome. had I known. Resident 46 stated that the facility has a 24 hour report, but she did not have access to it, and I have to depend on what the nurse tells me during shift change. RN 5 also stated that there was no system of communication between CNAs and nurses. RN 5 stated that for example, she has heard CNAs discussing a resident who had experienced diarrhea, and she told the CNAs they should be reporting those types of things to the nurse on duty also. On [DATE] at 6:32 PM, a telephone interview was conducted with RN 3. RN 3 stated that she had been assigned to resident 46 for one shift after the facility received an order for the resident to have a stat ultrasound on [DATE]. RN 3 stated that when she came on shift on the morning of Saturday, [DATE], resident 36 had been throwing up throughout the night, so I went to give Zofran. RN 3 stated that staff had been texting the physician in an attempt to get the ordered ultrasound completed, because the contract radiology company would not complete the ultrasound on a weekend. RN 3 stated that the contract radiology company would not complete the ultrasound until Monday, [DATE]. RN 3 stated that when she spoke with resident 46 during her shift, the resident reported that he was in pain and was requesting prune juice. RN 3 stated that she did not provide resident 46 with any prune juice, because resident 46's emesis was a brown color and I was trying to determine if it was brown because of blood or prune juice. RN 3 stated that the resident's emesis looked like prune juice, but did not have anything that looked like coffee grounds. RN 3 stated that resident 46 repeatedly asked for prune juice because he did not feel he was having bowel movements. RN 3 stated that resident 46 had actually had a bowel movement during her shift that she observed, and stated it was huge, and yellowy brown in color and didn't look like it had blood in it. RN 3 stated that she had spoken with LPN 3, who was also working that day, about resident 46's vomiting. RN 3 stated that LPN 3 told her that she should notify the physician, but RN 3 told LPN 3 that RN 5 had already contacted the physician, so LPN 3 told RN 3 to wait and see what the doctor wants to do. RN 3 stated that she texted the physcian during her shift because resident 46 had vomited during the evening of [DATE] and night shift hadn't cleaned him up well so he had gotten red on that left side. RN 3 stated that she did not notify the physician about the resident vomiting, only the redness on the resident's skin. RN 3 stated that the physician's response was we will keep an eye on it, and did not provide any new orders. RN 3 stated that the physician did not say anything about the ultrasound. RN 3 stated that she did not realize the ultrasound order had been written as a stat order. On [DATE] at 3:15 PM, an interview was conducted with the DON. The DON stated that she was aware that resident 46 was vomiting during the last week of the resident's life, but could not recall how she received that information. The DON stated that no one had spoken to her about resident 46 and his change of condition. The DON stated that we should have at least sent him to the ER (emergency room ) to get evaluated if the stat order was written. The DON stated that they did complete 24 hour reports, but she was unable to locate any of them. On [DATE] at 11:17 AM, a telephone interview was conducted with NP 3. NP 3 stated that his first day at the facility was on [DATE], the same day he saw and evaluated resident 46 for the first time. NP 3 stated that he was unable to comment on the resident, because he could not locate the resident in the electronic health record system he was using. On [DATE] at 11:31 AM, a telephone interview was conducted with NP 2. NP 2 stated that she had visited with resident 46 on [DATE], and he was his normal self. NP 2 stated that sometime after that visit, the resident had starting vomiting, and staff had contacted the other provider who was on call the night of [DATE]. NP 2 stated she was unsure who evaluated and provided the Rocephin prescription for resident 46 on [DATE], and was unable to determine that. On [DATE] at 12:08 PM, a second interview was conducted with NP 2. NP 2 stated that she was unaware if any previous issues had occurred with the contracted radiology provider. NP 2 stated that other buildings just figure it out how to get the resident in sooner when they received an order to get a stat ultrasound. NP 2 stated she did not think the facility staff accurately communicated resident 46's change of condition to her. When asked if NP 2 was aware that resident 46 had a history of gastrointestinal bleeds, NP 2 stated, No. If I would have known that I would have sent him out to the local hospital. NP 2 stated that the facility was not uploading all of residents' information into the electronic health records, so if she was working from home on a day that the facility staff contacted her, she would not have all of the residents' information available to her. NP 2 stated that other facilities had a 24 hour nursing report to refer to, and a dedicated DON she could speak with, but that at this facility she had to speak with every nurse to obtain information about the residents. On [DATE] at 1:32 PM, a telephone interview was conducted with NP 1. NP 1 stated that she evaluated approximately 150 patients each week and did not recall if she had evaluated resident 46. NP 1 stated that her company did not document anything when an on-call provider was contacted about a specific resident. NP 1 stated that she did not recall if she had written the Rocephin prescription for resident 46 on [DATE]. NP 1 stated that she did not recall why or how she had evaluated resident 46 to diagnose him with cholecystitis. NP 1 stated that typically if she suspected a resident had cholecystitis, she would have the facility start Rocephin injections to control the infection until the ultrasound could be performed. NP 1 stated that if she wrote something as a stat order, she expected it to be done within an hour or two. NP 1 stated that she did not receive any other phone calls from the facility regarding resident 46, nor was she notified that the ultrasound could not be performed on the weekend. NP 1 stated that if the resident did not stabilize or have a reduction in symptoms after receiving the Rocephin injections, then the facility should have sent the resident out to the hospital for further evaluation. NP 1 further stated, I would have expected a phone call back to know that so I could send him out or continue to monitor his symptoms. NP 1 stated that cholecystitis typically responded well to Rocephin. NP 1 stated that had she known about resident 46's ongoing symptoms after receiving the Rocephin, she would have sent him to the hospital no question because his condition has changed. [Cross refer to F684] 50200 2. Resident 298 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, essential hypertension, benign prostatic hyperplasia without lower urinary symptoms, acute kidney failure, weakness, and anxiety disorder. Resident 298's medical record was reviewed on [DATE]. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 298 had a Brief Interview for Mental Status (BIMS) score of 13. A BIMS score of 13 to 15 would suggest intact cognition. A review of resident 298's paper medical chart revealed an order dated [DATE], for a right lower extremity ultrasound to rule out a DVT [deep vein thrombosis]. A review of resident 298's progress notes revealed: a. On [DATE] at 3:22 PM, a health status noted documented, PT [patient] APPT [appointment] C [with] MDR [medical doctor] WAS CANCELLED PER ADMIN [administration] HIS RLE [right lower extremity] IS QUITE A BIT BIGGER THAN PRIOR TO RECENT HOSPITAL STAY. ,D [sic] WAS INT [sic] TO SEE PT AND HE ORDERED THAT HE SEES HIA [sic] ORTHO [orthopedic doctor] ASAP [as soon as possible] AND A U/S [ultrasound] TO RLE TO R/O [rule out] DVT SO THIS RN [registered nurse] CALLED TO SET UP MOBILE EXAM WHEN I DID THE [sic] SAID IT WOULD BE DONE UNTIL [DATE]TH WHICH THAT IS THE [NAME] [sic] DAY THT [sic] HIS APPT WAS RESCHEDULED FOR SO I BUT IT THE MD PHONE THIS INFO MAYBE HE WANTED US TO TAKE PT INTO HOSPITAL FOR EXAM. PT IS ALERT ORIENTED TO TIME AND ABLE TO FEED SELF. ABX [antibiotics] GIVEN AS PER 0RDER [sic] INCISION IS CLEAN DRY ANDEDGES [sic] ARE WELL AOPROXAMATED [sic]. WCTM [will continue to monitor] b. On [DATE] at 4:22 PM, a health status note documented, [name redacted] in for US of RLE. Patient was out on an appointment and I told [name redacted] that they made the appoinment [sic] in the afternoon as he had am [sic] appointments. The rep for [name redacted] took the number and said she would call back and come back if he was available. I told her that it had to be done. No calls were returned from [name redacted]. c. On [DATE] at 11:08 AM, a health status note documented, [name redacted] came in to do an US to residents RLE. RESULTS: Thrombus in common femoral. Femoral veins pros[proximal] and dist [distal], popliteal and posterior tibial veins with minimal flow. Veins non compressible. IMPRESSION: RLE DVT MD [medical doctor] notified immediately. d. On [DATE] at 11:30 AM, a health status note documented, MD called and orders to send to ER [emergency room ] for tx [treatment] of DVT. On [DATE] at 12:23 PM, an interview was conducted with NP 2. NP 2 stated she saw him on the 14th [ [DATE]] and his right leg was hurting and an ultrasound was ordered to rule out a DVT. We usually did a stat [immediately] order to rule out. NP 2 stated with the seriousness of the DVT she would 100% order STAT. On [DATE] at 1:03 PM, a follow up telephone interview was conducted with NP 2. NP 2 stated that she expected the facility to watch the leg and to get the ultrasound done as soon as possible. NP 2 stated resident 298 should have automatically been put on a blood thinner after he had femur surgery. NP 2 stated they were not advised by the facility that he was not on a blood thinner. NP 2 stated she was unsure if the facility had a policy regarding residents who had a suspected DVT, but

Based on interview, observation and record review, the facility did not ensure that policies were established and implemented to ensure that identified quality deficiencies were corrected. Specifically, multiple areas of immediate jeopardy and harm were identified. In addition, multiple areas of non compliance were cited on the previous survey and again during the current recertification survey. Resident identifiers: 46 and 298. Findings include: 1. Based on interview and record review, the facility did not ensure that 2 of 30 sample residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, ongoing monitoring for changes in condition were not provided after one resident experienced ongoing emesis and abdominal pain, and a second resident had a deep vein thrombosis. The findings for resident 46 were determined to have resulted in immediate jeopardy for resident 46. Resident identifiers: 46 and 298. [Cross refer to F684] 2. Based on observation, interview, and record review, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents and the resident environment did not remain as free of accident hazards as was possible. Specifically, for 1 out of 30 sampled residents, a resident was not provided adequate supervision and interventions to reduce hazards and risks that resulted in an acute complete femoral neck fracture with partial displacement. Resident identifiers: 298. [Cross refer to F689] 3. Based on interview and record review, the facility did not ensure for 2 of 30 sample residents that radiology and other diagnostic services were provided to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. Specifically, residents were not provided with ultrasounds as ordered by the physician. This resulted in a finding of Immediate Jeopardy for resident 46. Resident identifiers: 46 and 298. [Cross refer to F776] 4. Based on interview and record review, the facility did not ensure that pain management was provided to residents who required such services. Specifically, for 1 out of 30 sampled residents, a resident with an acute complete femoral neck fracture was not provided pain management prior to being discharged to the hospital. Resident identifiers: 298. [Cross refer to F697] 5. In addition, during the October 2022 recertification survey, the facility was cited F550, F580, F584, F609, F610, F641, F656, F684, F689, F692, F697, F755, F760, F761, F773, F812, F835, F840, F842, F867, F880, F882, and F923 among other areas of non-compliance. These same areas were again identified during the current recertificaiton survey.

Based on observation, interview, and record review, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents and the resident environment did not remain as free of accident hazards as was possible. Specifically, for 1 out of 30 sampled residents, a resident was not provided adequate supervision and interventions to reduce hazards and risks that resulted in an acute complete femoral neck fracture with partial displacement. Resident identifiers: 298. Findings included: 1. Resident 298 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, dementia, essential hypertension, acute kidney failure, and anxiety disorder. Resident 298's medical record was reviewed on 8/7/24. A Baseline Care Plan signed by the Director of Nursing (DON) on 3/28/24, documented that resident 298 did not have a history of falls and a Fall Management Care Plan was not implemented. On 3/29/24, a Morse Fall Scale documented that resident 298 was a High Risk for Falling with a score of 50. A resident was considered a High Risk with a score of 45 and higher. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 298 had a Brief Interview for Mental Status (BIMS) score of 13. A BIMS score of 13 to 15 would indicate intact cognition. The Care Area Assessment Summary of the MDS documented that falls had triggered to be care planned. On 4/11/24 at 8:29 AM, a Fall Incident Report documented Staff radio nurse, to report resident fell . Nurse knocked and entered res [resident] room. Staff reported fall was witnessed. Res was assessed, res cognitive to baseline, A&O [alert and oriented] x2, name and situation. PERRLA [pupils are equal, round, and reactive to light and accommodation] WNL [within normal limits], ROM [range of motion] completed without difficulty, res assisted into bed. Res was painful r/t [related to] skin tear to R [right] elbow., res had a reddened area R lateral side just below hair line. Staff reported that redness to forehead was there earlier before the fall. Res had a large skin tear to R elbow, wound Tx [treatment] provided, affected area was cleansed with wound cleaner, pat dry. using steri strips tear was close and approximated well. Bacitracin applied, covered with non-adherent dressing, and wrapped. Neuro's [neurological's] started per protocol. MD [Medical Director], family notified via voicemail, and DON 04/12/2023. Res stated his feet fell out from under him and he fell to the ground. Res stated he hit head and touched over red area to R side of forehead. [Note: Neuro's were unable to be located.] A care plan Focus initiated on 4/12/24, documented The resident has had an actual fall with minor injury d/t [due to] Hypotension and Unsteady gait. The interventions included: a. Anticipate patients needs and monitor for unsteady balance. Date Initiated 4/11/24. b. Continue interventions on the at-risk plan. Date initiated 4/12/24. [Note: The at-risk plan was unable to be located.] On 5/18/24 at 3:59 AM, a Health Status Note documented Note Text: Resident fell in his room about 1900 [7:00 PM]. It was an unwitnessed fall lost his balance and went down on his left side. Able to move all his extremities without pain. A small red mark was found on his left back shoulder. He was too weak to get up on his own. Three maximum assist to left [sic] him onto his lounge chair. Vital signs taken and T [temperature] 98.0, P [pulse] 64, R [respirations] 28 B/P [blood pressure] 96/56 and 02 [oxygen] sats [saturations] 92% on room air. MD notified of low B/P and fall at 2238 [10:38 PM]. Administrator and DON notified at 0345 [3:45 AM] and 0348 [3:48 AM] this morning. Morning nurse to be notified in am and family. Neuro checks and VS [vital signs] doing well no changes. [Note: No new interventions were implemented to prevent falls after the fall 5/18/24.] On 5/19/24 at 9:00 AM, an Incident Follow up documented Date of Incident: 5/19/2024 Type of Incident: Fall Root Cause: Unsteady gait Treatment Required: None Interventions put into place: Neuros, call light given to resident, rounds every 15 minutes Referrals Made: None. [Note: No new interventions were implemented to prevent falls after the fall on 5/19/24. An assessment after the fall was unable to be located.] On 5/19/24 at 11:00 PM, an encounter documented Date of Service: 05/20/2024 Visit Type: Acute Transition of Care: No transition occurred. Progress Note . Chief Complaint / Nature of Presenting Problem: Fall History Of Present Illness: Patient is a [AGE] year-old male with a past medical history significant for Alzheimer's dementia. He was previously a resident at the [name redacted] and was admitted here one month ago. He has tried to escape multiple times and constantly packs his things to leave. He often waits by the locked door of the unit to leave. Today CNA [Certified Nursing Assistant] reported that patient had 2 falls over the weekend. Denied hitting his head. Patient reports that he is fine. He denied any uncontrolled pain. He denied any issues or concerns. The Nurse Practitioner (NP) signed the note on 5/20/24 at 8:39 AM. On 5/19/24 at 4:45 PM, a Fall Incident Report documented . Client had an unobserved fall out of dining room chair. Client pulled tablecloth halfway off. When CNA walked into dining room to check on clients, other residents were helping client off of floor. Client stated 'I feel. I am okay.' Client was put on neuros and observed every 15 minutes. [Note: No new interventions were implemented to prevent falls after the second fall on 5/19/24.] On 5/20/24 at 2:50 PM, an Orders - General Note from electronic record (eRecord) documented Note Text: CNA comes to nurse and stated resident had an assisted fall and was lowered to ground after being toileted. He lost his balance and she grabbed him and lowered him. Both South and North nurse in to assist resident and transfer him to his w/c [wheel chair]. He did not appear to be in pain but rather confused. He sustained a small r elbow tear to his arm from the w/c during transfer. Cleaned and dressed. He then rested quietly throughout the rest of the shift. [Note: No new interventions were implemented to prevent falls after the fall on 5/20/24.] On 5/20/24 at 11:00 PM, an encounter documented Date of Service: 05/21/2024 Visit Type: Acute Transition of Care: No transition occurred. Progress Note . Chief Complaint / Nature of Presenting Problem: Right hip pain History Of Present Illness: [Resident 298] is a [AGE] year-old long-term care resident here at [name redacted]. Per the nurses report he has had a couple of falls over the weekend. He was evaluated yesterday but denied any significant pain. It is unclear if he had another fall since yesterday's evaluation but currently he has complaints of right hip pain. He has been unable to stand. Most of his pain is localized to the anterior and lateral right hip. General: Elderly male in mild distress. Does appear confused which is his baseline Musculoskeletal: Patient does have tenderness to palpation over the right hip laterally anteriorly. He does have pain with internal and external rotation of the right hip. This localizes anteriorly. Acute right hip pain Patient's right hip pain appears to be acute and it is unclear whether this is related to a fall over the weekend or a new fall today. Given his acute right hip pain and evaluation today I do recommend x-rays of the right hip stat [immediately]. These were ordered today. Plan to follow-up after x-rays. Fall On fall precautions. The MD signed the note on 5/21/24 at 11:17 AM. On 5/21/24 at 11:40 AM, a Health Status Note documented Note Text: NEW ORDER: Pt [patient] is not bearing any wt [weight] on rt [right] leg has a lg [large] skin tear on rt elbow. md notified ordered a xray it has been ordered and they stated it wil [sic[ be done today. pt had a shr [shower] today. On 5/21/24, the Diagnostics report documented . Right hip, 2 views Comparison: None. Findings: There is an acute complete femoral neck fracture with partial displacement compatible with a Garden Classification III fracture. IMPRESSION: 1. Garden classification III acute femoral neck fracture. The diagnostics report was signed by the diagnostics radiologist on 5/21/24 at 6:23 PM. On 5/22/24 at 2:51 AM, a Health Status Note documented Note Text: Follow up on res x-ray: Impressions noted; There is an acute complete femoral neck Fx [fracture] with partial displacement compatible with a Garden class III. Mild degree of osteopenia. Moderate osteoarthritis. X-ray results sent to MD, response pending. WCTM [will continue to monitor]. On 5/22/24 at 5:30 AM, a Health Status Note documented Note Text: Staff reported res, has been up all night did not sleep a wink, trying to wiggle his way out of bed. Staff has continuously throughout shift had to re center res into bed and remind resident that he, could not walk d/t broken femur. will pass on to upcoming shift nurse for monitoring and follow-up. On 5/22/24 at 6:54 AM, an Orders - General Note from eRecord documented Note Text: MD notified of results of Xray and new order for resident to be sent to ER [emergency room ] for eval/tx [evaluation and treatment]. Preparing paperwork. On 5/22/24 at 3:01 PM, a Health Status Note documented Note Text: Received call from [hospital name redacted]. They will do surgergy [sic] this afternoon and resident to be admitted to med [medical] surg [surgical] floor. On 8/7/24 at 12:23 PM, an interview was conducted with NP 2. NP 2 stated she saw resident 298 because he had a fall. NP 2 stated that resident 298 was walking around pushing his recliner around and had no pain. NP 2 stated the MD came in the next day and said that resident 298 had a broken femur. NP 2 stated that she did not do a full hip exam because resident 298 was moving fine. NP 2 stated that she did not expect a break. NP 2 stated that the MD sent resident 298 out and resident 298 did have a break. On 8/8/24 at 11:50 AM, an interview was conducted with the DON. The DON stated that resident 298 had an unwitnessed fall on 5/18/24 at about 3:00 AM. The DON stated that resident 298 had another fall on 5/19/24 at 9:00 AM. The DON stated the fall on 5/20/24, was an assisted fall at 3:00 PM. The DON stated at that time herself and the CNA lowered resident 298 to the floor and the DON stated that she did not notice anything. The DON stated that the NP saw resident 298 the morning of 5/21/24, and noted we need an xray. The DON stated that resident 298 somehow had a shower during that time on 5/21/24. The DON stated the facility called the x-ray company at 11:34 AM, and they arrived at the facility at 5:41 PM, to do the x-ray on 5/21/24. The DON stated at 6:23 PM, the x-ray company either faxed the results or notified the facility of the results. The DON stated that the nurse on 5/22/24, made a progress note that results were pending from the doctor. The DON stated at the end of the shift the nurse made a note that resident 298 was up all night and passed the information to the oncoming nurse which was the DON. The DON stated at 6:55 AM, she notified the doctor and resident 298 was sent out to the hospital. On 8/14/24 at 7:29 AM, an interview was conducted with CNA 3. CNA 3 stated that if a resident was a fall risk the resident would have something on there door like a color indicating if they were a fall risk or a runaway risk. CNA 3 stated that she started at the facility in May or June 2024. CNA 3 stated that she met resident 298 after her second day and resident 298 had fallen and broken his femur. CNA 3 stated resident 298 would try and roll out of bed or get up. CNA 3 stated there were interventions after the fracture to keep resident 298 in bed and resident 298 had a wedge pillow. CNA 3 stated that resident 298 would try and get up even though he had a broken femur. CNA 3 stated that she would get in report if a resident was a fall risk. CNA 3 stated that she did not know if there was a kardex for residents or where to see interventions. CNA 3 stated that 15 minute checks were done with neuros. CNA 3 stated that 15 minute checks we done for the first hour, then 30 minute checks, then 45 minute checks, and then every hour for three days. CNA 3 stated the nurse had a form at the nurses station that the CNAs would document the neuro checks. CNA 3 stated that neuros were done after every fall. CNA 3 stated if a resident had an intervention to anticipate needs she would observe what the resident was like and what the resident needed. CNA 3 stated if the resident was cold then she would get them a blanket, if the resident was dirty she would give them a shower regardless if it was the residents shower day. On 8/14/24 at 7:39 AM, an interview was conducted with the DON. The State Survey Agency (SSA) Lead Licensor asked the DON what an At Risk Plan was and how was that a fall care plan intervention. The DON stated why was that there and that should not be there. The DON stated that was assuming that the nurses knew what the at risk plan was for the resident. The DON stated that she had no idea why that was on the care plan. The DON stated to her an at risk plan was why the resident fell . The DON stated the at risk plan did not tell her anything if that was on the care plan as an intervention. The DON stated where did they get that. The DON stated the facility used to have a form that was stapled to the incident form and would document why the resident was falling and would go more in depth. The DON stated that she would not recommend the at risk plan as an intervention because you need to fix the problem. The DON stated the at risk told the staff nothing. The SSA Lead Licensor asked the DON what the intervention 15 minute checks meant. The DON stated that 15 minute checks meant neuros and vital signs every 15 minutes. The DON stated that neuros were conducted with an unwitnessed fall. The DON stated that 15 minute checks were done in four sets. The DON stated that anticipate needs meant that the resident was a high fall risk and the staff need to have eyes more on the resident. The DON stated to have eyes more on the resident meant to make sure staff were watching the resident and a little bit more eyes on the resident. The DON stated it was impossible to do a one on one in the facility. The DON stated that all the nurses should be doing the care plans. The DON stated that interventions could be customized. The DON stated that staff needed to find out why the fall happened and if the fall fell into any of the categories on the computer then great if not the intervention could be customized. On 8/14/24 at 8:42 AM, a follow up interview was conducted with the DON. The SSA Lead Licensor asked the DON if she had details regarding resident 298's fracture. The DON stated that resident 298 was not in any pain that day and had no signs of a fracture. The DON stated the CNA was getting resident 298 ready to toilet and the DON went in to assist and resident 298 was lowered to the ground. The DON stated that she had been told if the fall was assisted she did not have to do a fall. The DON stated there may have been a fall the next day also but she was not sure. The DON stated that neuro checks were only done if the resident hit their head. The DON stated that she usually kept the neuro checks and she had record of them.

Based on interview and record review, the facility did not ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. Specifically, for 1 out of 30 sampled residents, a resident was not provided their ordered nutritional supplement shake and the resident had weight loss. Resident identifier: 298. Findings included: Resident 298 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia, essential hypertension, benign prostatic hyperplasia without lower urinary symptoms, acute kidney failure, weakness, and anxiety disorder. Resident 298's medical record was reviewed on 8/7/24. An admission Minimum Data Set assessment date 4/10/24, documented that resident 298 had a Brief Interview for Mental Status (BIMS) score of 13. A BIMS score of 13 to 15 would suggest intact cognition. A care plan Focus addressing nutrition initiated on 4/12/24, documented New resident with potential nutrition defects r/t [related to] : advanced age, dementia. The interventions included: a. Diet order: Regular, regular, thins b. Supplements/snacks as ordered A review of resident 298's electronic medical record documented the following weights for resident 298: a. 165.2 pounds on 3/28/24. b. 163.6 pounds on 3/31/24. c. 166.8 pounds on 4/7/24. d. 199.8 pounds on 4/8/24. e. 168.6 pounds on 5/10/24. f. 167.0 pounds on 5/27/24. g. 156.6 pounds on 6/2/24. h. 140.3 pounds on 7/11/24. From 6/2/24 to 7/11/24, resident 298 had a 10.41% loss of weight. It was to be noted, no revisions to the care plan were made to address the weight loss. A review of resident 298's paper medical chart revealed the following dietary orders: a. Mighty shakes three times a day (TID) with]meals. Order date 5/31/24. b. Fortify diet. Order date 6/14/24. c. Fortify diet. Add mighty shakes TID with meals. Order date 6/28/24. A review of resident 298's electronic medical record revealed the following orders: a. REGULAR diet MECHANICAL SOFT texture, Regular consistency, Mechanical Soft Fortified. Start date 6/15/24. b. REGULAR diet MECHANICAL SOFT texture, Regular consistency, Add mighty shakes TID with meals for Fortified diet related to post hip surgery replacement. Start date 6/29/24. On 6/28/24, a physician progress note documented, Malnutrition, unspecified type. Patient has had a decrease in weight by 9.1% of entire body weight. He weighed 156.6 pounds on 6/16/24 and his most recent weight on 6/23/24 was 143.2 pounds. I am concerned about patient's rapid weight loss and believe that he is experiencing malnutrition. Dietitian in to eval [evaluate] and treat. Push for increase if daily nutritional PO [oral] intake. On 8/7/24 at 1:42 PM, an interview was conducted via text messaging with the Registered Dietitian (RD). The RD texted that resident 298 had a fortified diet ordered and health shakes to help with his weight loss. The RD texted that the facility had a weekly weight list and weekly meetings to discuss residents that had weight loss. On 8/8/24 at 10:45 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the residents received the mighty shakes with the medication pass three times a day. The DON stated that the order for mighty shakes was located on the Medication Administration Record (MAR). The DON stated that it was checked off in the MAR when the resident received their mighty shake. The DON stated that the facility did not record the amount of mighty shake consumed by the residents. A review of resident 298's MAR revealed that resident 298 did not receive mighty shakes from 6/1/24 to 7/12/24.

Based on interview and record review, the facility did not ensure that pain management was provided to residents who required such services. Specifically, for 1 out of 30 sampled residents, a resident with an acute complete femoral neck fracture was not provided pain management prior to being discharged to the hospital. Resident identifiers: 298. Findings included: Resident 298 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, dementia, essential hypertension, acute kidney failure, and anxiety disorder. Resident 298's medical record was reviewed on 8/7/24. A care plan Focus initiate on 3/29/24, documented Resident has pain related to general body aches. The Goal included Resident will suffer no unrelieved episodes of pain during facility stay. The interventions initiated on 3/29/24, included: a. Assess intensity of pain using pain scale. b. Assess type, duration, and frequency of pain. c. Discuss with resident effective and ineffective measures. d. Encourage verbalization of feelings about the pain. e. Medications as ordered. An admission Minimum Data Set assessment dated [DATE], documented that resident 298 had a Brief Interview for Mental Status (BIMS) score of 13. A BIMS score of 13 to 15 would indicate intact cognition. On 4/11/24 at 8:29 AM, a Fall Incident Report documented Staff radio nurse, to report resident fell . Nurse knocked and entered res [resident] room. Staff reported fall was witnessed. Res was assessed, res cognitive to baseline, A&O [alert and oriented] x2, name and situation. PERRLA [pupils are equal, round, and reactive to light and accommodation] WNL [within normal limits], ROM [range of motion] completed without difficulty, res assisted into bed. Res was painful r/t [related to] skin tear to R [right] elbow., res had a reddened area R lateral side just below hair line. Staff reported that redness to forehead was there earlier before the fall. Res had a large skin tear to R elbow, wound Tx [treatment] provided, affected area was cleansed with wound cleaner, pat dry. using steri strips tear was close and approximated well. Bacitracin applied, covered with non-adherent dressing, and wrapped. Neuro's [neurological's] started per protocol. MD [Medical Director], family notified via voicemail, and DON [Director of Nursing] 04/12/2023. Res stated his feet fell out from under him and he fell to the ground. Res stated he hit head and touched over red area to R side of forehead. On 5/18/24 at 3:59 AM, a Health Status Note documented Note Text: Resident fell in his room about 1900 [7:00 PM]. It was an unwitnessed fall lost his balance and went down on his left side. Able to move all his extremities without pain. A small red mark was found on his left back shoulder. He was too weak to get up on his own. Three maximum assist to left [sic] him onto his lounge chair. Vital signs taken and T [temperature] 98.0, P [pulse] 64, R [respirations] 28 B/P [blood pressure] 96/56 and 02 [oxygen] sats [saturations] 92% on room air. MD notified of low B/P and fall at 2238 [10:38 PM]. Administrator and DON notified at 0345 [3:45 AM] and 0348 [3:48 AM] this morning. Morning nurse to be notified in am and family. Neuro checks and VS [vital signs] doing well no changes. On 5/19/24 at 9:00 AM, an Incident Follow up documented Date of Incident: 5/19/2024 Type of Incident: Fall Root Cause: Unsteady gait Treatment Required: None Interventions put into place: Neuros, call light given to resident, rounds every 15 minutes Referrals Made: None. On 5/19/24 at 11:00 PM, an encounter documented Date of Service: 05/20/2024 Visit Type: Acute Transition of Care: No transition occurred. Progress Note . Chief Complaint / Nature of Presenting Problem: Fall History Of Present Illness: Patient is a [AGE] year-old male with a past medical history significant for Alzheimer's dementia. He was previously a resident at the [name redacted] and was admitted here one month ago. He has tried to escape multiple times and constantly packs his things to leave. He often waits by the locked door of the unit to leave. Today CNA [Certified Nursing Assistant] reported that patient had 2 falls over the weekend. Denied hitting his head. Patient reports that he is fine. He denied any uncontrolled pain. He denied any issues or concerns. The Nurse Practitioner (NP) signed the note on 5/20/24 at 8:39 AM. On 5/19/24 at 4:45 PM, a Fall Incident Report documented . Client had an unobserved fall out of dining room chair. Client pulled tablecloth halfway off. When CNA walked into dining room to check on clients, other residents were helping client off of floor. Client stated 'I feel. I am okay.' Client was put on neuros and observed every 15 minutes. On 5/20/24 at 2:50 PM, an Orders - General Note from electronic record (eRecord) documented Note Text: CNA comes to nurse and stated resident had an assisted fall and was lowered to ground after being toileted. He lost his balance and she grabbed him and lowered him. Both South and North nurse in to assist resident and transfer him to his w/c [wheel chair]. He did not appear to be in pain but rather confused. He sustained a small r elbow tear to his arm from the w/c during transfer. Cleaned and dressed. He then rested quietly throughout the rest of the shift. On 5/20/24 at 11:00 PM, an encounter documented Date of Service: 05/21/2024 Visit Type: Acute Transition of Care: No transition occurred. Progress Note . Chief Complaint / Nature of Presenting Problem: Right hip pain History Of Present Illness: [Resident 298] is a [AGE] year-old long-term care resident here at [name redacted]. Per the nurses report he has had a couple of falls over the weekend. He was evaluated yesterday but denied any significant pain. It is unclear if he had another fall since yesterday's evaluation but currently he has complaints of right hip pain. He has been unable to stand. Most of his pain is localized to the anterior and lateral right hip. General: Elderly male in mild distress. Does appear confused which is his baseline Musculoskeletal: Patient does have tenderness to palpation over the right hip laterally anteriorly. He does have pain with internal and external rotation of the right hip. This localizes anteriorly. Acute right hip pain Patient's right hip pain appears to be acute and it is unclear whether this is related to a fall over the weekend or a new fall today. Given his acute right hip pain and evaluation today I do recommend x-rays of the right hip stat [immediately]. These were ordered today. Plan to follow-up after x-rays. Fall On fall precautions. The MD signed the note on 5/21/24 at 11:17 AM. On 5/21/24 at 11:40 AM, a Health Status Note documented Note Text: NEW ORDER: Pt [patient] is not bearing any wt [weight] on rt [right] leg has a lg [large] skin tear on rt elbow. md notified ordered a xray it has been ordered and they stated it wil [sic[ be done today. pt had a shr [shower] today. On 5/21/24, the Diagnostics report documented . Right hip, 2 views Comparison: None. Findings: There is an acute complete femoral neck fracture with partial displacement compatible with a Garden Classification III fracture. IMPRESSION: 1. Garden classification III acute femoral neck fracture. The diagnostics report was signed by the diagnostics radiologist on 5/21/24 at 6:23 PM. On 5/22/24 at 2:51 AM, a Health Status Note documented Note Text: Follow up on res x-ray: Impressions noted; There is an acute complete femoral neck Fx [fracture] with partial displacement compatible with a Garden class III. Mild degree of osteopenia. Moderate osteoarthritis. X-ray results sent to MD, response pending. WCTM [will continue to monitor]. On 5/22/24 at 5:30 AM, a Health Status Note documented Note Text: Staff reported res, has been up all night did not sleep a wink, trying to wiggle his way out of bed. Staff has continuously throughout shift had to re center res into bed and remind resident that he, could not walk d/t broken femur. will pass on to upcoming shift nurse for monitoring and follow-up. On 5/22/24 at 6:54 AM, an Orders - General Note from eRecord documented Note Text: MD notified of results of Xray and new order for resident to be sent to ER [emergency room ] for eval/tx [evaluation and treatment]. Preparing paperwork. On 5/22/24 at 3:01 PM, a Health Status Note documented Note Text: Received call from [hospital name redacted]. They will do surgergy [sic] this afternoon and resident to be admitted to med [medical] surg [surgical] floor. The May 2024 Medication Administration Record was reviewed. A physician's order dated 3/28/24, documented PAIN SCALE ASSESS PAIN BID [twice daily] USING VERBAL SCALE (0-10) every day and night shift. Resident 298 had no reported pain until 5/20/24. a. On 5/20/24 at 6:00 PM, verbal scale 5. b. On 5/21/24 at 6:00 AM, verbal scale 5. c. On 5/21/24 at 6:00 PM, Face, Legs, Activity, Cry, and Consolability (FLACC) scale 7. d. On 5/22/24 at 6:00 AM, FLACC scale 7. (Note: The Order Summary Report was reviewed and resident 298 did not have any pain management medications available prior to being discharged to the hospital on 5/22/24.) On 8/5/24 at 2:10 PM, a telephone interview was conducted with Registered Nurse (RN) 5. RN 5 stated that she had identified that resident 298 was not receiving any pain medication, and that other staff did not identify the issue sooner. RN 5 stated that after she brought this to the physician's attention, the resident was prescribed Tramadol. RN 5 stated, I don't think anybody should be in pain. On 8/7/24 at 12:23 PM, an interview was conducted with NP 2. NP 2 stated she saw resident 298 because he had a fall. NP 2 stated that resident 298 was walking around pushing his recliner around and had no pain. NP 2 stated the MD came in the next day and said that resident 298 had a broken femur. NP 2 stated that she did not do a full hip exam because resident 298 was moving fine. NP 2 stated that she did not expect a break. NP 2 stated that the MD sent resident 298 out and resident 298 did have a break. On 8/8/24 at 11:50 AM, an interview was conducted with the DON. The DON stated that resident 298 had an unwitnessed fall on 5/18/24 at about 3:00 AM. The DON stated that resident 298 had another fall on 5/19/24 at 9:00 AM. The DON stated the fall on 5/20/24, was an assisted fall at 3:00 PM. The DON stated that herself and the CNA lowered resident 298 to the floor and the DON stated that she did not notice anything. The DON stated that the NP saw resident 298 the morning of 5/21/24, and noted we need an xray. The DON stated that resident 298 somehow had a shower during that time on 5/21/24. The DON stated the facility called the x-ray company at 11:34 AM, and they arrived at the facility at 5:41 PM, to do the x-ray on 5/21/24. The DON stated at 6:23 PM, the x-ray company either faxed the results or notified the facility of the results. The DON stated that the nurse on 5/22/24, made a progress note that results were pending from the doctor. The DON stated at the end of the shift the nurse made a note that resident 298 was up all night and passed the information to the oncoming nurse which was the DON. The DON stated at 6:55 AM, she notified the doctor and resident 298 was sent out to the hospital. On 8/14/24 at 8:42 AM, an interview was conducted with the DON. The State Survey Agency Lead Licensor asked the DON if she had details regarding resident 298's fracture. The DON stated that resident 298 was not in any pain that day and had no signs of a fracture. The DON stated the CNA was getting resident 298 ready to toilet and the DON went in to assist and resident 298 was lowered to the ground. The DON stated that she had been told if the fall was assisted she did not have to record it as a fall. The DON stated there may have been a fall the next day also but she was not sure. The DON stated that neuro checks were only done if the resident hit their head. The DON stated that she usually kept the neuro checks and she had record of them.

Based on observation, interview and record review it was determined, for 8 of 33 sampled residents, that in response to an allegation of abuse the facility did not report immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse. In addition, the facility did not report the results of the investigation within 5 working days of the incident and if the alleged violation was verified appropriate corrective action was taken. Specifically, the facility did not report within 2 hours when a resident was found with another resident without clothing, the resident was found without clothing, and the same resident was found being touched in the genitals by another resident. Additional, the facility did not report when two residents, who were unable to consent, were found having oral sex. This was found to have occurred at an immediate jeopardy level. In addition, a bruise was discovered on a resident and it was not reported. In addition, there was physical abuse between residents that was not reported. Resident identifiers: 9, 13, 14, 15, 26, 31, 36 and 39. Findings include: On 10/26/22 at 9:30 AM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent various forms of abuse. Notice of the IJ was given verbally to the facility Administrator (ADM). On 11/9/22 at 8:32 AM, the facility Consultant Group provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 11/9/22 at 10:00 AM: 1. Resident #26 was placed on a unit that has only male residents and placed on 1:1 supervision on 10/17/22 and remains on 1:1. Resident #31 no longer resides in the community; therefore, no individualized plan of correction is indicated. Resident #31 discharged to another community on 11/4/2022. An investigation was initiated on 11/1/22 for the alleged incident between Resident #36 and #13. Resident #26, #31, #36 and #13 were assessed by the LCSW (Licensed Clinical Social Worker) for capacity to consent to sexual intimacy on 11/1/22. 2. Residents residing in the facility were assessed for signs and symptoms of abuse by an LCSW on 11/1/22. For residents who are unable to be interviewed due to dementia, observation tools are being completed to identify any changes in mood or behavior that may be indicative of signs of past abuse. 3. Education was initiated on 11/1/22 by the consultants regarding the community abuse policy including reporting allegations of abuse to the abuse prevention coordinator, reporting allegations of abuse to the proper authorities, and conducting thorough investigations. Signs were posted throughout the facility on how to contact the Abuse Coordinator. The NHA/designee will be responsible for contacting the appropriate authorities for allegations of abuse. Each allegation will be discussed verbally with the consultants and the consultants will have access to the report to ensure that reports are submitted timely to the health department. Progress notes to be reviewed (M-F) by the DON/designee daily to ensure that any allegations of abuse are being reported per community expectations to management and to the appropriate authorities, and that allegations of abuse are thoroughly investigated. Identified concerns to be addressed immediately and investigations initiated. The Temporary Managers will provide the community with a new daily standup meeting agenda. This agenda will include an abuse reporting log to track and trend all reported allegations for the month. The community also initiated afternoon stand down meetings (Monday through Friday) to ensure follow up items from the morning meeting were completed. 4. The NHA/designee will report findings from the audits to the QAPI Committee monthly for three (3) months. The QAPI committee will identify any trends and take corrective action as needed. 5. Please accept this abatement plan of corrective action - effective 11/10/2022 at 12PM. On 11/14/22, after the completion of the survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 11/10/22. Immediate Jeopardy 1. Resident 31 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, unspecified dementia with behavioral disturbance, and depression. Resident 31's medical record was reviewed. An annual Minimum Data Set (MDS) dated [DATE] revealed resident 31 did not have a Brief Interview for Mental Status (BIMS) because she rarely/never understood. The MDS further revealed resident 31 had short and long term memory problems. The MDS revealed her cognitive skills for daily decision making was severely impaired. The MDS revealed resident 31 required extensive one person assistance with dressing. Resident 31's care plan dated 3/27/17 revealed The resident has a behavior problem of wearing multiple layers of clothing and resisting to change or remove the clothing. The goal with a target date of 5/27/22 was The resident will have fewer episodes of wearing multiple layers of clothing weekly, by review date. Interventions included Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately; Explain all procedures to the resident before starting and allow the resident 5-10 to adjust to changes; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Praise any indication of The resident's progress/improvement in behavior. Another care plan for resident 31 dated 8/25/16 revealed, The resident has a behavior problem of wearing multiple layers of clothing and resisting to change or remove the clothing The goal with a target date of 5/27/22 revealed, The resident will have fewer episodes of wearing multiple layers of clothing weekly, by review date. Interventions were Assist the resident to develop more appropriate methods of coping and interacting; Encourage the resident to express feelings appropriately; Explain all procedures to the resident before starting and allow the resident 5-10 to adjust to changes; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Praise any indication of The resident's progress/improvement in behavior. Resident 26 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, diabetes mellitus, and hypertension. Resident 26's medical record was reviewed. Resident 26's quarterly MDS dated [DATE] revealed a BIMS score of 5 which indicated severe cognitive impairment. The MDS further revealed resident 26 walked in corridor, walked in room, locomotion on the unit and locomotion off the unit required supervision and setup help only. Resident 26's care plan 8/3/21 revealed The resident has a behavior problem r/t (related to) Schizophrenia. The goal was The resident will have no evidence/decrease of behavior problems by review date. Interventions developed were Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. On 8/29/21, resident 26 was found in a room with resident 31 by a surveyor during a recertification survey. Resident 26 had his penis exposed while standing directly in front of resident 31. Resident 31 had her back to the wall. This incident was cited as part of the annual recertification survey. There were no progress notes in resident 26's or resident 31's medical record regarding the incident on 8/29/21. A nursing progress note dated 9/4/21 at 10:41 PM revealed, resident 26 was observed touching staff and other residents without consent. On 9/17/21 at 2:57 PM, the facility reported to the State Survey Agency that resident 31 had been found naked with resident 26 in a room in the memory care unit at 7:15 AM. It should be noted this allegation was reported over 8 hours after the incident occurred. A nursing progress note by Licensed Practical Nurse (LPN) 1 in resident 31's medical record revealed on 9/17/21 at 3:24 PM, Resident was found in room [ROOM NUMBER] on the bed naked with another resident (male). CNA informed me and RN and we directed male resident back to his room and resident was assessed by RN and CNA then re-dressed while I informed the Administrator at 0645 (6:45 AM), which he addressed the occurrence to proper authorities. Resident was transported to [local hospital] ER (emergency room ) to be assessed. Resident returned with order for doxycyline 100 mg one PO (by mouth) BID (twice daily) x 7 days.Incident report completed. A nursing progress note by the DON dated 9/17/21 revealed that a physician's order was received to transfer resident 26 to the emergency room for possible transfer to a mental health facility. At 4:21 PM, resident was transported to emergency room (ER) for mental health evaluation. A nursing progress note by LPN 1 in resident 26's medical record revealed on 9/17/21 at 2:59 PM, Resident was found by CNA in room [ROOM NUMBER] with another resident (Female) naked on the bed at 0645 (6:45 AM). CNA informed Me (Nurse) and Charge nurse and we directed resident to his room and informed him to stay in his room until one of us (Nursing staff) comes back. RN and CNA assessed the female resident and re-dressed her and remained with her. I Phoned Facility Administrator at time of incident and informed him of the incident. Administrator stated he will advise and report to proper authorities, I informed Administrator both individuals were separated and one on one staff until further notice. A nursing progress note dated 9/18/21 at 10:04 PM revealed, resident 26 was moved to a room outside of the locked unit. The note further revealed resident 26 frequently wandered into the rooms of female resident and was sexually inappropriate with residents and staff. Staff were to continue to monitor resident 26. A nursing progress note dated 9/25/21 at 11:06 PM revealed resident 26 had been sexually inappropriate with the female staff. Resident 26's Medication Administration Record indicated that staff were to monitor resident 26 for sexually inappropriate behaviors as of 9/25/21. Resident 26 was also started on Risperdol as of 9/26/21. A physician's progress note for resident 31 dated 10/18/21 at 12:54 PM, .On 9/17 she was found naked with a male resident on top of her. She was transported to the ER where evaluation did not reveal signs of physical trauma. A nursing progress note dated 12/4/21 at 10:18 PM revealed resident 26 was occasionally sexually inappropriate. A nursing progress note dated 1/2/22 at 1:29 AM revealed resident 26 had not harmed anyone. A nursing progress note dated 7/10/22 at 2:18 AM revealed resident 26 was discovered missing about 7:30 PM. Staff checked every room and the outside around the entire building. Police, Administrator and physician were notified. A nursing progress note dated 7/10/22 at 1:22 PM revealed police returned resident 26 at approximately 10:30 AM and a physician's order was obtained to change room to memory lane, despite his history of sexually abusing resident 31, who still resided on the memory care unit. The progress note indicated that resident 26 was happy to see his old roommate. The facility reported resident 26's elopement on 7/11/22 at 7:41 AM. The facility reported resident 26 eloped at 12:14 AM on 7/10/22. It should be noted the elopement was not reported to the State Agency for over 31 hours. Resident 26's monthly nurses assessments for the months of September 2021, October 2021, November 2021, December 2021, January 2022, April 2022, June 2022, and July 2022 documented that resident 26 had sexual behaviors but did not indicate what the behaviors were. [It should be noted that the monthly assessments for February 2022, March 2022, May 2022, August 2022, and September 2022 were not able to be located in resident 26's medical record.] A nursing medication administration note dated 8/28/22 at 1:32 PM, revealed resident 26 was seen by other resident pulling a female resident into his bathroom. he noticed he was caught and let her go. An entity report dated 8/29/22 revealed that on 8/26/22 resident 31 and resident 26 lived on the secured unit in the nursing facility. Resident 31 was often found pacing. She wanders in and out of any room and often climbed into bed when she is tired. She also immediately takes off her brief when they are wet. It is believed that she climbed into his bed. He often sleeps with just a T-shirt or naked. While CNAs were doing rounds they found them both in bed with no briefs on. The RN did checks and found no evidence of any encounter. Residents were sent to their own rooms. [Resident 26] is a client of [local mental health company] the provider is looking at adjusting medications and increased visits from case manager and LCSW. Resident 26 and 31's nursing progress notes were reviewed and there were no notes in either of the residents medical records regarding this event. A nursing progress note regarding resident 26 dated 9/4/22 at 12:16 AM revealed, has been doing about the same. We have to watch him so he doesn't coax one of the ladies into his room. On 10/1/22, resident 26 was documented as demonstrating inappropriate behavior, such as making inappropriate comments to this nurse. Resident says 'I need you tonight' 'I love women and trying to kiss on the hand. Resident was reminded of appropriate communication and that these comments are unacceptable. Resident verbalized understanding 'okay okay '. Review of resident 26's September and October 2022 Treatment Administration Record (TAR) indicated that staff had not been consistently documenting resident 26's sexual behaviors. Review of resident 26's care plan indicated that no interventions had been put into place to prevent further incidents with resident 31 after the incident on 8/26/22. An incident/accident report dated 10/5/22 at 2:15 PM, revealed resident 31 was walking through the hallway without her clothes on, CNA found resident's clothes in closet of room # 104 ? at 2:15 PM. No injuries. [It should be noted the 104 was written over another room number that was unreadable.] The additional comments and/or steps taken to prevent reoccurrence were clothes to be ordered; to remind staff that designated CNA needs to be on the unit at ALL TIMES; and ensure staff on unit. The incident report was not signed by the Medical Director or Administrator on 10/17/22 when it was reviewed. A nursing progress note dated 10/5/22 at 3:48 PM by LPN 1 revealed, Resident walking down hall on memory unit without her clothes on and other residents saw her naked. CNA's assisted resident to cloth her. CNA found resident's clothes in closet of room [ROOM NUMBER]. Resident's granddaughter witnessed the incident, and she is CNA here today this shift. I counseled the designated CNA working on memory unit and wrote action taken form and DON present during this write up. Copy of write up given to Admin '[name removed]'. NP informed as well as family. On 10/12/22, both residents were observed to resided on the memory care unit that was the locked unit of the facility. Resident 26 resided in room [ROOM NUMBER] and resident 31 resided in room [ROOM NUMBER]. On 10/12/22 an observation was made of resident 31. At 2:59 PM, resident 31 was observed to wander into the door way of room [ROOM NUMBER] and was redirected by staff. At 3:03 PM, resident 31 was wandering into room [ROOM NUMBER]. At 3:08 PM, resident 31 wandered into room [ROOM NUMBER]. On 10/11/22 at 4:10 AM, an observation was made of RN 1, CNA 6 and CNA 7 at the nurses station. The memory care unit was unattended until 4:22 AM when CNA 6 was observed to enter the unit. At 4:43 AM, CNA 6 was observed to exit the memory care unit. At 5:48 AM, CNA 6 entered the memory care unit. Resident 36 was observed to be ambulating up and down the hallway during that time. [It should be noted the memory care unit was unattended for 1 hour and 5 minutes.] On 10/22/22 at 10:40 PM, an observation was made of CNA 6, CNA 7 and RN 5 at the nurses station. The memory care unit was unattended until 10:51 PM. Resident 36 was observed wandering the hallway. At 11:19 PM, CNA 6 was observed to leave the memory care unit. At 11:25 PM, CNA 6 was observed to return to the memory care unit. At 11:56 PM, CNA 6 and CNA 7 were observed to leave the memory care unit. At 11:57 PM, RN 5 entered the memory care unit. On 10/23/22 at 12:04 AM, RN 5 was observed to leave the memory care unit and open the door to the magnet. RN 5 was observed to wheel the charts in front of the open door. Resident 36 was observed wandering the hallway. RN 5 was observed to sit behind the charts near the open door. At 12:35 AM, CNA 6 and CNA 7 were observed to enter the memory care unit. At 12:37 AM, resident 31 was observed wandering the hallway without pants, wearing only a sweatshirt and brief. Resident 36 and resident 7 were observed in the hallway. On 10/12/22 at 10:17 AM, an interview was conducted with CNA 2, who was also resident 31's family member. Resident 31's family member stated on 10/5/22 it was shift change about 2:00 PM, there were no staff members on the memory care unit. Resident 31's staff member stated that a resident was banging on the doors to get staff attention outside of the memory care unit. Resident 31's family member stated she looked in and resident 31 was walking down the hall naked with no clothes on. Resident 31's family member stated that resident 31's clothes were nowhere to be found. Resident 31's family member stated that resident 31's clothing were found in room [ROOM NUMBER]'s closet. Resident 31's family member stated resident 31 was able to take her pants down but did not take her brief off and resident 31 was not capable of placing her clothing in a closet. Resident 31's family member stated that she was upset about the incident and talked to the DON. Resident 31's family member stated that DON told her to talk to the Administrator. Resident 31's family member stated she told the Administrator but the Administrator had people in her office and she stated to the resident's family member she was busy doing payroll. Resident 31's family member stated the Administrator stated to her she needed to talk to the nurse. Resident 31's family member stated she went back to the DON and demanded that something happen. Resident 31's family member stated she was trying to report an abuse allegation. Resident 31's family member stated the DON reviewed the camera footage of the memory care unit with her. Resident 31's family member stated there was nothing on the footage because room [ROOM NUMBER] was directly below the cameras. Resident 31's family member stated all they could see was resident 31 walking in the hallway naked. Resident 31's family member stated they could not see resident 31 walk into a room and when they saw her she was in the hallway with clothing and then suddenly she was naked. Resident 31's family member stated resident 26's room was joined to room [ROOM NUMBER] through a bathroom. Resident 31's family member stated that CNA 1 was counseled about not leaving the locked unit unattended. Resident 31's family member stated she felt something was happening to resident 31 from resident 26. Resident 31's family member stated that resident 26 stated to her that resident 31 was beautiful and he loved her. Resident 31's family member stated that resident 31 wandered into other resident rooms and if there was no staff in the hallway, she will go into anyone's room. Resident 31's family member stated resident 31 would not let staff take off her pants and would say No, don't touch me dirty man. Resident 31's family member stated resident 31 was very jumpy and resident 31 was never like that before. On 10/22/22 at 11:22 AM, an interview was conducted with CNA 6. CNA 6 stated she witnessed an incident between resident 26 and resident 31 a couple of months ago. CNA 6 stated she finished changing resident 31's brief and went into another residents room and was changing another resident. CNA 6 stated when she went back to check resident 31 she was missing. CNA 6 stated she searched room to room and found resident 31's brief and pants were off and resident 26's brief and pants were pulled down to his knees. CNA 6 stated she told RN 6. CNA 6 stated that she was not questioned by the Administrator or DON regarding the incident. CNA 6 stated that resident 31 was placed on 15 minutes checks. CNA 6 stated that resident 26 continued to reside on the memory care unit after the incident. CNA 6 stated resident 26 told the nurse that he was in trouble and he knew what he did was wrong. CNA 6 stated he keeps doing it and he gets caught every time he does anything to resident 31. CNA 6 stated a CNA reported to her on evening shift that resident 26 was holding the door closed in the shower room with resident 31. CNA 6 stated another time she was told that resident 31 was in resident 26's room naked behind the curtain. CNA 6 stated that she was told to keep an eye on him. CNA 6 stated sometimes she had to leave the memory care unit unattended to make sure other residents were receiving care. [It should be noted that the incidents referenced above had not been reported to the State Survey Agency.] The incident when resident 31 and resident 26 were found in the bathroom together was not reported to the State Survey Agency. The incidents CNA 6 when resident 31 was found naked behind a curtain in resident 26's room was not reported to the State Survey Agency. On 10/17/22 at approximately 10:00 AM, an interview was conducted with the DON. The DON stated that CNA 2, who was a family member to resident 31, was upset on 10/5/22 and the DON stated she assumed the nurse had addressed it and that CNA 2 talked to the Administrator. The DON stated that CNA 2 returned from talking to the Administrator and CNA 2 told the DON she wanted something done. The DON stated that she reviewed camera footage because CNA 2 insisted to find out what happened to resident 31's clothing. The DON stated that resident 31 was in the memory care unit hallway with no clothing on. The DON stated that CNA 2 was very upset. The DON stated she was having a hard time remembering what she saw from the camera footage. The DON stated she thought resident 31 exited room [ROOM NUMBER] without clothing and did not see resident 31 enter a room because the video footage jumped 5 minutes at a time. The DON stated the memory care unit was unattended by staff for about 10 minutes. The DON stated the locked unit was supposed to have staff at all times. The DON stated she had LPN 1 complete an incident report. The DON stated she reported the incident to the Administrator immediately. The DON stated she put a care plan in for resident 31 after the incident. The DON stated that in the position she was in, she did everything she could by watching LPN 1 counsel CNA 1 about not leaving the unit. The DON stated she educated CNA's that this happens with dementia and with increasing dementia this can happen. The DON stated resident 31 was able to remove her own clothing. The DON stated she also would like the family to be involved with care planning and maybe getting resident 31 onesies that zip in the back so she was unable to remove her clothing. The DON stated after resident 31 was found naked in the hallway she assessed resident 31. The DON stated resident 31 was clothed and there was no bruising or red marks on her back. The DON stated that In my opinion, I couldn't tell if it was an abuse allegation or an incident. On 10/17/22 at 11:13 AM, an interview was conducted with CNA 1. CNA 1 stated on 10/5/22 when resident 31 was found naked in the locked unit, I was off the hall. CNA 1 stated she was waiting for the next shift to come into work. CNA 1 stated she was talking to another staff member and resident 31 was walking down the hallway with no clothes on. CNA 1 stated staff ran down the hallway to resident 31. CNA 1 stated resident 31 went into room [ROOM NUMBER] which was resident 26's room and her clothes were found in room [ROOM NUMBER]'s closet. CNA 1 stated resident 26 and his roommate were in their room when resident 31 went in. CNA 1 stated resident 31 wanders everywhere. CNA 1 stated she figured out a different system for resident 31. CNA 1 stated resident 31 was changed at 12:30 PM or 1:00 PM and then at 3:00 PM because that was when she usually had a bowel movement. CNA 1 stated there should be staff in the locked unit at all times. CNA 1 stated I was not on the hall which I take responsibility for. CNA 1 stated she was not sure if resident 31's clothing was soiled or wet when they were found. CNA 1 stated resident 31 was pacing the hallway yesterday and needed to be changed and did not take her clothing off. CNA 1 stated she was instructed by LPN 1 and the DON to stay in the memory care unit at all times and keep an eye on resident 31 and anyone that tried to bother her. CNA 1 stated other staff have told her that resident 31 takes her clothing off, but she had never seen resident 31 take her clothing off. CNA 1 stated she had found resident 31 without a brief on so she figured resident 31 removed it herself. On 10/17/22 at 2:18 PM, an interview was conducted with CNA 8. CNA 8 stated 2 or 3 weeks ago she was sitting at the desk at about 2:20 PM and was waiting for another CNA to come to the locked unit to get report. CNA 8 stated resident 9 was knocking on the door and was asking for ice. CNA 8 stated she opened the door to give resident 9 ice and saw resident 31 naked in the hallway. CNA 8 stated resident 31 was outside the dining room toward her room. CNA 8 stated she took resident 31 to her room and dressed her. CNA 8 stated CNA 2, CNA 3 and CNA 4 were at the facility. CNA 8 stated she reported to the nurse what had happened. CNA 8 stated after the incident, she was told to be in the hall and care for the residents even though she was scheduled to work another hallway. CNA 8 stated she also told the DON about the incident. CNA 8 stated the DON was mad at us because no one was in the hallway. CNA 8 stated she stayed a little bit because CNA 2 was mad and wanted to look at the cameras to see what happened. CNA 8 stated she was the first CNA to see resident 31 naked in the hallway and there were other residents in the hallway. CNA 8 stated resident 31's mind was not good, so she did not know what was happening. CNA 8 stated resident 26 knew what was happening. CNA 8 stated she did not want anything to happen to resident 31 so she puts her on the couch. CNA 8 stated a Night CNA told her that when she received report to make sure resident 26 was not close to resident 31. CNA 8 stated she did not ask why she needed to keep them apart. CNA 8 stated she had been told that resident 31 and resident 26 had been found in bed together. CNA 8 stated she would be more careful with resident 31 and not leave her alone since she knew the residents had been found in bed together. CNA 8 stated she tried not to leave her alone since then, but things happened really fast. CNA 8 stated that resident 31 was unable to remove her own clothing. CNA 8 stated resident 31 won't allow for staff to pull her pants down when she needed to be changed. CNA 8 stated resident 31 would need assistance with removing all of her clothing including her shirt. On 10/17/22 at 11:28 AM, an interview was conducted with the Administrator. The Administrator stated it was a daily occurrence that resident 31 did not have clothing on. The Administrator stated that once resident 31 was wet, she removed her bottoms. The Administrator stated that she had been trying to find things like taking her to the bathroom, so she did not remove her clothing. The Administrator stated resident 31 wandered all the time and removed her clothing wherever she wanted and continued wandering. The Administrator stated resident 31 wandered in and out of everyone's room on the locked unit. The Administrator stated resident 31 was friendly with everyone. The Administrator stated she was not sure if resident 31 was able to removed her shirt herself. The Administrator stated resident 31 could get her bottoms of fast. The Administrator stated she would not have looked into anything or questioned possible abuse with resident 31 coming out of another residents room with no clothing. The Administrator stated there were times the memory care unit was unattended by staff when staff were passing and going but staff should ask other members to cover the hallway. On 10/17/22 at 11:38 AM, an interview was conducted with Medical Director (MD). The MD stated there was an incident report dated 10/5/22 regarding resident 31 not having her clothing on in the hallway. The MD stated it was reported to her but when she reviewed the incident report, the room number on the incident report was changed. The MD stated she was informed that resident 31's clothing was found in room [ROOM NUMBER], but it was changed to room [ROOM NUMBER]. The MD stated she had not received all the details about the incident. The incident on 10/5/22 was not reported to the State Survey Agency. On 10/17/22 at 12:10 PM, a follow up interview was conducted with the MD. The MD stated she was informed by CNA 1 that resident 26 was found fondling resident 31 today. The MD stated she talked to resident 26 and he stated I need to go to jail. The MD stated resident 26 stated I was playing around with an older woman, [resident 31]. The MD stated he did not go into specifics but he said sexual stuff. On 10/17/22 at 12:21 PM, an interview was conducted with resident 26. Resident 26 was observed in the locked unit dining room. Resident 26 stated he had sex and pointed to resident 31. Resident 26 stated her name was resident 31. Resident 26 stated he needed to go to jail because she walked around with her pants down. Resident 26 stated he did not always have full sex sometimes it was him putting his penis from front to back on resident 31 like a hot dog. Resident 26 stated he had sex with her six times. On 10/17/22 at 12:22 PM, an interview was conducted with CNA 2. CNA 2 stated that at approximately 11:00 AM that day, she was assisting CNA 4 in walking resident 36 to the shower room. CNA 2 stated resident 31 was sitting on a sofa in the hallway which was near resident 26's room. CNA 2 stated she helped get resident 36 into the shower room and turned on the hot water and went back to the hallway. CNA 2 stated resident 31 was nowhere to be found. CNA 2 stated she went back to CNA 4 and stated she was unable to find resident 31. CNA 2 stated she went to resident 26's room and found resident 31 standing in front of resident 26 sitting on the toilet. CNA 2 stated resident 31's pants were down and resident 26 had a couple fingers inside of resident 31's vagina. CNA 2 stated she told resident 26 you do not do that. CNA 2 stated she pulled up resident 31's pants and lead her out of the bathroom and yelled for CNA 4 to report it to the DON. CNA 2 stated she was being written up by management because of the incident for leaving resident 31 unattended. A nursing progress note from resident 26's medical record dated 10/17/22 at 11:30 AM by the DON revealed, Report from CNA about incident on Memory Lane where resident was in bathroom with a male resident with her pants down. Upon arriving to scene, resident had her pants up and walking in hallway. Took resident to her room with a CNA and did a physical assessment. No bruising, contusions noted to peri area. While removing brief, resident had a soiled brief. MD notified immediately, after reports by CNA family notified [TRUNCATED]

Based on observation, interview and record review it was determined, for 8 of 33 sampled residents, that in response to allegation of abuse, the facility did not have evidence that all all leeged violation were thoroughly investigated and reported to the State Survey Agency within 5 days of the incident, and if the alleged violations were verified appropriate corrective action was taken. Specifically, there were no thorough investigations when a severly impared cognitive resident was sexually abused by a resident that was cognitively intact and when two residents were not assessed for ablitiy to consent, engaged in oral sex. These example were cited at an Immediate Jeopary level. In addition, the facility did not thoroughly investigate when a resident eloped from the facility, a resident had a bruise of unknown source and residents had a physical altercation. These examples were cited at a potiential for harm. Resident identifiers: 9, 13, 14, 15, 26, 31, 36 and 39. Findings include: On 10/26/22 at 9:30 AM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent various forms of abuse. Notice of the IJ was given verbally to the facility Administrator (ADM). On 11/9/22 at 8:32 AM, the facility Consultant Group provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 11/9/22 at 10:00 AM: 1.Resident #26 was placed on a unit that has only male residents and placed on 1:1 supervision on 10/17/22 and remains on 1:1. Resident #31 no longer resides in the community; therefore, no individualized plan of correction is indicated. Resident #31 discharged to another community on 11/4/2022. An investigation was initiated on 11/1/22 for the alleged incident between Resident #36 and #13. Neither resident recall the incident. Resident #26, #31, #36 and #13 were assessed for capacity to consent to sexual intimacy by the LCSW. 2. Residents residing in the facility were assessed for signs and symptoms of abuse by an LCSW on 11/1/22. For residents who are unable to be interviewed due to dementia, observation tools are being completed to identify any changes in mood or behavior that may be indicative of signs of past abuse. 3. Education was initiated on 11/1/22 by the consultants regarding the community abuse policy including reporting allegations of abuse to the abuse prevention coordinator, reporting allegations of abuse to the proper authorities, and conducting thorough investigations. Thorough investigations to include immediate protection of the residents, interviewing the alleged victim, alleged assailant, any witnesses, other residents who could potentially be affected by the alleged violation, family/visitors if there are any who may have pertinent information, conducting an assessment of the alleged victim, conducting observations of cares if pertinent, conducting searches if necessary, and implementing pertinent interventions to attempt to prevent recurrence. NHA/designee will be responsible for contacting the appropriate authorities for allegations of abuse. Each allegation will be discussed verbally with the Temporary Managers and the Temporary Managers will have access to the report to ensure that reports are submitted timely to the health department. NHA/designee to complete review three(3) abuse allegations a week for three (3) months to ensure that the investigation was thorough, that there were interventions implemented to correct the alleged violations, and that there was protection of the alleged victim while the investigation was ongoing. The Temporary Managers will provide the community with a new daily standup meeting agenda. This agenda will include an abuse reporting log to track and trend all reported allegations for the month. The community also initiated afternoon stand down meetings (Monday through Friday) to ensure follow up items from the morning meeting were completed. 4. The NHA/designee will report findings from the audits to the QAPI Committee monthly for three (3) months. The QAPI committee will identify any trends and take corrective action as needed. 5. Please accept this abatement plan of corrective action - effective 11/10/2022 at 12PM. On 11/14/22, after the completion of the survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 11/10/22. Immediate Jeopardy: 1. Resident 31 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, unspecified dementia with behavioral disturbance, and depression. Resident 31's medical record was reviewed. An annual Minimum Data Set (MDS) dated [DATE] revealed resident 31 did not have a Brief Interview for Mental Status (BIMS) because she rarely/never understood. The MDS further revealed resident 31 had short and long term memory problems. The MDS revealed her cognitive skills for daily decision making were severely impaired. The MDS revealed resident 31 required extensive one person assistance with dressing. Resident 31's care plan dated 3/27/17 revealed The resident has a behavior problem of wearing multiple layers of clothing and resisting to change or remove the clothing. The goal with a target date of 5/27/22 was The resident will have fewer episodes of wearing multiple layers of clothing weekly, by review date. Interventions included Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately; Explain all procedures to the resident before starting and allow the resident 5-10 (minutes) to adjust to changes; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Praise any indication of The resident's progress/improvement in behavior. Another care plan for resident 31 dated 8/25/16 revealed, The resident has a behavior problem of wearing multiple layers of clothing and resisting to change or remove the clothing The goal with a target date of 5/27/22 revealed, The resident will have fewer episodes of wearing multiple layers of clothing weekly, by review date. Interventions were Assist the resident to develop more appropriate methods of coping and interacting; Encourage the resident to express feelings appropriately; Explain all procedures to the resident before starting and allow the resident 5-10 (minutes) to adjust to changes; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Praise any indication of The resident's progress/improvement in behavior. Resident 26 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, diabetes mellitus, and hypertension. Resident 26's medical record was reviewed. Resident 26's quarterly MDS dated [DATE] revealed a BIMS score of 5 which indicated severe cognitive impairment. The MDS further revealed resident 26 walked in corridor, walked in room, locomotion on the unit and locomotion off the unit required supervision and setup help only. Resident 26's care plan 8/3/21 revealed The resident has a behavior problem r/t (related to) Schizophrenia. The goal was The resident will have no evidence/decrease of behavior problems by review date. Interventions developed were Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. On 8/29/21, resident 26 was found in a room with resident 31 by a surveyor during a recertification survey. Resident 26 had his penis exposed while standing directly in front of resident 31. Resident 31 had her back to the wall. This incident was cited as part of the annual recertification survey. There were no progress notes in resident 26's or resident 31's medical record regarding the incident on 8/29/21. A nursing progress note dated 9/4/21 at 10:41 PM revealed, resident 26 was observed touching staff and other residents without consent. On 9/17/21 at 2:57 PM, the facility reported to the State Survey Agency that resident 31 had been found naked with resident 26 in a room in the memory care unit at 7:15 AM. A nursing progress note by Licensed Practical Nurse (LPN) 1 in resident 31's medical record revealed on 9/17/21 at 3:24 PM, Resident was found in room [ROOM NUMBER] on the bed naked with another resident (male). CNA informed me and RN and we directed male resident back to his room and resident was assessed by RN and CNA then re-dressed while I informed the Administrator at 0645 (6:45 AM), which he addressed the occurrence to proper authorities. Resident was transported to [local hospital] ER (emergency room ) to be assessed. Resident returned with order for doxycyline 100 mg one PO (by mouth) BID (twice daily) x 7 days.Incident report completed. A nursing progress note by the DON dated 9/17/21 revealed that a physician's order was received to transfer resident 26 to the emergency room for possible transfer to a mental health facility. At 4:21 PM, resident 26 was transported to a local emergency room (ER) for mental health evaluation. A nursing progress note by LPN 1 in resident 26's medical record revealed on 9/17/21 at 2:59 PM, Resident was found by CNA in room [ROOM NUMBER] with another resident (Female) naked on the bed at 0645 (6:45 AM). CNA informed Me (Nurse) and Charge nurse and we directed resident to his room and informed him to stay in his room until one of us (Nursing staff) comes back. RN and CNA assessed the female resident and re-dressed her and remained with her. I Phoned Facility Administrator at time of incident and informed him of the incident. Administrator stated he will advise and report to proper authorities, I informed Administrator both individuals were separated and one on one staff until further notice. A nursing progress note dated 9/18/21 at 10:04 PM revealed, resident 26 was moved to a room outside of the locked unit. The note further revealed resident 26 frequently wandered into the rooms of female resident and was sexually inappropriate with residents and staff. Staff were to continue to monitor resident 26. A nursing progress note dated 9/25/21 at 11:06 PM revealed resident 26 had been sexually inappropriate with the female staff. Resident 26's Medication Administration Record indicated that staff were to monitor resident 26 for sexually inappropriate behaviors as of 9/25/21. Resident 26 was also started on Risperdol as of 9/26/21. A physician's progress note for resident 31 dated 10/18/21 at 12:54 PM, .On 9/17 she was found naked with a male resident on top of her. She was transported to the ER where evaluation did not reveal signs of physical trauma. A nursing progress note dated 12/4/21 at 10:18 PM revealed resident 26 was occasionally sexually inappropriate. A nursing progress note dated 1/2/22 at 1:29 AM revealed resident 26 had not harmed anyone. A nursing progress note dated 7/10/22 at 2:18 AM revealed resident 26 was discovered missing about 7:30 PM. Staff checked every room and the outside around the entire building. Police, Administrator and physician were notified. A nursing progress note dated 7/10/22 at 1:22 PM revealed police returned resident 26 at approximately 10:30 AM and a physician's order was obtained to change room to memory lane. Resident 26 was happy to see his old roommate. The facility reported resident 26's elopement on 7/11/22 at 7:41 AM. The facility reported resident 26 eloped at 12:14 AM on 7/10/22. The investigation was [Resident 26] went out for the last smoke break at 7pm then returned to his room. Later when doing rounds [resident 26] was not in his bed. Facility was searched. Police Notified. Silver alert was sent out. At approx. (approximately) 9:30am an old employee texted and notified the facility that [resident 26] was at [local convenience store] a block away. Police were notified and picked him up. Returned to the facility at 10am. There were no interviews or further investigation. Resident 26's monthly nurses assessments for the months of September 2021, October 2021, November 2021, December 2021, January 2022, April 2022, June 2022, and July 2022 documented that resident 26 had sexual behaviors but did not indicate what the behaviors were. [It should be noted that the monthly assessments for February 2022, March 2022, May 2022, August 2022, and September 2022 were not able to be located in resident 26's medical record.] A nursing medication administration note dated 8/28/22 at 1:32 PM, revealed resident 26 was seen by other resident pulling a female resident into his bathroom. he noticed he was caught and let her go. The facility reported on 8/29/22 at 12:35 pm, that on 8/26/22 at 2:00 AM, resident 31 and resident 26 were found laying in bed together with no briefs. The Summary of the Investigation was Both residents live on the secured unit in the nursing facility. [Resident 31] is a constant wanderer and pacer. She wanders in and out of any room and often climbs into beds when she is tired. She also immediately takes off her briefs when they are wet. It is believed that she climbed into his bed. He often sleeps with just a tshirt or naked. While the CNAs were doing rounds they found them both in bed with no briefs on. The RN did checks and found no evidence of any encounter. Residents were sent to their own rooms. [Resident 26] is a client of [local mental health] the provider is looking at adjusting medications and increased visits from case manager and LCSW. It should be noted there were no documented interviews or further investigation. Resident 26 and 31's nursing progress notes were reviewed and there were no notes in either of the residents medical records regarding this event. On 10/22/22 at 11:22 AM, an interview was conducted with CNA 6. CNA 6 stated she witnessed an incident between resident 26 and resident 31 a couple months ago. CNA 6 stated she finished changing resident 31's brief and went into another residents room and was changing another resident. CNA 6 stated when she went back to check resident 31, she was missing. CNA 6 stated she searched room to room and found resident 31's brief and pants were off and resident 26's brief and pants were pulled down to his knees. CNA 6 stated she told the RN 6. CNA 6 stated that she was not questioned by the Administrator or DON regarding the incident. CNA 6 stated that resident 31 was placed on 15 minutes checks. CNA 6 stated that resident 26 continued to reside on the memory care unit after the incident. CNA 6 stated resident 26 told the nurse that he was in trouble and he knew what he did was wrong. CNA 6 stated he keeps doing it and he gets caught every time he does anything to resident 31. CNA 6 stated a CNA reported to her on evening shift that resident 26 was holding the door closed in the shower room with resident 31. CNA 6 stated another time she was told that resident 31 was in resident 26's room butt naked behind the curtain. CNA 6 stated that she was told to keep an eye on him. CNA 6 stated sometimes she had to leave the memory care unit unattended to make sure other residents were receiving care. The incident when resident 31 and resident 26 were found in the bathroom together was not reported to the State Survey Agency. The incidents when resident 31 was found naked behind a curtain in resident 26's room was not reported to the State Survey Agency. A nursing progress note regarding resident 26 dated 9/4/22 at 12:16 AM revealed, has been doing about the same. We have to watch him so he doesn't coax one of the ladies into his room. On 10/1/22, resident 26 was documented as demonstrating inappropriate behavior, such as making inappropriate comments to this nurse. Resident says 'I need you tonight' 'I love women' and trying to kiss on the hand. Resident was reminded of appropriate communication and that these comments are unacceptable. Resident verbalized understanding 'okay okay '. Review of resident 26's September and October 2022 Treatment Administration Record (TAR) indicated that staff had not been consistently documenting resident 26's sexual behaviors. Review of resident 26's care plan indicated that no interventions had been put into place to prevent further incidents with resident 31 after the incident on 8/26/22. An incident/accident report dated 10/5/22 at 2:15 PM, revealed resident 31 was walking through the hallway without her clothes on, CNA found resident's clothes in closet of room # 104 ? at 2:15 PM. No injuries. [It should be noted the 104 was written over another room number that was unreadable.] The additional comments and/or steps taken to prevent reoccurrence were clothes to be ordered; to remind staff that designated CNA needs to be on the unit at ALL TIMES; and ensure staff on unit. The incident report was not signed by the Medical Director or Administrator on 10/17/22 when it was reviewed. A nursing progress note dated 10/5/22 at 3:48 PM by LPN 1 revealed, Resident walking down hall on memory unit without her clothes on and other residents saw her naked. CNA's assisted resident to cloth her. CNA found resident's clothes in closet of room [ROOM NUMBER]. Resident's granddaughter witnessed the incident, and she is CNA here today this shift. I counseled the designated CNA working on memory unit and wrote action taken form and DON present during this write up. Copy of write up given to Admin '[name removed]'. NP informed as well as family. On 10/12/22, both residents were observed to residing on the memory care unit that was the locked unit of the facility. Resident 26 resided in room [ROOM NUMBER] and resident 31 resided in room [ROOM NUMBER]. On 10/12/22 an observation was made of resident 31. At 2:59 PM, resident 31 was observed to wander into the door way of room [ROOM NUMBER] and was redirected by staff. At 3:03 PM, resident 31 was wandering into room [ROOM NUMBER]. At 3:08 PM, resident 31 wandered into room [ROOM NUMBER]. On 10/11/22 at 4:10 AM, an observation was made of RN 1, Certified Nursing Assistant (CNA) 6 and CNA 7 at the nurses station. The memory care unit was unattended until 4:22 AM when CNA 6 was observed to enter the unit. At 4:43 AM, CNA 6 was observed to exit the memory care unit. At 5:48 AM, CNA 6 entered the memory care unit. Resident 36 was observed to be ambulating up and down the hallway during that time. [It should be noted the memory care unit was unattended for 1 hour and 5 minutes.] On 10/22/22 at 10:40 PM, an observation was made of CNA 6, CNA 7 and RN 5 at the nurses station. The memory care unit was unattended until 10:51 PM. Resident 36 was observed wandering the hallway. At 11:19 PM, CNA 6 was observed to leave the memory care unit. At 11:25 PM, CNA 6 was observed to return to the memory care unit. At 11:56 PM, CNA 6 and CNA 7 were observed to leave the memory care unit. At 11:57 PM, RN 5 entered the memory care unit. On 10/23/22 at 12:04 AM, RN 5 was observed to leave the memory care unit and open the door to the magnet. RN 5 was observed to wheel the charts in front of the open door. Resident 36 was observed wandering the hallway. RN 5 was observed to sit behind the charts near the open door. At 12:35 AM, CNA 6 and CNA 7 were observed to enter the memory care unit. At 12:37 AM, resident 31 was observed wandering the hallway without pants, wearing only a sweatshirt and brief. Resident 36 and resident 7 were observed in the hallway. On 10/12/22 at 10:17 AM, an interview was conducted with resident 31's family member. Resident 31's family member stated on 10/5/22 it was shift change about 2:00 PM, there were no staff members on the memory care unit. Resident 31's staff member stated that a resident was banging on the doors to get staff attention outside of the memory care unit. Resident 31's family member stated she looked in and resident 31 was walking down the hall naked with no clothes on. Resident 31's family member stated that resident 31's clothes were nowhere to be found. Resident 31's family member stated that resident 31's clothing were found in room [ROOM NUMBER]'s closet. Resident 31's family member stated resident 31 was able to take her pants down but did not take her brief off and resident 31 was not capable of placing her clothing in a closet. Resident 31's family member stated that she was upset and talked to the DON. Resident 31's family member stated that DON told her to talk to the Administrator. Resident 31's family member stated she told the Administrator but the Administrator had family in her office and she stated to the resident's family member she was busy doing payroll. Resident 31's family member stated the Administrator stated to her she needed to talk to the nurse. Resident 31's family member stated she went back to the DON and demanded that something happen. Resident 31's family member stated she was trying to report an abuse allegation. Resident 31's family member stated the DON reviewed the camera footage of the memory care unit with her. Resident 31's family member stated there was nothing on the footage because room [ROOM NUMBER] was directly below the cameras. Resident 31's family member stated all they could see was resident 31 walking in the hallway naked. Resident 31's family member stated they could not see resident 31 walk into a room and when they saw her she was in the hallway with clothing and then suddenly she was naked. Resident 31's family member stated resident 26's room was joined to room [ROOM NUMBER] through a bathroom. Resident 31's family member stated that CNA 1 was counseled about not leaving the locked unit unattended. Resident 31's family member stated she felt something was happening to resident 31 from resident 26. Resident 31's family member stated that resident 26 stated to her that resident 31 was beautiful and he loved her. Resident 31's family member stated that resident 31 wandered into other resident rooms and if there was no staff in the hallway, she will go into anyone's room. Resident 31's family member stated resident 31 she would not let staff take off her pants and would say No, don't touch me dirty man. Resident 31's family member stated resident 31 was very jumpy and resident 31 was never like that. On 10/17/22 at approximately 10:00 AM, an interview was conducted with the DON. The DON stated that CNA 2, who was a family member to resident 31, was upset on 10/5/22 and the DON stated she assumed the nurse had addressed it and that CNA 2 talked to the Administrator. The DON stated that CNA 2 returned from talking to the Administrator and CNA 2 told the DON she wanted something done. The DON stated that she reviewed camera footage because CNA 2 insisted to find out what happened to resident 31's clothing. The DON stated that resident 31 was in memory care unit hallway with no clothing on. The DON stated that CNA 2 was very upset. The DON stated she was having a hard time remembering what she saw from the camera footage. The DON stated she thinks resident 31 exited room [ROOM NUMBER] without clothing and did not see resident 31 enter a room because the video footage jumped 5 minutes at a time. The DON stated the memory care unit was unattended by staff for about 10 minutes. The DON stated the memory care unit was supposed to have staff at all times. The DON stated she had LPN 1 complete an incident report. The DON stated she reported the incident to the Administrator immediately. The DON stated she put a care plan in for resident 31 after the incident. The DON stated that in the position she was in, she did everything she could by watching LPN 1 counsel CNA 1 about not leaving the unit. The DON stated she educated CNA's that this happens with dementia and with increasing dementia this can happen. The DON stated resident 31 was able to removed her own clothing. The DON stated she also would like the family to be involved with care planning and maybe getting resident 31 onesies that zip in the back so she was unable to remove her clothing. The DON stated after resident 31 was found naked in the hallway she assessed resident 31. The DON stated resident 31 was clothed and there was no bruising or red marks on her back. The DON stated that In my opinion, I couldn't tell if it was an abuse allegation or an incident. On 10/17/22 at 11:13 AM, an interview was conducted with CNA 1. CNA 1 stated on 10/5/22 when resident 31 was found naked in the locked unit, I was off the hall. CNA 1 stated she was waiting for the next shift to come into work. CNA 1 stated she was talking to another staff member and resident 31 was walking down the hallway with no clothes on. CNA 1 stated staff ran down the hallway to resident 31. CNA 1 stated resident 31 went into room [ROOM NUMBER] which was resident 26's room and her clothes were found in room [ROOM NUMBER]'s closet. CNA 1 stated resident 26 and his roommate were in their room when resident 31 went in. CNA 1 stated resident 31 wanders everywhere. CNA 1 stated she figured out a different system for resident 31. CNA 1 stated resident 31 was changed at 12:30 PM or 1:00 PM and then at 3:00 PM because that was when she usually had a bowel movement. CNA 1 stated there should be staff in the locked unit at all times. CNA 1 stated I was not on the hall which I take responsibility for. CNA 1 stated she was not sure if resident 31's clothing was soiled or wet when they were found. CNA 1 stated resident 31 was pacing the hallway yesterday and needed to be changed and did not take her clothing off. CNA 1 stated she was instructed by LPN 1 and the DON to stay in the memory care unit at all times and keep an eye on resident 31 and anyone that tried to bother her. CNA 1 stated other staff have told her that resident 31 takes her clothing off, but she had never seen resident 31 take her clothing off. CNA 1 stated she had found resident 31 without a brief on so she figured resident 31 removed it herself. On 10/17/22 at 2:18 PM, an interview was conducted with CNA 8. CNA 8 stated 2 or 3 weeks ago she was sitting at the desk at about 2:20 PM and was waiting for another CNA to come to the locked unit to get report. CNA 8 stated resident 9 was knocking on the door and was asking for ice. CNA 8 stated she opened the door to give resident 9 ice and saw resident 31 naked in the hallway. CNA 8 stated resident 31 was outside the dining room toward her room. CNA 8 stated she took resident 31 to her room and dressed her. CNA 8 stated CNA 2, CNA 3 and CNA 4 were at the facility. CNA 8 stated she reported to the nurse what had happened. CNA 8 stated after the incident, she was told to be in the hall and care for the residents even though she was scheduled to work another hallway. CNA 8 stated she also told the DON about the incident. CNA 8 stated the DON was mad at us because no one was in the hallway. CNA 8 stated she stayed a little bit because CNA 2 was mad and wanted to look at the cameras to see what happened. CNA 8 stated she was the first CNA to see resident 31 naked in the hallway and there were other residents in the hallway. CNA 8 stated resident 31's mind was not good, so she did not know what was happening. CNA 8 stated resident 26 knew what was happening. CNA 8 stated she did not want anything to happen to resident 31 so she puts her on the couch. CNA 8 stated a Night CNA told her that when she received report to make sure resident 26 was not close to resident 31. CNA 8 stated she did not ask why she needed to keep them apart. CNA 8 stated she had been told that resident 31 and resident 26 had been found in bed together. CNA 8 stated she would be more careful with resident 31 and not leave her alone since she knew the residents had been found in bed together. CNA 8 stated she tried not to leave her alone since then, but things happened really fast. CNA 8 stated that resident 31 was unable to remove her own clothing. CNA 8 stated resident 31 won't allow for staff to pull her pants down when she needed to be changed. CNA 8 stated resident 31 would need assistance with removing all of her clothing including her shirt. On 10/17/22 at 11:28 AM, an interview was conducted with the Administrator. The Administrator stated it was a daily occurrence that resident 31 did not have clothing on. The Administrator stated that once resident 31 was wet, she removed her bottoms. The Administrator stated that she had been trying to find things like taking her to the bathroom, so she did not remove her clothing. The Administrator stated resident 31 wandered all the time and removed her clothing wherever she wanted and continued wandering. The Administrator stated resident 31 wandered in and out of everyone's room on the locked unit. The Administrator stated resident 31 was friendly with everyone. The Administrator stated she was not sure if resident 31 was able to remove her shirt herself. The Administrator stated resident 31 could get her bottoms off fast. The Administrator stated she would not have looked into anything or questioned possible abuse with resident 31 coming out of another residents room with no clothing. The Administrator stated there were times the memory care unit was unattended by staff when staff were coming and going but staff should ask other members to cover the hallway. On 10/17/22 at 11:38 AM, an interview was conducted with Medical Director (MD). The MD stated there was an incident report dated 10/5/22 regarding resident 31 not having her clothing on in the hallway. The MD stated it was reported to her but when she reviewed the incident report, the room number on the incident report was changed. The MD stated she was informed that resident 31's clothing was found in room [ROOM NUMBER], but it was changed to room [ROOM NUMBER]. The MD stated she had not received all the details about the incident. The incident on 10/5/22 was not reported to the State Survey Agency. There was no investigation documented regarding the incident besides the information on the incident report. On 10/17/22 at 12:10 PM, a follow up interview was conducted with the MD. The MD stated she was informed by CNA 1 that resident 26 was found fondling resident 31 today. The MD stated she talked to resident 26 and he stated I need to go to jail. The MD stated resident 26 stated I was playing around with an older woman, [resident 31]. The MD stated he did not go into specifics but he said sexual stuff. On 10/17/22 at 12:21 PM, an interview was conducted with resident 26. Resident 26 was observed in the locked unit dining room. Resident 26 stated he had sex and pointed to resident 31. Resident 26 stated her name was (resident 31). Resident 26 stated he needed to go to jail because she walked around with her pants down. Resident 26 stated he did not always have full sex sometimes it was him putting his penis from front to back on resident 31 like a hot dog. Resident 26 stated he had sex with her six times. On 10/17/22 at 12:22 PM, an interview was conducted with CNA 2. CNA 2 stated that at approximately 11:00 AM that day, she was assisting CNA 4 in walking resident 36 to the shower room. CNA 2 stated resident 31 was sitting on a sofa in the hallway which was near resident 26's room. CNA 2 stated she helped get resident 36 into the shower room and turned on the hot water and went back to the hallway. CNA 2 stated resident 31 was nowhere to be found. CNA 2 stated she went back to CNA 4 and stated she was unable to find resident 31. CNA 2 stated she went to resident 26's room and found resident 31 standing in front of resident 26 sitting on the toilet. CNA 2 stated resident 31's pants were down and resident 26 had a couple fingers inside of resident 31's vagina. CNA 2 stated she told resident 26 you do not do that. CNA 2 stated she pulled up resident 31's pants and lead her out of

Based on observations, interviews and record review, it was determined that the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, abuse occurred within the facility on multiple occasions,but was not identified, reported or investigated; the staffing was inadequate and resulted in falls, abuse, and activities of daily living not being completed; Quality Assurance (QA) was not completed as required for approximately one year; medically necessary appointments were not scheduled by facility staff or the administrator; wound reports and pharmacy reviews were only accessible to the Administrator, who did not provide them to nursing staff; and multiple staff reported to the Administrator their concerns about resident safety while a specific nurse was working, however no follow up by the Administrator was completed. The identified deficient practice was found to have occurred at the Immediate Jeopardy (IJ) Level. Resident identifiers: 4, 8, 9, 10, 11, 13, 22, 26, 29, 30, 31, 32, 34, 36 and 93. Findings include: On 10/27/22 at 7:15 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to administer the facility in a manner that enabled it to use its resources effectively. Notice of the IJ was given verbally to the facility Administrator (ADM). On 11/10/22 at 11:56 AM, the facility Consultant Group provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 11/10/22 at 12:00 PM: 1. Please refer to the abatement plan for F600, F609 and 610. The facility has hired an NHA (Nursing Home Administrator), who started work at the facility on 10/31/22 to oversee the daily operations of the facility. The community has Temporary Managers who will provide mentoring and assistance to the administrator through regular contact and visitation to the building. The NHA was provided with names of staffing agencies who are local to assist with having adequate staffing levels for CNAs (Certified Nursing Assistants) and Nurses. The Temporary Managers provided education on the QAPI (Quality Assurance Performance Improvement) program and tools for process improvement and tracking and trending of resident care areas. The QAPI meetings will be held at least monthly with oversight of the NHA The facility did develop, with the assistance of the Temporary Managers, a process for scheduling resident appointments, arranging for transportation to and from appointments, and obtaining information from the appointments and having that information available in the resident record. Appointments were scheduled for Resident #4 for GI (Gastroenterology) consult and Neurology appointment for Resident #30. The NHA is researching the cardiologist group that placed the pacemaker for Resident #34, and A care conference will be scheduled for resident #32 to discuss the option of a feeding tube. The new NHA and the acting DON (Director of Nursing) will get access to the rounding wound service portal to ensure that all recommendations and information is available in the medical record The Consultant Pharmacist reports were received and follow up on all recommendations were completed on 11/1/22. The facility implemented, in addition to narcotic count, a narcotic card count to be completed each shift on 11/1/22. RN #1 is no longer employed by the facility and will be reported to the board of nursing 2. Residents in the community have the potential to be affected by this alleged deficient practice. 3. The community has Temporary Managers who will provide mentoring and assistance to the administrator through regular contact and visitation to the building. The NHA is working minimally 40 hours a week at the community. The NHA job description was reviewed to ensure that it meets acceptable standards of practice. The Temporary Managers will provide a structured review process to the Administrator and will conduct a periodic and thorough evaluation of their performance following their job description requirements. Evaluations will be completed at 30 days, 90 days, and annually. Additional training and/or oversight will be provided by the temporary management company and corporate office based upon the outcomes of these reviews. The community will implement bimonthly QAPI meetings for a quarter to go over audits for the survey and identify any trends and take corrective action as needed. 4. The Temporary Managers and or designee will report findings from the audits to the QAPI Committee monthly for 3 months. The QAPI committee will identify any trends and take corrective action as needed. 5. Please accept this abatement plan of corrective action - effective 11/10/2022 at 12PM. On 11/14/22, after the completion of the survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 11/10/22. I. ABUSE 1. Resident 31 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, unspecified dementia with behavioral disturbance, and depression. Resident 31's medical record was reviewed. An annual Minimum Data Set (MDS) dated [DATE] revealed resident 31 did not have a Brief Interview for Mental Status (BIMS) because she rarely/never understood. The MDS further revealed resident 31 had short and long term memory problems. The MDS revealed her cognitive skills for daily decision making were severely impaired. The MDS revealed resident 31 required extensive one person assistance with dressing. Resident 31's care plan dated 3/27/17 revealed The resident has a behavior problem of wearing multiple layers of clothing and resisting to change or remove the clothing. The goal with a target date of 5/27/22 was The resident will have fewer episodes of wearing multiple layers of clothing weekly, by review date. Interventions included Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately; Explain all procedures to the resident before starting and allow the resident 5-10 (minutes) to adjust to changes; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Praise any indication of The resident's progress/improvement in behavior. Another care plan for resident 31 dated 8/25/16 revealed, The resident has a behavior problem of wearing multiple layers of clothing and resisting to change or remove the clothing The goal with a target date of 5/27/22 revealed, The resident will have fewer episodes of wearing multiple layers of clothing weekly, by review date. Interventions were Assist the resident to develop more appropriate methods of coping and interacting; Encourage the resident to express feelings appropriately; Explain all procedures to the resident before starting and allow the resident 5-10 (minutes) to adjust to changes; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Praise any indication of The resident's progress/improvement in behavior. Resident 26 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, diabetes mellitus, and hypertension. Resident 26's medical record was reviewed. Resident 26's quarterly MDS dated [DATE] revealed a BIMS score of 5 which indicated severe cognitive impairment. The MDS further revealed resident 26 walked in corridor, walked in room, locomotion on the unit and locomotion off the unit required supervision and setup help only. Resident 26's care plan 8/3/21 revealed The resident has a behavior problem r/t (related to) Schizophrenia. The goal was The resident will have no evidence/decrease of behavior problems by review date. Interventions developed were Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. On 8/29/21, resident 26 was found in a room with resident 31 by a surveyor during a recertification survey. Resident 26 had his penis exposed while standing directly in front of resident 31. Resident 31 had her back to the wall. This incident was cited as part of the annual recertification survey. There were no progress notes in resident 26's or resident 31's medical record regarding the incident on 8/29/21. A nursing progress note dated 9/4/21 at 10:41 PM revealed, resident 26 was observed touching staff and other residents without consent. On 9/17/21, the facility reported to the state survey agency that resident 31 had been found naked with resident 26 in a room in the locked unit. A nursing progress note by Licensed Practical Nurse (LPN) 1 in resident 31's medical record revealed on 9/17/21 at 3:24 PM, Resident was found in room [ROOM NUMBER] on the bed naked with another resident (male). CNA informed me and RN and we directed male resident back to his room and resident was assessed by RN and CNA then re-dressed while I informed the Administrator at 0645 (6:45 AM), which he addressed the occurrence to proper authorities. Resident was transported to [local hospital] ER (emergency room ) to be assessed. Resident returned with order for doxycyline 100 mg one PO (by mouth) BID (twice daily) x 7 days.Incident report completed. A nursing progress note by the DON dated 9/17/21 revealed that a physician's order was received to transfer resident 26 to the emergency room for possible transfer to a mental health facility. At 4:21 PM, resident 26 was transported to a local emergency room (ER) for mental health evaluation. A nursing progress note by LPN 1 in resident 26's medical record revealed on 9/17/21 at 2:59 PM, Resident was found by CNA in room [ROOM NUMBER] with another resident (Female) naked on the bed at 0645 (6:45 AM). CNA informed Me (Nurse) and Charge nurse and we directed resident to his room and informed him to stay in his room until one of us (Nursing staff) comes back. RN and CNA assessed the female resident and re-dressed her and remained with her. I Phoned Facility Administrator at time of incident and informed him of the incident. Administrator stated he will advise and report to proper authorities, I informed Administrator both individuals were separated and one on one staff until further notice. A nursing progress note dated 9/18/21 at 10:04 PM revealed, resident 26 was moved to a room outside of the locked unit. The note further revealed resident 26 frequently wandered into the rooms of female resident and was sexually inappropriate with residents and staff. Staff were to continue to monitor resident 26. A nursing progress note dated 9/25/21 at 11:06 PM revealed resident 26 had been sexually inappropriate with the female staff. Resident 26's Medication Administration Record indicated that staff were to monitor resident 26 for sexually inappropriate behaviors as of 9/25/21. Resident 26 was also started on Risperdol as of 9/26/21. A physician's progress note for resident 31 dated 10/18/21 at 12:54 PM, .On 9/17 she was found naked with a male resident on top of her. She was transported to the ER where evaluation did not reveal signs of physical trauma. A nursing progress note dated 12/4/21 at 10:18 PM revealed resident 26 was occasionally sexually inappropriate. A nursing progress note dated 1/2/22 at 1:29 AM revealed resident 26 had allegedly not harmed anyone. A nursing progress note dated 7/10/22 at 2:18 AM revealed resident 26 was discovered missing about 7:30 PM. Staff checked every room and the outside around the entire building. Police, Administrator and physician were notified. A nursing progress note dated 7/10/22 at 1:22 PM revealed police returned resident 26 at approximately 10:30 AM and a physician's order was obtained to change room to memory lane, despite his history of sexually abusing resident 31, who still resided on the memory care unit. The progress note indicated that resident 26 was happy to see his old roommate. Resident 26's monthly nurses assessments for the months of September 2021, October 2021, November 2021, December 2021, January 2022, April 2022, June 2022, and July 2022 documented that resident 26 had sexual behaviors but did not indicate what the behaviors were. [It should be noted that the monthly assessments for February 2022, March 2022, May 2022, August 2022, and September 2022 were not able to be located in resident 26's medical record.] A nursing medication administration note dated 8/28/22 at 1:32 PM, revealed resident 26 was seen by other resident pulling a female resident into his bathroom. he noticed he was caught and let her go. An entity report dated 8/29/22 revealed that on 8/26/22 resident 31 and resident 26 lived on the secured unit in the nursing facility. Resident 31 was often found pacing. She wanders in and out of any room and often climbed into bed when she is tired. She also immediately takes off her brief when they are wet. It is believed that she climbed into his bed. He often sleeps with just a T-shirt or naked. While CNAs were doing rounds they found them both in bed with no briefs on. The RN did checks and found no evidence of any encounter. Residents were sent to their own rooms. [Resident 26] is a client of [local mental health company] the provider is looking at adjusting medications and increased visits from case manager and LCSW. Resident 26 and 31's nursing progress notes were reviewed and there were no notes in either of the residents medical records regarding this event. Review of resident 26's care plan indicated that no interventions had been put into place to prevent further incidents with resident 31 after the incident on 8/26/22. A nursing progress note regarding resident 26 dated 9/4/22 at 12:16 AM revealed, has been doing about the same. We have to watch him so he doesn't coax one of the ladies into his room. On 10/1/22, resident 26 was documented as demonstrating inappropriate behavior, such as making inappropriate comments to this nurse. Resident says 'I need you tonight' 'I love women and trying to kiss on the hand. Resident was reminded of appropriate communication and that these comments are unacceptable. Resident verbalized understanding 'okay okay '. Review of resident 26's September and October 2022 TAR indicated that staff had not been consistently documenting resident 26's sexual behaviors. An incident/accident report dated 10/5/22 at 2:15 PM, revealed resident 31 was walking through the hallway without her clothes on, CNA found resident's clothes in closet of room # 104 ? at 2:15 PM. No injuries. [It should be noted the 104 was written over another room number that was unreadable.] The additional comments and/or steps taken to prevent reoccurrence were clothes to be ordered; to remind staff that designated CNA needs to be on the unit at ALL TIMES; and ensure staff on unit. The incident report was not signed by the Medical Director or Administrator until 10/17/22 when it was reviewed. A nursing progress note dated 10/5/22 at 3:48 PM by LPN 1 revealed, Resident (31) walking down hall on memory unit without her clothes on and other residents saw her naked. CNA's assisted resident to cloth (sic) her. CNA found resident's clothes in closet of room [ROOM NUMBER]. Resident's granddaughter witnessed the incident, and she is CNA here today this shift. I counseled the designated CNA working on memory unit and wrote action taken form and DON present during this write up. Copy of write up given to Admin '[name removed]'. NP (Nurse Practitioner) informed as well as family. On 10/12/22, both residents were observed to residing on the memory care unit that was the locked unit of the facility. Resident 26 resided in room [ROOM NUMBER] and resident 31 resided in room [ROOM NUMBER]. On 10/12/22 an observation was made of resident 31. At 2:59 PM, resident 31 was observed to wander into the door way of room [ROOM NUMBER] and was redirected by staff. At 3:03 PM, resident 31 was wandering into room [ROOM NUMBER]. At 3:08 PM, resident 31 wandered into room [ROOM NUMBER]. On 10/11/22 at 4:10 AM, an observation was made of RN 1, Certified Nursing Assistant (CNA) 6 and CNA 7 at the nurses station. The memory care unit was unattended until 4:22 AM when CNA 6 was observed to enter the unit. At 4:43 AM, CNA 6 was observed to exit the memory care unit. At 5:48 AM, CNA 6 entered the memory care unit. Resident 36 was observed to be ambulating up and down the hallway during that time. [It should be noted the memory care unit was unattended for 1 hour and 5 minutes.] On 10/22/22 at 10:40 PM, an observation was made of CNA 6, CNA 7 and RN 5 at the nurses station. The memory care unit was unattended until 10:51 PM. Resident 36 was observed wandering the hallway. At 11:19 PM, CNA 6 was observed to leave the memory care unit. At 11:25 PM, CNA 6 was observed to return to the memory care unit. At 11:56 PM, CNA 6 and CNA 7 were observed to leave the memory care unit. At 11:57 PM, RN 5 entered the memory care unit. On 10/23/22 at 12:04 AM, RN 5 was observed to leave the memory care unit and open the door to the magnet. RN 5 was observed to wheel the charts in front of the open door. Resident 36 was observed wandering the hallway. RN 5 was observed to sit behind the charts near the open door. At 12:35 AM, CNA 6 and CNA 7 were observed to enter the memory care unit. At 12:37 AM, resident 31 was observed wandering the hallway without pants, wearing only a sweatshirt and brief. Resident 36 and resident 7 were observed in the hallway. On 10/22/22 at 11:22 AM, an interview was conducted with CNA 6. CNA 6 stated she witnessed an incident between resident 26 and resident 31 a couple of months ago. CNA 6 stated she finished changing resident 31's brief and went into another residents room and was changing another resident. CNA 6 stated when she went back to check resident 31 she was missing. CNA 6 stated she searched room to room and found resident 31's brief and pants were off and resident 26's brief and pants were pulled down to his knees. CNA 6 stated she told RN 6. CNA 6 stated that she was not questioned by the Administrator or DON regarding the incident. CNA 6 stated that resident 31 was placed on 15 minutes checks. CNA 6 stated that resident 26 continued to reside on the memory care unit after the incident. CNA 6 stated resident 26 told the nurse that he was in trouble and he knew what he did was wrong. CNA 6 stated he keeps doing it and he gets caught every time he does anything to resident 31. CNA 6 stated a CNA reported to her on evening shift that resident 26 was holding the door closed in the shower room with resident 31. CNA 6 stated another time she was told that resident 31 was in resident 26's room naked behind the curtain. CNA 6 stated that she was told to keep an eye on him. CNA 6 stated sometimes she had to leave the memory care unit unattended to make sure other residents were receiving care. [It should be noted that the incidents referenced above had not been reported to the State Survey Agency.] On 10/12/22 at 10:17 AM, an interview was conducted with CNA 2, who was also resident 31's family member. Resident 31's family member stated on 10/5/22 it was shift change about 2:00 PM, there were no staff members on the memory care unit. Resident 31's staff member stated that a resident was banging on the doors to get staff attention outside of the memory care unit. Resident 31's family member stated she looked in and resident 31 was walking down the hall naked with no clothes on. Resident 31's family member stated that resident 31's clothes were nowhere to be found. Resident 31's family member stated that resident 31's clothing were found in room [ROOM NUMBER]'s closet. Resident 31's family member stated resident 31 was able to take her pants down but did not take her brief off and resident 31 was not capable of placing her clothing in a closet. Resident 31's family member stated that she was upset about the incident and talked to the DON. Resident 31's family member stated that DON told her to talk to the Administrator. Resident 31's family member stated she told the Administrator but the Administrator had people in her office and she stated to the resident's family member she was busy doing payroll. Resident 31's family member stated the Administrator stated to her she needed to talk to the nurse. Resident 31's family member stated she went back to the DON and demanded that something happen. Resident 31's family member stated she was trying to report an abuse allegation. Resident 31's family member stated the DON reviewed the camera footage of the memory care unit with her. Resident 31's family member stated there was nothing on the footage because room [ROOM NUMBER] was directly below the cameras. Resident 31's family member stated all they could see was resident 31 walking in the hallway naked. Resident 31's family member stated they could not see resident 31 walk into a room and when they saw her she was in the hallway with clothing and then suddenly she was naked. Resident 31's family member stated resident 26's room was joined to room [ROOM NUMBER] through a bathroom. Resident 31's family member stated that CNA 1 was counseled about not leaving the locked unit unattended. Resident 31's family member stated she felt something was happening to resident 31 from resident 26. Resident 31's family member stated that resident 26 stated to her that resident 31 was beautiful and he loved her. Resident 31's family member stated that resident 31 wandered into other resident rooms and if there was no staff in the hallway, she will go into anyone's room. Resident 31's family member stated resident 31 would not let staff take off her pants and would say No, don't touch me dirty man. Resident 31's family member stated resident 31 was very jumpy and resident 31 was never like that before. On 10/17/22 at approximately 10:00 AM, an interview was conducted with the DON. The DON stated that CNA 2, who was a family member to resident 31, was upset on 10/5/22 and the DON stated she assumed the nurse had addressed it and that CNA 2 talked to the Administrator. The DON stated that CNA 2 returned from talking to the Administrator and CNA 2 told the DON she wanted something done. The DON stated that she reviewed camera footage because CNA 2 insisted to find out what happened to resident 31's clothing. The DON stated that resident 31 was in the memory care unit hallway with no clothing on. The DON stated that CNA 2 was very upset. The DON stated she was having a hard time remembering what she saw from the camera footage. The DON stated she thought resident 31 exited room [ROOM NUMBER] without clothing and did not see resident 31 enter a room because the video footage jumped 5 minutes at a time. The DON stated the memory care unit was unattended by staff for about 10 minutes. The DON stated the locked unit was supposed to have staff at all times. The DON stated she had LPN 1 complete an incident report. The DON stated she reported the incident to the Administrator immediately. The DON stated she put a care plan in for resident 31 after the incident. The DON stated that in the position she was in, she did everything she could by watching LPN 1 counsel CNA 1 about not leaving the unit. The DON stated she educated CNA's that this happens with dementia and with increasing dementia this can happen. The DON stated resident 31 was able to remove her own clothing. The DON stated she also would like the family to be involved with care planning and maybe getting resident 31 onesies that zip in the back so she was unable to remove her clothing. The DON stated after resident 31 was found naked in the hallway she assessed resident 31. The DON stated resident 31 was clothed and there was no bruising or red marks on her back. The DON stated that In my opinion, I couldn't tell if it was an abuse allegation or an incident. On 10/17/22 at 11:13 AM, an interview was conducted with CNA 1. CNA 1 stated on 10/5/22 when resident 31 was found naked in the locked unit, I was off the hall. CNA 1 stated she was waiting for the next shift to come into work. CNA 1 stated she was talking to another staff member and resident 31 was walking down the hallway with no clothes on. CNA 1 stated staff ran down the hallway to resident 31. CNA 1 stated resident 31 went into room [ROOM NUMBER] which was resident 26's room and her clothes were found in room [ROOM NUMBER]'s closet. CNA 1 stated resident 26 and his roommate were in their room when resident 31 went in. CNA 1 stated resident 31 wanders everywhere. CNA 1 stated she figured out a different system for resident 31. CNA 1 stated resident 31 was changed at 12:30 PM or 1:00 PM and then at 3:00 PM because that was when she usually had a bowel movement. CNA 1 stated there should be staff in the locked unit at all times. CNA 1 stated I was not on the hall which I take responsibility for. CNA 1 stated she was not sure if resident 31's clothing was soiled or wet when they were found. CNA 1 stated resident 31 was pacing the hallway yesterday and needed to be changed and did not take her clothing off. CNA 1 stated she was instructed by LPN 1 and the DON to stay in the memory care unit at all times and keep an eye on resident 31 and anyone that tried to bother her. CNA 1 stated other staff have told her that resident 31 takes her clothing off, but she had never seen resident 31 take her clothing off. CNA 1 stated she had found resident 31 without a brief on so she figured resident 31 removed it herself. On 10/17/22 at 2:18 PM, an interview was conducted with CNA 8. CNA 8 stated 2 or 3 weeks ago she was sitting at the desk at about 2:20 PM and was waiting for another CNA to come to the locked unit to get report. CNA 8 stated resident 9 was knocking on the door and was asking for ice. CNA 8 stated she opened the door to give resident 9 ice and saw resident 31 naked in the hallway. CNA 8 stated resident 31 was outside the dining room toward her room. CNA 8 stated she took resident 31 to her room and dressed her. CNA 8 stated CNA 2, CNA 3 and CNA 4 were at the facility. CNA 8 stated she reported to the nurse what had happened. CNA 8 stated after the incident, she was told to be in the hall and care for the residents even though she was scheduled to work another hallway. CNA 8 stated she also told the DON about the incident. CNA 8 stated the DON was mad at us because no one was in the hallway. CNA 8 stated she stayed a little bit because CNA 2 was mad and wanted to look at the cameras to see what happened. CNA 8 stated she was the first CNA to see resident 31 naked in the hallway and there were other residents in the hallway. CNA 8 stated resident 31's mind was not good, so she did not know what was happening. CNA 8 stated resident 26 knew what was happening. CNA 8 stated she did not want anything to happen to resident 31 so she puts her on the couch. CNA 8 stated a Night CNA told her that when she received report to make sure resident 26 was not close to resident 31. CNA 8 stated she did not ask why she needed to keep them apart. CNA 8 stated she had been told that resident 31 and resident 26 had been found in bed together. CNA 8 stated she would be more careful with resident 31 and not leave her alone since she knew the residents had been found in bed together. CNA 8 stated she tried not to leave her alone since then, but things happened really fast. CNA 8 stated that resident 31 was unable to remove her own clothing. CNA 8 stated resident 31 won't allow for staff to pull her pants down when she needed to be changed. CNA 8 stated resident 31 would need assistance with removing all of her clothing including her shirt. On 10/17/22 at 11:28 AM, an interview was conducted with the Administrator. The Administrator stated it was a daily occurrence that resident 31 did not have clothing on. The Administrator stated that once resident 31 was wet, she removed her bottoms. The Administrator stated that she had been trying to find things like taking her to the bathroom, so she did not remove her clothing. The Administrator stated resident 31 wandered all the time and removed her clothing wherever she wanted and continued wandering. The Administrator stated resident 31 wandered in and out of everyone's room on the locked unit. The Administrator stated resident 31 was friendly with everyone. The Administrator stated she was not sure if resident 31 was able to remove her shirt herself. The Administrator stated resident 31 could get her bottoms off fast. The Administrator stated she would not have looked into anything or questioned possible abuse with resident 31 coming out of another residents room with no clothing. The Administrator stated there were times the memory care unit was unattended by staff when staff were coming and going but staff should ask other members to cover the hallway. On 10/17/22 at 11:38 AM, an interview was conducted with Medical Director (MD). The MD stated there was an incident report dated 10/5/22 regarding resident 31 not having her clothing on in the hallway. The MD stated it was reported to her but when she reviewed the incident report, the room number on the incident report was changed. The MD stated she was informed that resident 31's clothing was found in room [ROOM NUMBER], but it was changed to room [ROOM NUMBER]. The MD stated she had not received all the details about the incident. On 10/17/22 at 12:10 PM, a follow up interview was conducted with the MD. The MD stated she was informed by CNA 1 that resident 26 was found fondling resident 31 today. The MD stated she talked to resident 26 and he stated I need to go to jail. The MD stated resident 26 stated I was playing around with an older woman, [resident 31]. The MD stated he did not go into specifics but he said sexual stuff. On 10/17/22 at 12:21 PM, an interview was conducted with resident 26. Resident 26 was observed in the locked unit dining room. Resident 26 stated he had sex and pointed to resident 31. Resident 26 stated her name was (resident 31). Resident 26 stated he needed to go to jail because resident 31 walked around with her pants down. Resident 26 stated he did not always have full sex with resident 31 sometimes it was him putting his penis from front to back on resident 31 like a hot dog. Resident 26 stated he had sex with resident 31 six times. On 10/17/22 at 12:22 PM, an interview was conducted with CNA 2. CNA 2 stated that at approximately 11:00 AM that day, she was assisting CNA 4 in walking resident 36 to the shower room. CNA 2 stated resident 31 was sitting on a sofa in the hallway which was near resident 26's room. CNA 2 stated she helped get resident 36 into the shower room and turned on the hot water and went back to the hallway. CNA 2 stated resident 31 was nowhere to be found. CNA 2 stated she went back to CNA 4 and stated she was unable to find resident 31. CNA 2 stated she went to resident 26's room and found resident 31 standing in front of resident 26 sitting on the toilet. CNA 2 stated resident 31's pants were down and resident 26 had a couple fingers inside of resident 31's vagina. CNA 2 stated she told resident 26 you do not do that. CNA 2 stated she pulled up resident 31's pants and lead her out of the bathroom and yelled for CNA 4 to report it to the DON. CNA 2 stated she was being written up by management because of the incident for leaving resident 31 unattended. A nursing progress note from resident 26's medical record dated 10/17/22 at 11:30 AM by the DON revealed, Report from CNA about incident on Memory Lane where resident was in bathroom w [TRUNCATED]

Based on observations, interviews and record review, it was determined for 8 of 33 sampled residents, that the facility failed to protect the resident's right to be free from physical abuse and sexual abuse by other residents. Specifically, one resident with severe cognitive impairment was sexually abused by a resident that was congitively intact. This identified deficient practice was found to have occurred at the Immediate Jeopardy (IJ) Level. Additionally, incidents of physical abuse between residents and a bruise with an unknown origin were identified at a potiential for harm level. Resident identifiers: 7, 9, 14, 15, 26, 31, 36 and 39. Findings include: On 10/17/22 at 4:30 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent various forms of abuse. Notice of the IJ was given verbally to the facility Administrator (ADM). On 11/10/22 at 11:56 AM, the facility Consultant Group provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 11/10/22 at 12:00 PM: 1. Resident #26 was placed on a neighborhood that has only male residents and placed on 1:1 supervision on 10/17/22 and remains on 1:1. The community is looking at alternative placement for resident #26. The Medical Director will review medications for resident #26. Resident #31no longer resides in the community; therefore, no individualized plan of correction is indicated. Resident #31 discharged to another community on 11/4/2022. Resident #26 was assessed on 11/1/22 for capacity to consent to sexual intimacy by the LCSW (Licensed Clinical Social Worker). 2. Residents residing in the memory care neighborhood were assessed for signs and symptoms of abuse by an LCSW on 11/1/22. For residents who are unable to be interviewed due to dementia, observation tools are being completed to identify any changes in mood or behavior that may be indicative of signs of past abuse. 3. The community has hired a Nursing Home Administrator (NHA) and an Administrator in Training (AIT). The new NHA will be responsible to investigate and report any allegation of abuse. The community also has contracted with a RN (Registered Nurse) nurse manager to assist with implementation of clinical/behavioral policies and procedures and survey corrective actions. This RN will be on site in the community on 11/9/2022. This RN will be on site minimally for three days a week. The community will initiate Guardian Angel rounds. The IDT (Interdisciplinary Team) team will be responsible to meet with their assigned residents weekly to ensure care needs are met and that they feel safe in their environment and are free of any type of abuse. Residents who are non interviewable will continue to be assessed for any changes from baseline and reported to NHA or designee for additional review and follow up. Education was initiated on 11/1/2022 regarding the community abuse policy including reporting allegations of abuse to the abuse prevention coordinator, reporting allegations of abuse to the proper authorities, and conducting thorough investigations. Thorough investigations to include immediate protection of the residents, interviewing the alleged victim, alleged assailant, any witnesses, other residents who could potentially be affected by the alleged violation, family/visitors if there are any who may have pertinent information, conducting an assessment of the alleged victim, conducting observations of cares if pertinent, conducting searches if necessary, and implementing pertinent interventions to attempt to prevent recurrence. Progress notes to be reviewed (M-F) by the DON(Director of Nursing)/designee daily to ensure that any allegations of abuse are being reported per community expectations to management and to the appropriate authorities, and that allegations of abuse are thoroughly investigated. Identified concerns to be addressed immediately and investigations initiated. Additionally, the community has initiated daily morning huddles (M-F) (Monday through Friday) to discuss any changes in resident behaviors, any type of risk management concerns. The IDT team as well as nursing staff and dietary manager will participate in this morning huddle. NHA/designee will be responsible for contacting the appropriate authorities for allegations of abuse. Each allegation will be discussed verbally with the consultants and the consultants will have access to the report to ensure they are submitted timely to the health department. The Temporary Managers will provide the community with a new daily standup meeting agenda. This agenda will include an abuse reporting log to track and trend all reported allegations for the month. The community also initiated afternoon stand down meetings (Monday through Friday) to ensure follow up items from the morning meeting were completed. NHA/designee to complete review of three (3) abuse allegations a week for three (3) months to ensure that the investigation was thorough, that there were interventions implemented to correct the alleged violations, and that there was protection of the alleged victim while the investigation was ongoing. 4. The NHA/designee will report findings from the audits to the QAPI (Quality Assurance Performance Improvement) Committee monthly for three (3) months. The QAPI committee will identify any trends and take corrective action as needed. 5. Please accept this abatement plan of corrective action - effective 11/10/2022 at 12PM. On 11/14/22, after the completion of the survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 11/10/22. Immediate Jeopardy: 1. Resident 31 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, unspecified dementia with behavioral disturbance, and depression. Resident 31's medical record was reviewed. An annual Minimum Data Set (MDS) dated [DATE] revealed resident 31 did not have a Brief Interview for Mental Status (BIMS) because she rarely/never understood. The MDS further revealed resident 31 had short and long term memory problems. The MDS revealed her cognitive skills for daily decision making were severely impaired. The MDS revealed resident 31 required extensive one person assistance with dressing. Resident 31's care plan dated 3/27/17 revealed The resident has a behavior problem of wearing multiple layers of clothing and resisting to change or remove the clothing. The goal with a target date of 5/27/22 was The resident will have fewer episodes of wearing multiple layers of clothing weekly, by review date. Interventions included Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately; Explain all procedures to the resident before starting and allow the resident 5-10 (minutes) to adjust to changes; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Praise any indication of The resident's progress/improvement in behavior. Another care plan for resident 31 dated 8/25/16 revealed, The resident has a behavior problem of wearing multiple layers of clothing and resisting to change or remove the clothing The goal with a target date of 5/27/22 revealed, The resident will have fewer episodes of wearing multiple layers of clothing weekly, by review date. Interventions were Assist the resident to develop more appropriate methods of coping and interacting; Encourage the resident to express feelings appropriately; Explain all procedures to the resident before starting and allow the resident 5-10 (minutes) to adjust to changes; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Praise any indication of The resident's progress/improvement in behavior. Resident 26 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, diabetes mellitus, and hypertension. Resident 26's medical record was reviewed. Resident 26's quarterly MDS dated [DATE] revealed a BIMS score of 5 which indicated severe cognitive impairment. The MDS further revealed resident 26 walked in corridor, walked in room, locomotion on the unit and locomotion off the unit required supervision and setup help only. Resident 26's care plan 8/3/21 revealed The resident has a behavior problem r/t (related to) Schizophrenia. The goal was The resident will have no evidence/decrease of behavior problems by review date. Interventions developed were Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. On 8/29/21, resident 26 was found in a room with resident 31 by a surveyor during a recertification survey. Resident 26 had his penis exposed while standing directly in front of resident 31. Resident 31 had her back to the wall. This incident was cited as part of the annual recertification survey. There were no progress notes in resident 26's or resident 31's medical record regarding the incident on 8/29/21. A nursing progress note dated 9/4/21 at 10:41 PM revealed, resident 26 was observed touching staff and other residents without consent. On 9/17/21, the facility reported to the state survey agency that resident 31 had been found naked with resident 26 in a room in the locked unit. A nursing progress note by Licensed Practical Nurse (LPN) 1 in resident 31's medical record revealed on 9/17/21 at 3:24 PM, Resident was found in room [ROOM NUMBER] on the bed naked with another resident (male). CNA informed me and RN and we directed male resident back to his room and resident was assessed by RN and CNA then re-dressed while I informed the Administrator at 0645 (6:45 AM), which he addressed the occurrence to proper authorities. Resident was transported to [local hospital] ER (emergency room ) to be assessed. Resident returned with order for doxycyline 100 mg one PO (by mouth) BID (twice daily) x 7 days.Incident report completed. A nursing progress note by the DON dated 9/17/21 revealed that a physician's order was received to transfer resident 26 to the emergency room for possible transfer to a mental health facility. At 4:21 PM, resident 26 was transported to a local emergency room (ER) for mental health evaluation. A nursing progress note by LPN 1 in resident 26's medical record revealed on 9/17/21 at 2:59 PM, Resident was found by CNA in room [ROOM NUMBER] with another resident (Female) naked on the bed at 0645 (6:45 AM). CNA informed Me (Nurse) and Charge nurse and we directed resident to his room and informed him to stay in his room until one of us (Nursing staff) comes back. RN and CNA assessed the female resident and re-dressed her and remained with her. I Phoned Facility Administrator at time of incident and informed him of the incident. Administrator stated he will advise and report to proper authorities, I informed Administrator both individuals were separated and one on one staff until further notice. A nursing progress note dated 9/18/21 at 10:04 PM revealed, resident 26 was moved to a room outside of the locked unit. The note further revealed resident 26 frequently wandered into the rooms of female resident and was sexually inappropriate with residents and staff. Staff were to continue to monitor resident 26. A nursing progress note dated 9/25/21 at 11:06 PM revealed resident 26 had been sexually inappropriate with the female staff. Resident 26's Medication Administration Record indicated that staff were to monitor resident 26 for sexually inappropriate behaviors as of 9/25/21. Resident 26 was also started on Risperdol as of 9/26/21. A physician's progress note for resident 31 dated 10/18/21 at 12:54 PM, .On 9/17 she was found naked with a male resident on top of her. She was transported to the ER where evaluation did not reveal signs of physical trauma. A nursing progress note dated 12/4/21 at 10:18 PM revealed resident 26 was occasionally sexually inappropriate. A nursing progress note dated 1/2/22 at 1:29 AM revealed resident 26 had allegedly not harmed anyone. A nursing progress note dated 7/10/22 at 2:18 AM revealed resident 26 was discovered missing about 7:30 PM. Staff checked every room and the outside around the entire building. Police, Administrator and physician were notified. A nursing progress note dated 7/10/22 at 1:22 PM revealed police returned resident 26 at approximately 10:30 AM and a physician's order was obtained to change room to memory lane, despite his history of sexually abusing resident 31, who still resided on the memory care unit. The progress note indicated that resident 26 was happy to see his old roommate. Resident 26's monthly nurses assessments for the months of September 2021, October 2021, November 2021, December 2021, January 2022, April 2022, June 2022, and July 2022 documented that resident 26 had sexual behaviors but did not indicate what the behaviors were. [It should be noted that the monthly assessments for February 2022, March 2022, May 2022, August 2022, and September 2022 were not able to be located in resident 26's medical record.] A nursing medication administration note dated 8/28/22 at 1:32 PM, revealed resident 26 was seen by other resident pulling a female resident into his bathroom. he noticed he was caught and let her go. An entity report dated 8/29/22 revealed that on 8/26/22 resident 31 and resident 26 lived on the secured unit in the nursing facility. Resident 31 was often found pacing. She wanders in and out of any room and often climbed into bed when she is tired. She also immediately takes off her brief when they are wet. It is believed that she climbed into his bed. He often sleeps with just a T-shirt or naked. While CNAs were doing rounds they found them both in bed with no briefs on. The RN did checks and found no evidence of any encounter. Residents were sent to their own rooms. [Resident 26] is a client of [local mental health company] the provider is looking at adjusting medications and increased visits from case manager and LCSW. Resident 26 and 31's nursing progress notes were reviewed and there were no notes in either of the residents medical records regarding this event. Review of resident 26's care plan indicated that no interventions had been put into place to prevent further incidents with resident 31 after the incident on 8/26/22. A nursing progress note regarding resident 26 dated 9/4/22 at 12:16 AM revealed, has been doing about the same. We have to watch him so he doesn't coax one of the ladies into his room. On 10/1/22, resident 26 was documented as demonstrating inappropriate behavior, such as making inappropriate comments to this nurse. Resident says 'I need you tonight' 'I love women and trying to kiss on the hand. Resident was reminded of appropriate communication and that these comments are unacceptable. Resident verbalized understanding 'okay okay '. Review of resident 26's September and October 2022 TAR indicated that staff had not been consistently documenting resident 26's sexual behaviors. An incident/accident report dated 10/5/22 at 2:15 PM, revealed resident 31 was walking through the hallway without her clothes on, CNA found resident's clothes in closet of room # 104 ? at 2:15 PM. No injuries. [It should be noted the 104 was written over another room number that was unreadable.] The additional comments and/or steps taken to prevent reoccurrence were clothes to be ordered; to remind staff that designated CNA needs to be on the unit at ALL TIMES; and ensure staff on unit. The incident report was not signed by the Medical Director or Administrator until 10/17/22 when it was reviewed. A nursing progress note dated 10/5/22 at 3:48 PM by LPN 1 revealed, Resident (31) walking down hall on memory unit without her clothes on and other residents saw her naked. CNA's assisted resident to cloth (sic) her. CNA found resident's clothes in closet of room [ROOM NUMBER]. Resident's granddaughter witnessed the incident, and she is CNA here today this shift. I counseled the designated CNA working on memory unit and wrote action taken form and DON present during this write up. Copy of write up given to Admin '[name removed]'. NP (Nurse Practitioner) informed as well as family. On 10/12/22, both residents were observed to residing on the memory care unit that was the locked unit of the facility. Resident 26 resided in room [ROOM NUMBER] and resident 31 resided in room [ROOM NUMBER]. On 10/12/22 an observation was made of resident 31. At 2:59 PM, resident 31 was observed to wander into the door way of room [ROOM NUMBER] and was redirected by staff. At 3:03 PM, resident 31 was wandering into room [ROOM NUMBER]. At 3:08 PM, resident 31 wandered into room [ROOM NUMBER]. On 10/11/22 at 4:10 AM, an observation was made of RN 1, Certified Nursing Assistant (CNA) 6 and CNA 7 at the nurses station. The memory care unit was unattended until 4:22 AM when CNA 6 was observed to enter the unit. At 4:43 AM, CNA 6 was observed to exit the memory care unit. At 5:48 AM, CNA 6 entered the memory care unit. Resident 36 was observed to be ambulating up and down the hallway during that time. [It should be noted the memory care unit was unattended for 1 hour and 5 minutes.] On 10/22/22 at 10:40 PM, an observation was made of CNA 6, CNA 7 and RN 5 at the nurses station. The memory care unit was unattended until 10:51 PM. Resident 36 was observed wandering the hallway. At 11:19 PM, CNA 6 was observed to leave the memory care unit. At 11:25 PM, CNA 6 was observed to return to the memory care unit. At 11:56 PM, CNA 6 and CNA 7 were observed to leave the memory care unit. At 11:57 PM, RN 5 entered the memory care unit. On 10/23/22 at 12:04 AM, RN 5 was observed to leave the memory care unit and open the door to the magnet. RN 5 was observed to wheel the charts in front of the open door. Resident 36 was observed wandering the hallway. RN 5 was observed to sit behind the charts near the open door. At 12:35 AM, CNA 6 and CNA 7 were observed to enter the memory care unit. At 12:37 AM, resident 31 was observed wandering the hallway without pants, wearing only a sweatshirt and brief. Resident 36 and resident 7 were observed in the hallway. On 10/22/22 at 11:22 AM, an interview was conducted with CNA 6. CNA 6 stated she witnessed an incident between resident 26 and resident 31 a couple of months ago. CNA 6 stated she finished changing resident 31's brief and went into another residents room and was changing another resident. CNA 6 stated when she went back to check resident 31 she was missing. CNA 6 stated she searched room to room and found resident 31's brief and pants were off and resident 26's brief and pants were pulled down to his knees. CNA 6 stated she told RN 6. CNA 6 stated that she was not questioned by the Administrator or DON regarding the incident. CNA 6 stated that resident 31 was placed on 15 minutes checks. CNA 6 stated that resident 26 continued to reside on the memory care unit after the incident. CNA 6 stated resident 26 told the nurse that he was in trouble and he knew what he did was wrong. CNA 6 stated he keeps doing it and he gets caught every time he does anything to resident 31. CNA 6 stated a CNA reported to her on evening shift that resident 26 was holding the door closed in the shower room with resident 31. CNA 6 stated another time she was told that resident 31 was in resident 26's room naked behind the curtain. CNA 6 stated that she was told to keep an eye on him. CNA 6 stated sometimes she had to leave the memory care unit unattended to make sure other residents were receiving care. [It should be noted that the incidents referenced above had not been reported to the State Survey Agency.] On 10/12/22 at 10:17 AM, an interview was conducted with CNA 2, who was also resident 31's family member. Resident 31's family member stated on 10/5/22 it was shift change about 2:00 PM, there were no staff members on the memory care unit. Resident 31's staff member stated that a resident was banging on the doors to get staff attention outside of the memory care unit. Resident 31's family member stated she looked in and resident 31 was walking down the hall naked with no clothes on. Resident 31's family member stated that resident 31's clothes were nowhere to be found. Resident 31's family member stated that resident 31's clothing were found in room [ROOM NUMBER]'s closet. Resident 31's family member stated resident 31 was able to take her pants down but did not take her brief off and resident 31 was not capable of placing her clothing in a closet. Resident 31's family member stated that she was upset about the incident and talked to the DON. Resident 31's family member stated that DON told her to talk to the Administrator. Resident 31's family member stated she told the Administrator but the Administrator had people in her office and she stated to the resident's family member she was busy doing payroll. Resident 31's family member stated the Administrator stated to her she needed to talk to the nurse. Resident 31's family member stated she went back to the DON and demanded that something happen. Resident 31's family member stated she was trying to report an abuse allegation. Resident 31's family member stated the DON reviewed the camera footage of the memory care unit with her. Resident 31's family member stated there was nothing on the footage because room [ROOM NUMBER] was directly below the cameras. Resident 31's family member stated all they could see was resident 31 walking in the hallway naked. Resident 31's family member stated they could not see resident 31 walk into a room and when they saw her she was in the hallway with clothing and then suddenly she was naked. Resident 31's family member stated resident 26's room was joined to room [ROOM NUMBER] through a bathroom. Resident 31's family member stated that CNA 1 was counseled about not leaving the locked unit unattended. Resident 31's family member stated she felt something was happening to resident 31 from resident 26. Resident 31's family member stated that resident 26 stated to her that resident 31 was beautiful and he loved her. Resident 31's family member stated that resident 31 wandered into other resident rooms and if there was no staff in the hallway, she will go into anyone's room. Resident 31's family member stated resident 31 would not let staff take off her pants and would say No, don't touch me dirty man. Resident 31's family member stated resident 31 was very jumpy and resident 31 was never like that before. On 10/17/22 at approximately 10:00 AM, an interview was conducted with the DON. The DON stated that CNA 2, who was a family member to resident 31, was upset on 10/5/22 and the DON stated she assumed the nurse had addressed it and that CNA 2 talked to the Administrator. The DON stated that CNA 2 returned from talking to the Administrator and CNA 2 told the DON she wanted something done. The DON stated that she reviewed camera footage because CNA 2 insisted to find out what happened to resident 31's clothing. The DON stated that resident 31 was in the memory care unit hallway with no clothing on. The DON stated that CNA 2 was very upset. The DON stated she was having a hard time remembering what she saw from the camera footage. The DON stated she thought resident 31 exited room [ROOM NUMBER] without clothing and did not see resident 31 enter a room because the video footage jumped 5 minutes at a time. The DON stated the memory care unit was unattended by staff for about 10 minutes. The DON stated the locked unit was supposed to have staff at all times. The DON stated she had LPN 1 complete an incident report. The DON stated she reported the incident to the Administrator immediately. The DON stated she put a care plan in for resident 31 after the incident. The DON stated that in the position she was in, she did everything she could by watching LPN 1 counsel CNA 1 about not leaving the unit. The DON stated she educated CNA's that this happens with dementia and with increasing dementia this can happen. The DON stated resident 31 was able to remove her own clothing. The DON stated she also would like the family to be involved with care planning and maybe getting resident 31 onesies that zip in the back so she was unable to remove her clothing. The DON stated after resident 31 was found naked in the hallway she assessed resident 31. The DON stated resident 31 was clothed and there was no bruising or red marks on her back. The DON stated that In my opinion, I couldn't tell if it was an abuse allegation or an incident. On 10/17/22 at 11:13 AM, an interview was conducted with CNA 1. CNA 1 stated on 10/5/22 when resident 31 was found naked in the locked unit, I was off the hall. CNA 1 stated she was waiting for the next shift to come into work. CNA 1 stated she was talking to another staff member and resident 31 was walking down the hallway with no clothes on. CNA 1 stated staff ran down the hallway to resident 31. CNA 1 stated resident 31 went into room [ROOM NUMBER] which was resident 26's room and her clothes were found in room [ROOM NUMBER]'s closet. CNA 1 stated resident 26 and his roommate were in their room when resident 31 went in. CNA 1 stated resident 31 wanders everywhere. CNA 1 stated she figured out a different system for resident 31. CNA 1 stated resident 31 was changed at 12:30 PM or 1:00 PM and then at 3:00 PM because that was when she usually had a bowel movement. CNA 1 stated there should be staff in the locked unit at all times. CNA 1 stated I was not on the hall which I take responsibility for. CNA 1 stated she was not sure if resident 31's clothing was soiled or wet when they were found. CNA 1 stated resident 31 was pacing the hallway yesterday and needed to be changed and did not take her clothing off. CNA 1 stated she was instructed by LPN 1 and the DON to stay in the memory care unit at all times and keep an eye on resident 31 and anyone that tried to bother her. CNA 1 stated other staff have told her that resident 31 takes her clothing off, but she had never seen resident 31 take her clothing off. CNA 1 stated she had found resident 31 without a brief on so she figured resident 31 removed it herself. On 10/17/22 at 2:18 PM, an interview was conducted with CNA 8. CNA 8 stated 2 or 3 weeks ago she was sitting at the desk at about 2:20 PM and was waiting for another CNA to come to the locked unit to get report. CNA 8 stated resident 9 was knocking on the door and was asking for ice. CNA 8 stated she opened the door to give resident 9 ice and saw resident 31 naked in the hallway. CNA 8 stated resident 31 was outside the dining room toward her room. CNA 8 stated she took resident 31 to her room and dressed her. CNA 8 stated CNA 2, CNA 3 and CNA 4 were at the facility. CNA 8 stated she reported to the nurse what had happened. CNA 8 stated after the incident, she was told to be in the hall and care for the residents even though she was scheduled to work another hallway. CNA 8 stated she also told the DON about the incident. CNA 8 stated the DON was mad at us because no one was in the hallway. CNA 8 stated she stayed a little bit because CNA 2 was mad and wanted to look at the cameras to see what happened. CNA 8 stated she was the first CNA to see resident 31 naked in the hallway and there were other residents in the hallway. CNA 8 stated resident 31's mind was not good, so she did not know what was happening. CNA 8 stated resident 26 knew what was happening. CNA 8 stated she did not want anything to happen to resident 31 so she puts her on the couch. CNA 8 stated a Night CNA told her that when she received report to make sure resident 26 was not close to resident 31. CNA 8 stated she did not ask why she needed to keep them apart. CNA 8 stated she had been told that resident 31 and resident 26 had been found in bed together. CNA 8 stated she would be more careful with resident 31 and not leave her alone since she knew the residents had been found in bed together. CNA 8 stated she tried not to leave her alone since then, but things happened really fast. CNA 8 stated that resident 31 was unable to remove her own clothing. CNA 8 stated resident 31 won't allow for staff to pull her pants down when she needed to be changed. CNA 8 stated resident 31 would need assistance with removing all of her clothing including her shirt. On 10/17/22 at 11:28 AM, an interview was conducted with the Administrator. The Administrator stated it was a daily occurrence that resident 31 did not have clothing on. The Administrator stated that once resident 31 was wet, she removed her bottoms. The Administrator stated that she had been trying to find things like taking her to the bathroom, so she did not remove her clothing. The Administrator stated resident 31 wandered all the time and removed her clothing wherever she wanted and continued wandering. The Administrator stated resident 31 wandered in and out of everyone's room on the locked unit. The Administrator stated resident 31 was friendly with everyone. The Administrator stated she was not sure if resident 31 was able to remove her shirt herself. The Administrator stated resident 31 could get her bottoms off fast. The Administrator stated she would not have looked into anything or questioned possible abuse with resident 31 coming out of another residents room with no clothing. The Administrator stated there were times the memory care unit was unattended by staff when staff were coming and going but staff should ask other members to cover the hallway. On 10/17/22 at 11:38 AM, an interview was conducted with Medical Director (MD). The MD stated there was an incident report dated 10/5/22 regarding resident 31 not having her clothing on in the hallway. The MD stated it was reported to her but when she reviewed the incident report, the room number on the incident report was changed. The MD stated she was informed that resident 31's clothing was found in room [ROOM NUMBER], but it was changed to room [ROOM NUMBER]. The MD stated she had not received all the details about the incident. On 10/17/22 at 12:10 PM, a follow up interview was conducted with the MD. The MD stated she was informed by CNA 1 that resident 26 was found fondling resident 31 today. The MD stated she talked to resident 26 and he stated I need to go to jail. The MD stated resident 26 stated I was playing around with an older woman, [resident 31]. The MD stated he did not go into specifics but he said sexual stuff. On 10/17/22 at 12:21 PM, an interview was conducted with resident 26. Resident 26 was observed in the locked unit dining room. Resident 26 stated he had sex and pointed to resident 31. Resident 26 stated her name was (resident 31). Resident 26 stated he needed to go to jail because resident 31 walked around with her pants down. Resident 26 stated he did not always have full sex with resident 31 sometimes it was him putting his penis from front to back on resident 31 like a hot dog. Resident 26 stated he had sex with resident 31 six times. On 10/17/22 at 12:22 PM, an interview was conducted with CNA 2. CNA 2 stated that at approximately 11:00 AM that day, she was assisting CNA 4 in walking resident 36 to the shower room. CNA 2 stated resident 31 was sitting on a sofa in the hallway which was near resident 26's room. CNA 2 stated she helped get resident 36 into the shower room and turned on the hot water and went back to the hallway. CNA 2 stated resident 31 was nowhere to be found. CNA 2 stated she went back to CNA 4 and stated she was unable to find resident 31. CNA 2 stated she went to resident 26's room and found resident 31 standing in front of resident 26 sitting on the toilet. CNA

Based on interview, record review, and observation, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, residents, resident family members, and staff voiced concerns with the staffing levels. However, observations were made of the Memory Care Unit left unattended, there were not enough activity staff members, Activities of Daily Living (ADLs) were not completed, and at least one resident experienced a fall. Resident identifiers: 7, 9, 22, 26, 30, 31, 36, and 93. Findings Include: RESIDENT FALLS 1. Resident 30 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (MS), neuropathy, insomnia, obesity, chronic pain, and depression. On 10/11/22 at 9:40 AM, resident 30 was observed to be sitting in a wheelchair. Resident 30 stated that she had a recent fall because there is nobody to help get you up. On 10/31/22, resident 30's medical record review was completed. Fall reports were requested, and one was created for resident 30. On 6/12/22 at 11:00 AM, resident was transferring with the assistance of a Certified Nursing Assistant (CNA) from her bed to her wheelchair when resident missed the chair. Hit buttocks and head. Neuros (Neurological assessments) started. No injuries. Nursing notes revealed the following: a. On 11/6/21, resident 30 had a fall at approximately 8:00 AM in the dining room. Her wheelchair broke. b. On 6/12/22 at 11:56 AM, resident 30 had a fall at approximately 11:00 AM. fell while transferring to wheelchair, hit buttocks and head, no injuries .Will transfer resident 2 person assist today and as needed. c. On 7/21/22 at 5:37 AM, it was charted that resident 30 slid out of her wheelchair at 9:00 PM on 7/20/22. Resident 30 had been repositioned in her wheelchair prior to the fall and resident 30 was being assisted to the restroom. d. On 10/7/22 at 3:41 PM, it was reported that on 10/4/22, resident 30 had a fall. Resident 30's care plan revealed that resident 30 has limited physical mobility r/t (related to) weakness. Resident 30 was identified as moderate, risk for falls r/t gait/balance problems. Additionally, resident 30 had fall checks due to taking psychotropic medications. No actual falls were documented, and no fall interventions were initiated for resident 30. Physician and Nurse Practitioner (NP) notes on 2/7/22, 3/24/22, 7/21/22, 9/22/22, and 9/26/22 revealed that resident 30 stated her MS was getting worse and wanted to be seen by her neurologist. On 7/21/22, resident 30 had an appointment to see her neurologist in September, and resident 30 reported bowel control had decreased. On 2/7/22 at 2:13 PM, a new order (as stated in the nursing notes) was initiated for resident 30 to follow up with her neurologist because resident 30 was complaining of increased weakness in right arm and leg. Resident 30 was not able to follow-up with her neurologist. Resident 30 stated that she had made an appointment, but there was no one to take her, so the staff had canceled the appointment and had not made a new appointment. On 10/18/22 at 12:22 PM, an interview was conducted with CNA 4. CNA 4 stated that resident 30 required two CNAs to safely transfer her. On 10/27/22 at 12:24 PM, RN 3 was interviewed. RN 3 stated that resident 30 did not transfer on her own, and had not tried to self-transfer for several years. RN 3 stated that sometimes resident 30 required two people to transfer, depending on her strength. On 10/27/22 at 4:15 PM, an interview was conducted with CNA 5. CNA 5 stated that when resident 30 fell on [DATE], Registered Nurse (RN) 1 was transferring resident 30. CNA 5 stated that she told RN 1 not to transfer resident 30 because sometimes resident 30's legs buckled when she was being transferred. CNA 5 stated that RN 1 tried to transfer resident 30 alone and dropped her. CNA 5 stated that RN 1 called her phone and said that RN 1 had dropped resident 30. CNA 5 stated that she had reported to the interim DON that the fall had occurred and RN 1's role in the fall. RESIDENT INTERVIEWS 2. On 10/11/22 at 6:32 AM, an interview was conducted with resident 9. Resident 9 stated there were not enough staff. Resident 9 stated there were supposed to be 2 CNA's for each floor which is a joke. Resident 9 stated there was usually only 1 CNA for the entire facility. Resident 9 stated staff were expected to come to work sick. Resident 9 stated staff did not show up. Resident 9 stated he talked to the Director of Nursing (DON) about the issue. Resident 9 stated if he pushed the call light, then he had to wait 2 hours. Resident 9 stated he was only checked on every 2 hours when staff come to check briefs. 3. On 10/18/22 at 11:00 AM an interview with resident 9 was conducted. Resident 9 stated, again, that the facility did not have enough staff. Resident 9 stated that sometimes it would take staff two hours to answer his call light. 4. On 10/11/22 at 8:37 AM an interview with resident 22 was conducted. Resident 22 stated that the facility was understaffed. Resident 22 stated that it took a long time for the call light to be answered by staff. FAMILY INTERVIEWS 5. On 10/12/22 at 10:33 AM, an interview was conducted with resident 31's family member. Resident 31's family member stated there were not enough staff for the memory care unit and it had been left unattended. Resident 31's family member stated CNA 6, the night CNA, did not change residents briefs at night. Resident 31's family member stated CNA 6 did not get everything done at night. Resident 31's family member stated only 1 CNA showed up for the evening shift. On 10/17/22 at 12:22 PM, an interview was conducted with a family member (FM) of resident 31. The FM stated that resident 31 had been falling, and was recently abused. The FM stated that the staff weren't treating resident 31's skin issues, and when the FM attempted to talk to the Administrator (ADM), the ADM was always busy. 6. On 10/18/22 an interview was conducted with a FM for resident 93. When asked about the care at the facility, the FM stated they are terrible . If I could do it again I would never put my loved one there again. I would never say anything nice it was a hell hole. We were worried that she (resident 93) would pass and no one would know it. Resident 93's FM stated that residents in the Memory Care Unit were often left alone. Resident 93's FM also stated that the Memory Care Unit would be unlocked and then they are blocking it with resident charts. The FM stated that both she and other FMs had walked through the Memory Care Unit, and there were no staff present. The FM further stated that she had complained to the ADM multiple times about poor staffing. The FM stated that her family was so worried about their loved one, there was a family member present every day with resident 93, until resident 93's FMs were able to admit resident 93 to a different facility. OBSERVATIONS 7. On 10/11/22 at 4:10 AM, an observation was made of RN 1, CNA 6 and CNA 7 at the nurses station. The memory care unit was unattended until 4:22 AM when CNA 6 was observed to enter the unit. At 4:43 AM, CNA 6 was observed to exit the memory care unit. At 5:48 AM, CNA 6 entered the memory care unit. Resident 36 was observed to be ambulating up and down the hallway during that time. [It should be noted the memory care unit was unattended for 1 hour and 5 minutes.] 8. On 10/22/22 at 10:40 PM, an observation was made of CNA 6, CNA 7 and RN 5 at the nurses station. The memory care unit was unattended until 10:51 PM. Resident 36 was observed wandering the hallway. At 11:19 PM, CNA 6 was observed to leave the memory care unit. At 11:25 PM, CNA 6 was observed to return to the memory care unit. At 11:56 PM, CNA 6 and CNA 7 were observed to leave the memory care unit. At 11:57 AM, RN 5 entered the memory care unit. On 10/23/22 at 12:04 AM, RN 5 was observed to leave the memory care unit and open the door to the magnet. RN 5 was observed to wheel the charts in from of the open door. Resident 36 was observed wandering the hallway. RN 5 was observed to sit behind the charts near the open door. At 12:35 AM, CNA 6 and CNA 7 were observed to enter the memory care unit. At 12:37 AM, resident 31 was observed wandering the hallway without pants, wearing a sweatshirt and brief. Resident 36 and resident 7 were observed in the hallway. 9. On 10/27/22 between 2:00 PM and 2:15 PM, the DON, CNA 4, CNA 1, and CNA 3 were observed at the nurses station talking. The DON stated that the of the two CNAs that was supposed to show up did not, so CNA 5 was the only person scheduled for the evening shift from 2:00 PM to 10:00 PM. The CNA that did not show up for the evening shift was also the only CNA scheduled to work the night shift from 10:00 PM to 6:00 AM. The DON was observed to ask CNA 5 if she could work a double shift that day, for a total of 16 hours. CNA 5 stated that this was her first shift working after being released after a week stay in the hospital, and that she did not feel physically capable of working 2 shifts. On 10/27/22 at 4:15 PM CNA 5 was interviewed and stated she was going to work a double shift because there was no one else coming in. STAFF INTERVIEWS 10. On 10/20/22 at 10:00 AM, an interview was conducted with Employee (E) 4. E 4 stated that RN 1 had marijuana in the building, but the ADM did not want to fire RN 1 because of staffing issues. 11. On 10/22/22 at 11:27 PM, an interview was conducted with CNA 6. CNA 6 stated she worked the night shift and there were not always 2 CNAs, so she was often by herself. CNA 6 stated she asked the nurse to help and sometimes they were not available. CNA 6 stated if there was only 1 CNA, then she opened the doors to the memory care unit so the nurse could watch the memory care unit. CNA 6 stated the nurse alerted the CNA if there was a call light alarming. CNA 6 stated there were 2 residents that required 2 person assistance with bed mobility. CNA 6 stated that there was supposed to be at least one additional CNA on her shift, but that if the other person called in sick, the ADM would not make sure the shift was covered. CNA 6 stated that she was still expected to complete all of her assigned tasks even when she was the only CNA on duty, but she was unable to do so. 12. On 10/23/22 at 12:48 AM, an interview was conducted with CNA 7. CNA 7 stated Staffing is rough. CNA 7 stated usually there were 2 CNAs, but usually Wednesday and Sundays there was only 1 CNA. CNA 7 stated the nurse did not usually help. CNA 7 stated that she had worked with RN 1 and that RN 1 was regularly sleeping on the job, and RN 1 was not really functional. CNA 7 stated that it was difficult to tell what the exact problem was with RN 1, if she was under the influence of something. CNA 7 stated that extra cleaning stuff was not completed during her shift because of staffing. CNA 7 stated there were 2 residents that needed 2 staff members to change them. 13. On 10/27/22 at 4:15 PM, an interview was conducted with CNA 5. CNA 5 stated that the facility was short-staffed, and that she had reported her concerns to the DON and the ADM, but they had replied with we're working on it. CNA 5 stated that the dining rooms have to go unattended at times because of the staffing levels. CNA 5 confirmed that there were not always staff present on the Memory Care Unit because of the staffing levels. 14. On 10/24/22 at 2:30 PM, an interview was conducted with the DON. The DON stated that she was acting as the DON on an interim basis because she did not want to be the DON. The DON stated that she had been helping in that role for three years. The DON stated that in addition to her duties as a DON, she often was also the only nurse working the floor, and responsible for 40 residents. The DON stated that she wrote up staff for not showing up to work their shifts. The DON stated that RN 1 had been written up when she appeared to be impaired. The DON stated that she needed more staff working at night. The DON stated that there were only two CNAs that worked at night, which meant that it was difficult to watch the locked unit and get everything else done. The DON stated that the facility was short staffed, usually when the CNAs didn't show up to work. The DON stated that she was concerned particularly for the locked unit. The DON stated that she had told the ADM they needed more staffing at night because anything could happen back there (the Memory Care Unit). we could have abuse, neglect, everything, you name it. these people need to have somebody . a lot of them can't function by themselves. 15. On 10/25/22 at approximately 1:00 PM, RN 3 was interviewed. RN 3 stated that residents' appointments had to be canceled because staff couldn't guarantee transportation. RN 3 stated that there was not enough staff for transportation. On 10/27/22 at 1:36 PM, RN 3 was interviewed again. RN 3 stated that she and the DON had asked the ADM to work with an agency when they were struggling really bad in April 2022. RN 3 stated that she did not hear anything about agency staffing. RN 3 stated that the ADM called everyone who used to work there to find someone to work. RN 3 stated that she worked 5:00 AM to 5:00 PM, and had never had to work later than 9:00 PM, or 10:00 PM, but the DON had worked later many times. 16. On 10/26/22 at 6:11 PM, the Certified Therapeutic Recreation Specialist (CTRS) was interviewed. The CTRS stated that the last time she was contacted by the facility was in July, 2022. The CTRS stated that she was not consulted because no staff are working full time with activities. The CTRS stated that she found out in August, 2022, that the Therapeutic Recreational Technician (TRT) was not coming to the facility. The CTRS stated that she did not know there was no resident council, and there needed to be a minimum of 4 hours of therapeutic activities run by a TRT during the day. The CTRS stated that activities such as painting fingernails would be a diversionary activity. 17. On 10/27/22 at 1:27 PM, an interview as conducted with Employee 9 (E 9). E 9 stated that she had seen a CNA cry because the facility was short staffed. E 9 stated that the ADM was informed of the staffing issues, but nothing changed. 18. On 10/27/22 at 1:06 PM, a telephone interview was conducted with the Medical Director (MD). The MD stated that when the facility was short staffed, the ADM told her that the ADM could not afford to have agency in the building. The MD stated that she had been at the facility when there was only one nurse and one CNA working. The MD stated that she feared for the residents' safety due to the poor staffing levels. ADMINISTRATOR INTERVIEWS 19. On 10/20/22 at 12:55 PM, the ADM was interviewed. The ADM stated that when staff were required to provide one-on-one staffing for resident 26, staff were pulled away from doing maintenance, social work, and the kitchen. The ADM stated that the medical records staff and receptionist were utilized and weren't able to get much else done. The ADM stated that the interim DON had lots of time to be the nurse, get everything done, and then sit around. On 10/25/22 at 1:35 PM, the ADM was interviewed. The ADM stated that the facility did not have a resident advocate. The ADM stated that she was going to train the receptionist to do the resident advocate stuff. The ADM stated that when the facility has been short staffed overnight, the ADM asked the evening staff to stay, or has someone come in early to do rounds in the morning. The ADM stated, We're being real creative since nobody wants to work. On 10/27/22 at 2:00 PM, the ADM was interviewed. The ADM stated that she was responsible for the COVID-19 testing, and was not sure when staff was testing. The ADM stated that she did not have time to follow-up with staff to ensure testing occurred. The ADM stated that there was a new office person to help file documents in the resident's charts, but she doesn't know anything yet. The ADM stated that there was an accounting firm that assisted with residents' accounts who came to the facility on ce a quarter, but had not been to the facility in approximately 4 months. The ADM stated that there was usually only one nurse in the building each shift, responsible for the 41 residents. The ADM stated that it may be the interim DON or assistant DON (ADON), but they had plenty of time in the afternoon to take care of their DON duties. The ADM stated that if there were staffing issues, the ADM had to contact people to try to get someone to come in. The ADM stated that sometimes nurses and CNAs had to work extra shifts, and the ADM had been trying to get a contract with some of these agency things. The ADM stated that there was never a night without coverage. The ADM stated that she had not utilized agency staffing and had no contracts. The ADM stated that sometimes she stayed late and helped with trash and other duties that the CNAs didn't have time to do. The ADM stated that she could not afford to use agency long term. The ADM stated that she had a family member who was a nurse, but thought she was too good for nursing homes but would come and help occasionally. [Cross refer to F600, F676, F679, F689, F835, F838, and F840] 40334 22992 45470

Based on interview, record review, and interview, the facility did not develop and implement appropriate plans of action to correct identfied quality deficiencies. Specifically, multiple instances of harm or immediate jeopardy were identified during the annual recertification survey. In addition, during this survey mutliple deficiences cited on the previous annual recertification survey were not corrected, and were cited again during this survey. Resident identifiers: 4, 7, 8, 9, 10, 11, 13, 14, 15, 22, 26, 29, 30, 31, 32, 34, 36, 37, 39, 93, and 94. Findings include: 1. Based on observations, interviews and record review, it was determined for 8 of 33 sampled residents, that the facility failed to protect the resident's right to be free from physical abuse and sexual abuse by other residents. Specifically, one resident with severe cognitive impairment was sexually abused by a resident that was congitively intact. This identified deficient practice was found to have occurred at the Immediate Jeopardy (IJ) Level. Additionally, incidents of physical abuse between residents and a bruise with an unknown origin were identified at a potiential for harm level. Resident identifiers: 7, 9, 14, 15, 26, 31, 36 and 39. [Cross refer to F600] 2. Based on observations, interviews, and record reviews it was determined, for 2 of 33 sampled residents, that the facility did not provide residents with the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This included but was not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Specifically, residents were placed in the locked unit without assessments to determine if the residents met the criteria for the unit and were not provided with access codes or other information for independent egress. Resident identifiers: 7 and 9. [Cross refer to F603] 3.Based on observation, interview and record review it was determined, for 8 of 33 sampled residents, that in response to an allegation of abuse the facility did not report immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse. In addition, the facility did not report the results of the investigation within 5 working days of the incident and if the alleged violation was verified appropriate corrective action was taken. Specifically, the facility did not report within 2 hours when a resident was found with another resident without clothing, the resident was found without clothing, and the same resident was found being touched in the genitals by another resident. Additional, the facility did not report when two residents, who were unable to consent, were found having oral sex. This was found to have occurred at an immediate jeopardy level. In addition, a bruise was discovered on a resident and it was not reported. In addition, there was physical abuse between residents that was not reported. Resident identifiers: 9, 13, 14, 15, 26, 31, 36 and 39. [Cross refer to F609] 4. Based on observation, interview and record review it was determined, for 8 of 33 sampled residents, that in response to allegation of abuse, the facility did not have evidence that all all leeged violation were thoroughly investigated and reported to the State Survey Agency within 5 days of the incident, and if the alleged violations were verified appropriate corrective action was taken. Specifically, there were no thorough investigations when a severly impared cognitive resident was sexually abused by a resident that was cognitively intact and when two residents were not assessed for ablitiy to consent, engaged in oral sex. These example were cited at an Immediate Jeopary level. In addition, the facility did not thoroughly investigate when a resident eloped from the facility, a resident had a bruise of unknown source and residents had a physical altercation. These examples were cited at a potiential for harm. Resident identifiers: 9, 13, 14, 15, 26, 31, 36 and 39. [Cross refer to F610] 5. Based on observation, interview and record review it was determined, for 3 of 33 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident was not provided diabetic management, antibiotics as ordered, or wound care which resulted in an amputation. Another resident was not provided treatment for a rash and the resident was unable to move in bed. These were cited at a harm level. In addition, a resident was not treated for her psoriasis. Resident identifiers: 29, 31 and 32. [Cross refer to F684] 6. Based on interview, observation and record review, the facility did not ensure that 7 of 33 sample residents maintained acceptable parameters of nutritional status. Specifically, residents with weight loss did not receive timely and appropriate interventions. One resident will be cited at a harm level due to continued weight loss with no new interventions. Resident identifiers: 4, 7, 13, 31, 32, 36, and 37. [Cross refer to F692] 7. Based on observation, interview, and record review it was determined, for 1 of 33 sampled residents, that the facility failed to provide appropriate treatments and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. Specifically, physician orders to prevent a clogged feeding tube were not followed for a resident who was receiving enteral feeding. Resident identifier: 4. [Cross refer to F693] 8. Based on observation, interview and record review it was determined, for 2 of 33 sampled residents, that the facility did not ensure pain management was provided to residents who required such services. Specifically, a resident screamed out in pain when he was repositioned. Another resident went to the hospital and his scheduled pain medication was discontinued when he returned. The resident complained of uncontrolled pain. These examples will be cited at a harm level. Resident identifiers: 14 and 32. [Cross refer to F697] 9. Based on interview, record review, and observation, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, residents, resident family members, and staff voiced concerns with the staffing levels. However, observations were made of the Memory Care Unit left unattended, there were not enough activity staff members, Activities of Daily Living (ADLs) were not completed, and at least one resident experienced a fall. Resident identifiers: 7, 9, 22, 26, 30, 31, 36, and 93. 10. Based on interview and record review the facility did not ensure that 4 of 33 sampled residents were free of significant medication errors. Specifically, a resident was not administered the correct dose of insulin per physician orders resulting in uncontrolled diabetes. This example will be cited at a harm level. In addition, two residents' antibiotics were not administered according to physician orders, and another resident's coumadin was not administered according to physician orders. Resident identifiers: 22, 29, 32 and 94. [Cross refer to F760] 11. Based on observation, interview and record review it was determined, for 3 of 33 sampled residents, that the facility did not arrange outside resources in a timely manner for residents. Specifically, a resident was not scheduled for a Percutaneous Endoscopic Gastrostomy (PEG) tube placement and had multiple problems with the Nasojejunal (NJ) tube which was cited at a harm level. In addition, residents were not scheduled for a neurologist appointment and a cardiologist appointment. Resident identifiers: 4, 30 and 34. [Cross refer to F840] 12. Based on observations, interviews and record review, it was determined that the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, abuse occurred within the facility on multiple occasions,but was not identified, reported or investigated; the staffing was inadequate and resulted in falls, abuse, and activities of daily living not being completed; Quality Assurance (QA) was not completed as required for approximately one year; medically necessary appointments were not scheduled by facility staff or the administrator; wound reports and pharmacy reviews were only accessible to the Administrator, who did not provide them to nursing staff; and multiple staff reported to the Administrator their concerns about resident safety while a specific nurse was working, however no follow up by the Administrator was completed. The identified deficient practice was found to have occurred at the Immediate Jeopardy (IJ) Level. Resident identifiers: 4, 8, 9, 10, 11, 13, 22, 26, 29, 30, 31, 32, 34, 36 and 93. [Cross refer to F835] 13. F550, F565, F568, F578, F584, F656, F679, F680, F684, F692, F760, F761, F812, F842, F867, F880, F882 were cited on the previous annual survey completed 9/1/21. These deficiencies were also cited during this recertification survey, with F684, F692, F760 being cited at a harm level during the current survey. On 10/11/22 the sign in sheets for the last 12 months of the Quality Assurance (QA) meetings were requested verbally to the Adminstrator (ADM). On 10/12/22 at 9:50 AM, the sign in sheets for the last 12 months of the QA meetings were requested from the ADM via email. On 10/24/22 at 6:08 PM, an interview was conducted with the facility ADM. The ADM stated that QA meetings were conducted at least quarterly, but could not provide any sign in sheets to demonstrate who had attended and the dates the meetings were held. As of 10/31/22 at the time of exit, no sign in sheets for QA meetings was provided. On 10/24/22 at 2:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she thought there might have been a QA meeting in July 2022, but she wasn't really involved. On 10/24/22 at 12:20 PM, an interview was conducted with the facility Medical Director (MD). The MD stated that she had not been invited to a QA meeting since at least January 2022, and this was concerning to her.

Based on interview, record review, and interview, the facility did not maintain a quality assessment and assurance committee consisting of the Director of Nursing, Medical Director, and and least three other members of the facility's staff. In addition the committee did not meet quarterly. Findings include: On 10/11/22 the sign in sheets for the last 12 months of the Quality Assurance (QA) meetings were requested verbally to the Administrator (ADM). On 10/12/22 at 9:50 AM, the sign in sheets for the last 12 months of the QA meetings were requested from the ADM via email. On 10/24/22 at 6:08 PM, an interview was conducted with the facility ADM. The ADM stated that QA meetings were conducted at least quarterly, but could not provide any sign in sheets to demonstrate who had attended and the dates the meetings were held. As of 10/31/22 at the time of exit, no sign in sheets for QA meetings was provided. On 10/24/22 at 2:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she thought there might have been a QA meeting in July 2022, but she wasn't really involved. On 10/24/22 at 12:20 PM, an interview was conducted with the facility Medical Director (MD). The MD stated that she had not been invited to a QA meeting since at least January 2022, and this was concerning to her. [Cross refer to F867]

Based on observations, interviews, and record reviews it was determined, for 2 of 33 sampled residents, that the facility did not provide residents with the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This included but was not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Specifically, residents were placed in the locked unit without assessments to determine if the residents met the criteria for the unit and were not provided with access codes or other information for independent egress. Resident identifiers: 7 and 9. Findings Include: Harm 1. Resident 9 was admitted to the facility on [DATE] with diagnoses which include major depressive disorder, paranoid schizophrenia, cognitive communication deficit, type 2 diabetes mellitus, low back pain, essential hypertension, epilepsy, and hyperlipidemia. On 10/11/22 at 6:17 AM, an interview with resident 9 was conducted. Resident 9 was observed to have a room in the memory care unit. Resident 9 stated that he previously had a room outside of the locked unit. Resident 9 stated that he had an argument with another resident and left the facility at around 12:30 AM to cool down at his brother's house. Resident 9 stated that when he returned to the facility he was locked up in the locked unit. On 10/13/22 resident 9's medical record was reviewed. Resident 9's Annual Minimum Data Set (MDS) completed on 7/12/22 revealed that resident 9 scored a 12 on the Brief Interview for Mental Status (BIMS). It should be noted that a score of 12 suggests moderate impairment. A progress note from 10/30/21 at 4:45 AM stated Resident left facility at 0210 (2:10 AM) this morning. It is believed he had an argument with his room mate. Administrator notified. Police called. Description and cell phone number given to police . A progress note from 10/30/21 at 5:30 PM stated, It was reported to me at the beginning of my shift that resident had eloped at 0210 this AM. I called the police to see if they had found him, also asked administrator if he knew where he was. He did not know. About 1400 (2:00 PM) his brother was notified and it was noted that he was visiting him and outside smoking in the garage. MD (Medical Director) notified he was located and administrator went to visit him. He was brought back to facility . at 1715 (5:15 PM). A progress note from 10/30/21 at 5:42 PM stated, New order per MD to admit to SNU (Special Needs unit) locked unit d/t (due to) his dementia/schizophrenia and flight risk. Also to be put on assisted smoking. A progress note from 10/21/21 at 9:06 AM stated, Resident has been in his room since the room change . He states he is upset about changing rooms . Assessments to determine if the residents met the criteria for the unit were not found in resident 9's medical record. On 10/12/22 at 10:17 AM, an interview with Certified Nursing Assistant (CNA) 2 was conducted. CNA 2 stated that she did not know if resident 9 was appropriate to be in the locked unit. CNA 2 stated that resident 9 often complained about being on the unit and felt like it's a prison because he was locked in. On 10/24/22 at 2:30 PM, an interview with the Director of Nursing (DON) was conducted. The DON stated that she was not aware of any assessments regarding elopement except for the wander risk. A review of resident 9's medical records revealed that a document titled Wander Risk Scale was completed for resident 9 on 8/12/22. It should be noted that this assessment was completed approximately 10 months after resident 9 was moved to the locked unit. On 10/24/22 at 5:15 PM, an interview with resident 9 was conducted. Resident 9 stated he did not know that he needed to sign out or how to sign out when he left for his brother's house. Resident 9 stated that he was locked in because he did not sign out when he left the facility. On 10/25/22 at 1:35 PM, an interview with the Administrator (ADM) was conducted. That ADM stated that nurses completed an assessment to determine if residents fit the criteria for the locked unit. The ADM stated that she did not know where the assessments were located, and she did not know what the assessments were called. The ADM stated the Wander Risk Scale was part of the assessment, but she believed there was another part to the assessment. The ADM stated that she believed resident 9 was in the locked unit because he had eloped. The ADM stated that elopement was when a person did not know what they were doing, and they were escaping. The ADM stated that she did not have a good definition of elopement. The ADM stated that residents had to sign out in a book at the nurses' station if they resident was leaving the facility. The ADM stated that she did not know how residents were informed that they needed to sign out prior to leaving the facility. 30563 2. Resident 7 was admitted to the facility on [DATE] with diagnoses which included Schizoaffective disorder, dementia with behavioral disturbance, generalized anxiety, and type 2 diabetes. On 10/12/22 at 2:54 PM, an interview was conducted with resident 7. Resident 7 stated he did not care where his room was located but it was weird being locked in a unit. Resident 7 stated he did not need to be locked up like an animal. Resident 7's medical record was reviewed. An annual MDS dated [DATE] revealed a BIMS score of 15 which indicated resident 7 was cognitively intact. A care plan dated 8/3/21 revealed The resident requires a safe, secure, environment Elopement risk, Wandering risk. The goal with a target date of 3/30/22 was Resident will remain safe, without feelings of isolation, in the SNU (Special Needs Unit) . Interventions included to provide activities in the unit or supervised while outside of the unit, provide daily activities, provide meals in the SNU dining room and resident will reside in a room in the SNU. Resident 7's census section revealed he was in the memory care unit from 10/26/2020 until 12/4/2020 when he was moved out of the unit. Resident 7 was moved back to the memory care unit 12/18/2020. A physician's progress note dated 12/23/2020 revealed resident 7 was transferred to the COVID-19 unit and then back to his room. There were no assessment or nursing progress note regarding resident 7 needing to reside in the memory care unit. On 10/24/22 at 5:11 PM, a follow-up interview was conducted with resident 7. Resident 7 stated he did not really like being on the unit. Resident 7 stated he had his wallet and $30 stolen from his room. Resident 7 stated he had never been told why he had to be in the locked hallway. Resident 7 stated it was alright to be in the locked unit except his money had been stolen. On 10/24/22 at 2:30 PM, an interview was conducted with the DON. The DON stated Quite honestly, I'm not aware of an assessment except for the wander risk for elopement. The DON stated Honestly, there is no wander risk, we should have had one, and I would like to believe that we would do it quarterly and on admit. The DON stated she believed resident 7 was in the memory care unit because of his Montreal Cognitive Assessment (MOCA) score. The DON stated she did not know resident 7's cognitive level and was not aware his BIMS score was a 15. The DON stated she wanted to say the physical therapist evaluated resident's need to be in the memory care unit. The DON stated she did not know but maybe we can ask the social worker who did the assessments. On 10/26/22 at 5:46 PM, an interview was conducted with the Social Service Worker (SSW). The SSW stated she was not involved in determining if residents needed to reside in the memory care unit. The SSW stated she thought the Interdisciplinary Team (IDT) determined if a resident needed to reside in the memory care unit. On 10/25/22 at 1:35 PM, an interview was conducted with the Administrator. The Administrator stated the nurses completed an assessment or care plan and then obtained a physician's order for residents to be in the memory care unit. The Administrator stated she did not know what the assessment was called or where it was located in the medical records. The Administrator stated she thought the assessment had information about their diagnoses, if they wander or pace and if they have behavioral issues that required more supervision. The Administrator stated the wander risk scale was part of the assessment but not all of it. The Administrator stated she was not sure about resident 7's cognitive status and why he was in the memory care unit. The facility SNU Policy dated 3/1/18 revealed the following: Memory Lane/Special Needs Unit Admission criteria have been established to promote proper placement of the resident with dementia and other type of impairment requiring a secured environment. Specific admission and discharge criteria are in place for the memory care/secured unit residents in order to maximize safety and promote optimal functioning and well-being of the person. Decision regarding admission to and discharge form the memory care/secured unit are based on an individualized assessment and/or safety of person. 1. A resident is admitted to the memory care/secured unit when his/her identified needs can be met through the unit's scope of service for eligible admissions which includes, but is not limited to: a. A diagnosis of an irreversible dementia such as Alzheimer's disease, Lewy body dementia, vascular dementia, or Parkinson's dementia, etc. as diagnosed by a physician and with evidence of a dementia work-up Evidence of cognitive impairment b. The resident's behavior and behavioral needs. c. Psychosocial needs outweigh his/her nursing needs 2. The primary care physician provides a documented health assessment of physical and mental health conditions and a statement indicating that the prospective resident is appropriate for admission. Prospective residents are assessed by facility staff for appropriateness of admission through a comprehensive assessment of the resident's physical, psychosocial, and behavioral status including: a. Mental status Behavioral b. Falls Wandering and elopement c. Functional d. Psychosocial and well-being 3. Documentation in the residents record denotes the appropriateness of admission to the memory care/secured unit including: a. The clinical criteria met for placement in the secured/locked area by the resident's physician along with information provided by members of the interdisciplinary team b. Ongoing documentation of the review and revision of the resident's care plan as necessary, including whether he/she continues to meet the criteria for remaining in the secured/locked area, and if the interventions continue to meet the needs of the resident The facility POLICY AND PROCEDURE FOR PROHIBITING ABUSE with no date revealed the following definition: .Involuntary seclusion: Separation of a resident from other resident's or from his/her room or confinement to his/her room (with or without roommate) against the residents will, or the will of the resident's legal representative. This may includes residents who are living in an area of the facility which restricts their movement throughout the facility or temporarily separating a resident from other residents. [Emergency or short term monitored separation from other residents will not be considered involuntary seclusion and may be permitted if used for a limited period of time as a therapeutic intervention to reduce agitation until professional staff can develop a plan of care to meet the resident's needs.] .

Based on observation, interview and record review it was determined, for 3 of 33 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident was not provided diabetic management, antibiotics as ordered, or wound care which resulted in an amputation. Another resident was not provided treatment for a rash and the resident was unable to move in bed. These were cited at a harm level. In addition, a resident was not treated for her psoriasis. Resident identifiers: 29, 31 and 32. Findings include: Harm 1. Resident 29 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus with foot ulcer, schizoaffective disorder, neuropathy, generalized anxiety disorder, borderline intellectual functioning, hyperlipidemia, and hypomagnesemia. On 10/12/22, resident 29 was observed with a dressing on her right foot. Resident 29 stated that she recently had surgery. On 10/12/22 at 10:17 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that resident 29 often came to the nursing desk to ask the nurses for her medications, but some of the nurses ignored resident 29 and told her to wait. CNA 2 stated that resident 29's family did not provide any assistance to resident 29. CNA 2 stated that resident 29 had a lot of medical needs, and CNA 2 was not sure resident 29 received all the care she needed. On 10/11/22 at 5:05 AM, Registered Nurse (RN) 1 stated that she had not signed out resident 29's narcotic medication. On 10/12/22 at approximately 10:00 AM, resident 29 was interviewed. Resident 29 was observed to be ambulating in a wheelchair and stated that she had an appointment with her surgeon because she had foot issues. On 10/31/22, resident 29's medical record review was completed. Resident 29's physician orders included the following: a. Wound dressings were ordered for resident 29's right foot dated 11/11/21. b. Wound order to: cleanse wound, use oil emulsion, 4X4, and ace wrap .Wound to plantar right foot, cleans, apply iodosorb, cover and change QD (daily). c. Blood sugar checks before meals and at bedtime were initiated on 11/10/21. d. Bacitracin ointment, 500 units/gram, apply to wound topically, initiated on 11/10/21. e. Bactrim DS tablet, 800-160 MG (milligrams) (Sulfamethoxazole-Trimethoprim), 800 mg by mouth twice daily. f. Lantus solution, 100 units/mL, inject 70 units subcutaneously in the morning and 60 units subcutaneously in the evening. g. Humalog solution 100 units/mL, sliding scale. h. Metformin 1000 mg, twice daily. Resident 29's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed the following: a. In June, 2022, resident 29's Lantus was missed in the afternoon on 6/7, 6/13, 6/27, and 6/30; Metformin was missed in the afternoon on 6/7, 6/13, 6/27, and 6/30; Blood sugar checks were not done at 4:00 PM on 6/3, 6/13, 6/17, 6/20, 6/24, and 6/30; Blood sugar checks were not done at 9:00 PM - 6/7, 6/13, 6/27, and 6/30; the Humalog sliding scale was not provided at 4:00 PM on 6/3, 6/13, 6/17, 6/20, 6/24, and 6/30; the Humalog sliding scale was not provided at 9:00 PM, on 6/7, 6/13, 6/27, and 6/30; and Wound care to the right plantar foot: cleanse with wound spray, apply calcium alginate with lodosorb, cover with border gauze, wrap with Keflex and coban, change QD every day shift for wound care start 3/23/22, discontinued 8/2/22, not provided on 6/1, 6/8, 6/15, and 6/30/22. b. In July, 2022, for resident 29's Lantus 70 units subcutaneously two times a day for diabetes, was missed on evening shift 7/5 and 7/10; Metformin 1000 mg, I tablet twice daily for DM II with foot ulcer, was missed on evenings of 7/5, and 7/10, Pain was not assessed 7/5/22 in the PM; Blood sugar was not checked at 4:00 PM check on 7/5, 7/9, 7/11, 7/15, 7/18, 7/22, 7/29, and 7/30; Blood sugar was not checked at 9:00 PM on 7/5, and 7/10; Humalog solution 100 u/ml (Insulin Lispro) checks were ordered for 7:30 AM, 11:00 AM, 4:00 PM, and 9:00 PM. The 4:00 PM check and insulin were missed on 7/1, 7/5, 7/9, 7/11, 7/15, 7/16, 7/18, 7/22, 7/25, 7/29, and 7/30; The blood glucose check and insulin administration were missed at 9:00 PM on 7/5, and 7/10. c. In August, 2022, resident 29's Atorvastatin and Clozapine doses were missed on 8/10, and 8/28; Doxycycline was missed for the PM dose on 8/10, and the morning dose on 8/12 (with no extended doses); Doxycycline monohydrate tablet, 150 mg, Give 1 tablet by mouth two times a day for right foot for 14 Days was missed for the PM dose on 8/28/22; Lantus, Metformin, and gabapentin were not administered for the PM doses on 8/10, and 8/28; 4:00 PM Blood sugar checks missed on 8/1, 8/5, 8/10, 8/11, 8/12, 8/15, 8/22, and 8/26; 9:00 PM blood sugar checks were missed on 8/10, and 8/28; Humalog was not provided at 4:00 PM on 8/1, 8/5, 8/10, 8/11, 8/12, 8/15, and 8/22/22 and the 9:00 PM humalog was not provided on 8/10; and Wound care was not done on 8/15, and 8/27/22. d. In September, 2022, resident 29's Clozapine was not provided in the afternoon of 9/5, and 9/14; Clozapine was not provided in the morning on 9/14/22 and 9/16/22; Lantus was not provided on 9/5, and 9/14; Metformin was not administered in the PM on 9/5, and the AM on 9/14; Clindamycin HCL capsule 300 MG, give 1 capsule by mouth three times a day related to unspecified open wound, right foot, subsequent encounter for 10 days, missed 9/14 all 3 doses (Arise, Noon, PM), and noon on 9/16 and the dosing was not extended; Humalog solution 100 unit/mL (insulin lispro) sliding scale was not checked: 9/5 in the PM; 9/14 all day, 9/16 at noon, 9/26 at noon, and resident 29 was hospitalized on ,d+[DATE] and 9/29; Blood sugar checks were missed in the AM on 9/14, 11:00 AM on 9/14, 9/16, and 9/26, at 4:00 PM on 9/2, 9/5, 9/10, 9/11, 9/12, 9/16, 9/19, 9/20, 9/23, 9/24, 9/26, and 9/30, and at 9:00 PM on 9/5; Gabapentin was not administered on 9/5 in the PM, and on 9/14 in the AM, Noon, and PM; Magnesium not administered on 9/5 in the PM, and on 9/14 at Arise, Noon, and PM doses; Wound care was not provided on 9/1, 9/3, 9/5, 9/7, 9/24, 9/25, and 9/30/22. e. In October, 2022, resident 29 did not received the following: Clozapine on 10/5 in the PM, on 10/17 in the AM, and on 10/24 in the PM; Humalog check and administration at Noon, missed on 10/5, and 10/17; HumaLOG Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 149 = 0; 150 - 200 = 3; 201 - 250 = 6; 251 - 300 = 9; 301 - 350 = 12; 351 - 400 = 15 Call medical provider if BS is >400, subcutaneously three times a day related to TYPE 2 DIABETES MELLITUS WITH FOOT ULCER, the afternoon Humalog was missed on 10/5, and 10/24; Blood sugar checks were missed on 10/5 at 11:00 AM and at 4:00 PM, on 10/10 at 4:00 PM, on 10/17 at 11:00 AM and at 4:00 PM; and on 10/24 at 4:00 PM and at 9:00 PM; and Magnesium was not provided on 10/5 at PM dose, 10/17 at noon, and on 10/24 at PM dose. [Note: No charting was recorded that resident 29 refused cares or medications.] Resident 29's nursing notes revealed the following: a. On 11/15/21 at 2:05 PM, a Physician History and Physical (H&P) revealed that resident 29 had a chronic right heel wound. b. On 12/7/21 at 12:20 AM, resident 29 was disrespectful condescending challenging me being a nurse [and] would not let me do dressing change and then saying that she is allergic to honey I did not clean it well enough and not to [put] the tegaderm on it . c. On 4/26/22 at 9:00 AM, a nursing note revealed that resident 29 was examined by a wound healing company and the wound on resident 29's right foot was getting worse. Resident 29 was having delusions that the wound nurse wanted to cut her foot off. At 10:24 AM, the nurse noted a foul odor from the resident's foot and the ulceration appeared to be increasing in size and diameter. d. On 4/30/22 at 12:03 PM, resident 29's foot wound showed signs of infection and Bactrim was ordered. e. On 5/6/22 at 1:07 PM, resident 29's plantar foot wound had increased in size, width and depth. Wound has foul odor and drainage is thick . f. On 5/9/22 at 1:12 PM, a physician progress note revealed that resident 29 often removed her dressings. The wound is larger and deeper and appears infected . g. On 5/28/22 at 6:18 PM, a health status note revealed that resident 29 had redness above ankles on shin is flaring and spreading, resident continues scratching area even with anti-itch cream applied. Rash is only on the injured foot .Resident continues to sleep all day and not get out of bed even when she is encouraged to get out of bed . h. On 6/2/22 at 5:02 AM, resident 29 was taking antibiotics for the foot infection. i. On 6/3/22 at 2:33 AM, resident 29's antibiotics were extended for 7 more days. She is taking it for right foot ulcer which wound bed has red granulation tissue no foul odor . [Nurses document non-compliance with cares at times, including on 6/18/22 for checking blood glucose because it was too early.] j. On 7/14/22 at 11:06 AM, an NP (nurse practitioner)/PA (physician's assistant) progress note revealed that resident 29 had elevated blood sugars, she was noncompliant with wound care and would take the dressing off. k. On 7/26/22 at 10:06 AM, a health status note revealed that resident has a right foot wound. The dressing was removed and the wound was cleaned. Wound area is red/swollen and shiny with foul odor. Informed Tx (treatment) nurse of wound status. l. On 7/29/22 at 1:05 PM, resident 29 was on antibiotics for infection cellulitis. Resident continued on several types of antibiotics. m. On 8/5/22 at 2:16 PM, resident was too tired to get out of bed and wanted to sleep all day. n. On 8/5/22 at 4:04 PM, Noted a new sore on plantar next to the wound being treated. Appears to be a blistered ulcer, cream color appearance with blanching. 2x2 (2 inch square bandage) gauze applied and waiting for wound nurse to assess when she comes to change dressing on Tuesday 8/9/22. o. On 8/19/22 at 3:22 AM, after continued antibiotics, Some redness on top of foot with serous sang (blood tinged clear fluid) drainage draining moderate amount especially with pressure to wound bed area. Wound bed is red granulation tissue . p. On 9/15/22 at 6:57 PM, an order for a MRI was ordered of the right foot to check for osteomyelitis. q. On 9/16/22 at 2:04 AM, resident 29 had an open area on the top of her foot and draining was coming through the bottom ulcer of her foot. Her right great toe and 2nd toe are red and swollen r. On 9/22/22 at 3:41 PM, the MRI was completed at a nearby hospital. [Note: This was completed 7 days after the initial order.] s. On 9/23/22 at 2:37 PM, resident 29 was referred to a surgeon for osteomyelitis. t. On 9/28/22 at 1:53 PM, resident 29 was taken to the hospital for osteomyelitis. u. On 9/30/22 at 1:30 AM, resident 29 returned to the facility after the first metatarsal and toe were removed from her right foot. v. On 10/22/22 at 5:08 AM, resident stated that her dressing was coming off her foot. The nurse stated that the incision line that looked red and inflamed . w. On 10/26/22 at 4:34 PM, resident 29 had mild wound breakdown . Resident 29's wound care note from 10/18/22 revealed that resident 29 had no open areas on her foot. On 10/24/22, resident 29's wound was partially open. Resident 29's care plan was reviewed. Resident 29 only had one focus, which was activity participation. No focus was created for diabetes, mental health, wound care, etc. On 10/20/22 at approximately 10:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that he had obtained an order from the Medical Director (MD) to have a snack at bedtime for resident 29. LPN 1 stated that all residents should have a snack available, and a specific order should not have been necessary. LPN 1 stated that resident 29 had low blood sugar in the mornings. LPN 1 stated that resident 29 had significant blood glucose swings and needed to be monitored closely. On 10/25/22 at 10:09 AM, Registered Nurse (RN) 3 was interviewed. RN 3 stated that resident 29's wound had a bit of dehiscence (opened). Resident 29 was receiving antibiotics, but the wound was looking infected again. RN 3 stated that resident 29 needed to follow up with her surgeon. RN 3 stated there was a small amount of yellow-red drainage, and resident 29 was unable to walk on her foot after her surgery. RN 3 stated that any additional wound care should have been charted in the nursing notes or on the TAR. On 10/24/22 at 12:22 PM, the Medical Director (MD) was interviewed. The MD stated that she was not informed that resident 29's foot had reopened, and there was an area of what appeared to be necrotic tissue. The MD stated that the wound care company handled the wounds, and staff did not have the MD look at anyone's wounds. On 10/25/22 at 1:35 PM, the Administrator (ADM) stated that she was the only staff member in the facility who had access to wound care notes. The ADM stated that she had not been able to access the notes lately. The ADM could not produce the notes for the latest wound care rounds. 22992 2. Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia, chronic obstructive pyelonephritis, severe sepsis, aspiration pneumonitus, supraventricular tachycardia, acute kidney failure, bipolar disorder, epilepsy, thyrotoxicosis and osteoarthritis. Resident 32's medical records were reviewed between 10/11/22 and 10/31/22. Resident 32's hospital discharge orders dated 8/18/22 were reviewed. The discharge orders included the following wound care orders: Apply zinc oxide TID (three times a day) to buttock/scrotum area. Please use baza cleanse and protect spray with gentle care touch cloths for all peri cares. Change silicone foam over LLE (left lower extremity) weekly. No other skin issues were documented on resident 32's discharge information packet provided to the facility. No skin assessments could be located in resident 32's medical record. Resident 32's nursing progress notes included the following entries: a. On 8/19/22, . scrotum is red and excoriated with new order for Zinc oxide 40% to be applied TID. b. On 9/14/22, Nystatin Powder Apply to neck [and] L (left) armpit topically two times a day for rash use until resolved. c. On 9/18/22, . Resident has a rash on left side back that is healing. d. On 10/1/22, . Resident has a rash on left side back that is healing. e. On 10/9/22, . Resident has a rash on left side back that is healing. On 10/6/22, a Nurse Practitioner Note documented that resident 32 had no skin issues, including rashes. On 10/12/22, a physician's order was written to apply Hydrocortisone cream 1% to itchy, red areas topically every 8 hours as needed for itching. The October 2022 Medication Administration Record (MAR) for resident 32 was reviewed, and indicated that as of 10/26/22 resident 32 had not had any hydrocortisone applied. On 10/25/22 at 10:09 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that resident 32 had started with the rash on his left back/torso area since he was readmitted from the hospital in August 2022. RN 3 stated that resident 32 was being seen by a wound care provider for open areas on his ankles, but had not discussed resident 32's rash with them. When asked where those wound notes could be located, RN 3 stated that its been many months since I've seen those notes. RN 3 stated that the wound care provider would come in to see the resident, and then document their notes electronically. RN 3 stated that only the Administrator (ADM) had access to those wound care provider notes. On 10/26/22 at 11:04 AM, an observation was made of resident 32's torso area with Certified Nursing Assistants (CNAs) 3 and 4. Resident 32 presented with red to red/purple skin on the left side of his back and bilateral lower extremities below the knees. The skin was peeling (excoriated) with open wounds that were not dressed. There were four small (less than 1 centimeter) open, bleeding areas on resident 32's back, all on the left side of the resident's spine. The skin over the spine also appeared to be peeling and red. CNA 3 stated that the Director of Nursing (DON) would come in later to assess the wound to determine the appropriate dressing/cream. CNA 3 stated that the skin did not blanch and demonstrated that the purple/red areas on resident 32's left side did not blanch. CNA 3 stated that resident 32 had a lot of pain with his brief changes, and that they worked together every day to make sure he had the Calmoseptine cream on his red areas. CNA 4 stated that resident 32's skin appeared better than a month ago. Lotion was applied by the CNAs over resident 32's legs. On 10/24/22 at 12:20 PM, an interview was conducted with the facility Medical Director (MD). The MD stated that she had not been informed about the rash on resident 32's left torso area. On 10/24/22 at 2:02 PM, the MD stated that she had just gone to look at resident 32's rash, and that its pretty bad. it looks like heat rash, but its so bad its draining serosanguinous fluid. The MD stated that at the time of her observation, resident 32's incontinence brief was in bad need of being changed. The MD stated that after she had observed resident 32's rash, she spoke with the DON about it. The MD stated that the DON told her that resident 32's rash had been that way since the resident was readmitted from the hospital in August 2022, but that the DON had not seen the rash since that time. The MD also stated that the DON has no idea if resident 32 had been referred to a wound clinic for his rash. The MD also stated that she was unable to locate any skin checks in resident 32's medical record. On 10/24/22, the MD documented the following note in resident 32's medical record: A state surveyor notified me that she had been told [resident 32] has a rash on his back. The DON says this has been present for some time. [Observation]: left side of back with large area of redness with some yellow serous drainage, no signs of infection.Dermatitis - likely a heat rash. [Resident 32] lies (sic) in the same position and does not shower regularly. Will order calmoseptine and will have . wound provider look at it on next visit. On 10/25/22 the wound provider saw resident 32, however only documented that they had evaluated resident 32's pressure injuries on his lower extremities. 30563 Potential for Harm 3. Resident 31 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, unspecified dementia with behavioral disturbance, and depression. On 10/12/22 at 10:42 AM, an interview was conducted with resident 31's family member. The family member stated resident 31 had a big bruise on her ankle a few weeks ago. The family member stated the family was not notified. The family member stated resident 31 had psoriasis and needed a cream but it was not applied. On 10/21/22 at 12:59 PM, an interview was conducted with resident 31's family member. The family member stated the Power of Attorney (POA) was not notified that resident 31 had psoriasis on her ear and her ankle. The family member provided a picture of the ear and left lateral ankle and above the ankle. There were scratches on it. The family member stated the psoriasis was found by family on 9/18/22. The family member stated RN 6 was rude to the POA when he noticed a bandage on her leg with scratches. The family member stated resident 31's family was not notified of the open area, Band-Aid on her ankle and no cream was being applied. Resident 31's medical record was reviewed. An annual Minimum Data Set (MDS) dated [DATE] revealed resident 31 did not have skin break down. A care plan dated 8/25/16 revealed The resident has potential for pressure ulcer development r/t (related to) Immobility. The goal had a target date 5/27/22 was The resident will have intact skin, free of redness, blisters or discoloration by/through review date. Some of the intervention included to Administer medications as ordered. Monitor/document for side effects and effectiveness ; Follow facility policies/protocols for the prevention/treatment of skin breakdown; and Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs and symptoms) of infection, wound size (length X width X depth), stage. A nursing progress note dated 9/18/22 at 2:18 PM, Resident's family notified me that resident has a sore on her left lateral ankle with a dressing on it and a rash on her back and on her ear. They asked me to take a look at it. They had been visiting with their mother and grandmother. I stated that we needed to take her down to her room so I can look at these skin issues. So we walked her down to her room. The family started asking why she was not being treated. She had no orders. I took off the Band-Aid off her left ankle. She had scabbed area there about 1 inches long by 1 inch wide. I cleansed the area with would cleanser, took a picture of this area to send to the house physician. The granddaughter and son also took pictures. The son asked what I put on it and I told him wound cleanser and Band-Aid. I also took a picture to send to the MD (Medical Doctor) of her mid right back rash that was about 2 inches by 3 inches. No (sic) open but she had been scratching at it. No open areas. Pictures sent to MD with a request for a tx (treatment). They were upset that I did not put anything else on it. I explained that I would need an order from the doctor before I do this. They accused me of ignoring them when I left the room. They asked me for my name and became very confrontational. I told them I was not going to argue with them and then ask the assistant DON if I could talk to her alone about the situation. I was quite upset at this time. She did go out a talk with them. Resident 31's September 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) was reviewed. Triamcinolone Acetonide Cream 0.1% had a start dated of 9/18/22. The instructions were to apply to affected areas topically two times a day for psoriasis. The cream was documented as applied twice daily starting 9/18/22 through 9/30/22. Resident 31's October 2022 MAR and TAR was reviewed. The Tricamcinolone Acetonide Cream 0.1% was not applied twice daily. There was no check marks or nurses initial for hours of sleep on 10/3/22, 10/5/22, 10/10/22, 10/18/22, 10/22/22 and 10/24/22. There were no check marks or nurses initial for arise on 10/14/22 and 10/29/22. A form with no title revealed resident 31 had a rash on her back on 9/16/22. There was no nurses signature. On 10/18/22 at 10:04 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated when the MAR or TAR did not have a check mark or nurses initials, the it might not have gotten done those days because it wasn't charted as being done. On 10/23/22 at 12:20 AM, an interview was conducted with CNA 6. CNA 6 stated resident 31 had psoriasis on her ear and on her back. CNA 6 stated resident 31's back was healing up and her outer ankle. CNA 6 stated a nurse should be applying the cream as a part of her treatments. On 10/27/22 at 9:23 AM, an interview was conducted with the ADON. The ADON stated on 9/17/22, a CNA noticed an abrasion to resident 31's left ankle which was psoriasis. The ADON stated resident 31 had psoriasis on and off. The ADON stated there was Tricamcinolone cream scheduled and also as needed. The ADON stated in September 2022 her psoriasis had gotten worse. The ADON stated the Tricamcinolone cream was started it 9/18/22 after talking to the MD. The ADON stated CNA's tried to inform nursing staff if they noticed any new skin issues. On 10/27/22 at 9:37 AM, an interview was conducted with the resident 31's POA. Resident 31's POA stated he noticed resident 31 had a patch of psoriasis on her leg, and her ear. Resident 31's POA stated the psoriasis on her ear had cleared up. Resident 31's POA stated he got upset with staff and told them she needed the cream and then the cream was applied. On 10/24/22 at 12:19 PM, an interview was conducted with the DON. The DON stated the she did not know anything about resident 31 having psoriasis.

Based on interview, observation and record review, the facility did not ensure that 7 of 33 sample residents maintained acceptable parameters of nutritional status. Specifically, residents with weight loss did not receive timely and appropriate interventions. One resident will be cited at a harm level due to continued weight loss with no new interventions. Resident identifiers: 4, 7, 13, 31, 32, 36, and 37. Findings include: Harm 1. Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia, chronic obstructive pyelonephritis, severe sepsis, aspiration pneumonitus, supraventricular tachycardia, acute kidney failure, bipolar disorder, epilepsy, thyrotoxicosis and osteoarthritis. Resident 32's medical records were reviewed between 10/11/22 and 10/31/22. A 5 day Minimum Data Set (MDS) dated [DATE] revealed that resident 32's weight was 190 pounds (lbs) and there was no significant weight loss of 5% or more in the last month or more that 10% in the last 6 months. The MDS also indicated that the resident did not have any pressure ulcers at that time. A Nutritional Care Plan dated 8/21/22 revealed that resident 32 was at nutritional risk, but the reasons for the risk were not documented. The goals were resident 32 will have no significant weight change, resident will have moist mucous membranes and no tenting of skin, no aspiration/cough while eating, resident will tolerate diet, no discomfort due to eating, and skin will remain intact. The approaches developed were to monitor weekly weights, encourage 90 percent food intake, and a regular diet with thin liquids. The care plan had been changed to reflect that resident 32 was changed to a mechanical soft diet, a fortified diet, and high protein snacks twice daily, but no dates were documented with the changes. The care plan was updated on 9/9/22 indicating that resident 32's weight was down 2.3 % that week. However, no additional interventions were listed on the care plan. The care plan was updated on 9/16/22 indicating that resident 32's weight was down 3.8% that week. However, no additional interventions were listed on the care plan. The care plan was updated on 10/7/22 indicating that resident 32's weight was down 6.4% that month. However, no additional interventions were listed on the care plan. On 6/27/18, a physician's order was written for resident 32 to receive a high protein snack three times a day for weight loss. Review of the October Medication Administration Record (MAR) as of 10/26/22 revealed that resident 32 was not given the high protein snack on 10/2/22 (once), 10/18/22 (once), 10/19/22 (twice) and 10/24/22 (once). On 8/16/22, a physician's order was written for resident 32 to receive a mighty shake three times a day due to his weight loss. Review of the October 2022 MAR as of 10/26/22 revealed that resident 32 was not given the mighty shake on 10/18/22 (once), 10/19/22 (twice), and 10/24/22 (once). Nutrition notes were reviewed and revealed the following: a. On 8/19/22, facility staff completed a Nutritional Assessment for resident 32. His weight was documented as 219.14 pounds lbs. The assessment indicated that resident 32 received a regular mechanical soft diet. b. On 8/26/22, facility staff completed a Skin/Hydration/Weight Meeting note. The note indicated that the resident now weighed 198.4 lbs, a weight loss of 20.7# (Ibs) that week. Facility staff documented that they questioned the accuracy of the weight, but did not obtain a repeat weight. c. On 9/2/22, facility staff completed a Skin/Hydration/Weight Meeting note. The note indicated that resident 32 now weighed 195.4 lbs, a weight loss of 3# or 1.5% of his body weight that week. Facility staff documented that they would add high protein snacks twice daily and watch. It should be noted that this order was already in place as of 6/27/18, so this would not be considered a new intervention. d. On 9/9/22, facility staff completed a Skin/Hydration/Weight Meeting note. The note indicated that resident 32 now weighed 191#, a loss of 4.4 lbs or 2.3% of his body weight that week. Facility staff documented that they would fortify his diet, and add a mighty shake three times a day with meals, and a mighty shake in the evening. It should be noted that the order for the mighty shake three times a day was already in place as of 8/16/22, so this would not be considered a new intervention. Also, the order for the evening mighty shake was not entered into the MAR, and therefore this intervention had not been implemented as of review of the MAR on 10/26/22. Facility staff also documented that the weight loss may be due to increased pacing. However, during the entirety of the survey, resident 32 was not seen outside of his bed. During interviews conducted with resident 32 on 10/12/22 at 11:20 AM, and 10/26/22 at 10:50 AM, resident 32 stated that he was only in pain when he moved. Resident 32 stated that when he was moved, such as for a brief change, his pain was an 8 on one side of his body, and a 10 on the other side. Resident 32 stated as long as he was in a middle position, he did not have any pain. Resident 32 stated that his pain was at an 8 out of 10 when his briefs were changed. e. On 9/16/22, facility staff completed a Skin/Hydration/Weight Meeting note. The note indicated that resident 32 now weighed 183.8 lbs, a loss of 7.2 lbs or 3.8% of his body weight that week. Facility staff documented that they spoke with the resident, who . said he could not come to dining room as 'long as lucifer is there' refuses to even sit at 90 [degree angle] in room to eat. The note did not indicate what the facility staff was going to implement for resident 32 to prevent further weight loss. f. Two weeks later, on 9/30/22, facility staff completed a Skin/Hydration/Weight Meeting note. The note indicated that resident 32 now weighed 180.8 lbs, a loss of 3 lbs or 2.3% of his body weight that week. Facility staff documented that the weight loss was not desired, but that the resident's intake seemed to be increased the last few days, so staff would cont (continue) to watch [and] encourage intake. Will fill out 'risk vs benefit' this week. Facility staff did not indicate what the risk vs benefit document was for. g. On 10/7/22, facility staff completed a Skin/Hydration/Weight Meeting note. The note indicated that resident 32 now weighed 178.8 lbs, a loss of 6.4% of his body weight that month. The note also indicated that staff would refer to nsg (nursing) [and] Social Worker to look into getting NG (nasogastric) tube placed for supp (supplemental feeds). No other interventions were listed, and no evidence could be located that resident 32 had been referred for an NG tube evaluation. As of 10/26/22, no other weights were listed for resident 32 after 10/7/22. On 10/26/22 at 4:27 PM, an interview was conducted with the facility Dietary Manager (DM). The DM stated that she had additional documented weights for resident 32, but that they had not documented the weights or had a Skin/Hydration/Weight meeting regarding resident 32 since 10/7/22. The DM stated that on 10/9/22 resident 32's weight was 176.8 lbs, and on 10/16/22 his weight was 175.6. The DM could not provide documentation that the resident had been weighed since 10/16/22. A nurses note for resident 32 dated 10/18/22 revealed that the resident had been seen by a wound care provider that day for left ankle and right heel pressure ulcers. No other documentation was located in resident 32's medical record regarding the wounds. It should be noted that the first time the pressure ulcers were documented in the medical record was after the resident had experienced continued weight loss with no interventions. On 10/25/22 at 10:09 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 RN 3 stated that resident 32 was being seen by a wound care provider for open areas on his ankles. When asked where those wound notes could be located in an attempt to determine when the pressure ulcers began, RN 3 stated that its been many months since I've seen those notes. RN 3 stated that the wound care provider would come in to see the resident, and then document their notes electronically. RN 3 stated that only the Administrator (ADM) had access to those wound care provider notes. 30563 Potential for Harm 2. Resident 7 was admitted to the facility on [DATE] with diagnoses which included Schizoaffective disorder, dementia with behavioral disturbance, anxiety, concussion with loss of consciousness, and diabetes mellitus. On 10/12/22 at 11:55 AM, an interview was conducted with resident 7. Resident 7 stated he was not getting enough to eat and he was loosing weight. On 10/12/22 at 2:53 PM, a follow up interview was conducted with resident 7. Resident 7 stated the food was not healthy and he did not like rice. Resident 7 stated he was served a lot of rice. Resident 7's medical record was reviewed. An annual MDS dated [DATE] revealed resident's weight was 210 and there was no significant weight loss of 5% or more in the last month or more that 10% in the last 6 months. Resident 7 was not receiving a therapeutic diet (e.g. low salt, diabetic, low cholesterol). A care plan dated 8/10/22 revealed resident 7 was at nutritional risk as evidence by body mass index greater than 27, Reduced concentrated sweets (RCS) therapeutic diet. The goals were resident will have no significant weigh change, resident will have moist mucous membranes and no tenting of skin, no aspiration/cough while eating, no discomfort due to eating, and skin will remain intact. The approaches developed were to monitor weekly weights, encourage more that 85 % food intake, multivitamin with minerals, vitamin D and a diet order of RCS, regular texture, thin liquids. A physician's order dated 3/2/21 revealed resident 7 was to receive a reduced concentrated sweets diet related to type 2 diabetes mellitus with diabetic neuropathy. Resident 7's weights were: [Note: All weights were in pounds.] a. October 2021 was 216 b. April 2022 was 207.8 c. May 2022 was 205 d. June 2022 was 202.2 e. July 2022 was 200.4 f. August 2022 was 200.1 g. September 2022 was 201.1 h. October 2022 was 197.6. It should be noted that resident 7 experienced a 4.9% weight loss in 6 months, 1.3% in 3 months and 1.7% in a month. Resident 7's weight was trending downward. Resident 7's amount eaten documentation by the CNA (Certified Nursing Assistant)revealed inconsistent documentation. Resident 7 did not have documentation for 10/3/22, 10/4/22, 10/5/22, 10/8/22, 10/9/22, 10/10/22, 10/11/22, 10/13/22, 10/14/22, 10/15/22, 10/16/22, 10/18/22, 10/19/22, 10/20/22 and 10/23/22. Resident 7 ate 75-100% for 10 meals, resident 7 ate 51-75% 4 times, and resident 7 ate 2 meals of 26-50% from 10/1/22 until 10/25/22. A Quarterly Nutrition Note by the DM dated 8/10/22 revealed resident 7 was on a mechanical soft RCS diet and was eating 50-100% of his meals. Resident was dining in the secured unit and his skin was intact. The comments revealed the physician was notified of weekly weight, eating well, self directed with choices and intake. There were no changes made and would continue to monitor. On 10/11/22 at 7:45 AM, an observation was made of resident 7. Resident 7 was observed to be served a pancake, ground meat, grapes and cream of wheat. Resident 7's meal card revealed that resident 7 was to receive a RCS mechanical soft texture diet. On 10/20/22 at 11:49 AM, an observation was made of resident 7. Resident 7 was served a taco with shredded lettuce and lemon pie. All residents in the memory care unit were observed to be served lemon pie. On 10/26/22 at 3:51 PM, an interview was conducted with the DM. The DM stated resident 7 ate everything and she had not been worried resident 7 weight was trending downward. The DM stated resident 7 was on a mechanical soft diet. The DM stated grapes should be cut up and lettuce should be shredded for resident with mechanical soft diet orders. On 10/27/22 at 4:39 PM, an interview was conducted with CNA 5. CNA 5 stated that resident 7 did not like any of the food and he looked at her and said Look at this. I've lost 2 pounds. On 10/26/22 at 5:40 PM, a phone interview was conducted with the Medical Director (MD). The MD stated the weights were printed out months and she signed the graphs. The MD stated she was not aware of the facility skin and weight meeting process. The MD stated she was not notified beyond the graphs of resident's weights. 3. Resident 13 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included encephalopathy, paroxysmal atrial fibrillation, muscle weakness, dementia, and schizoaffective disorder. On 10/11/22 at 7:50 AM, an observation was made of resident 13. Resident 13 was observed to be served a pancake, sausage, oatmeal and grapes. Resident 13 was not observed to be served a mighty shake by nursing staff or dietary staff. On 10/26/22 at 11:46 AM, an observation was made of resident 13. Resident 13 was not observed to be served a mighty shake. Surveyor was in the memory care unit from 1:45 PM until 2:36 PM, and there was no nurse observed in the memory care unit to administer a mighty shake. Resident 13's medical record was reviewed. An annual MDS dated [DATE] revealed resident was 159 pounds with no weight loss or gain of 5% or more in the last more or more than 10% in the last 6 months. Resident 13 did not have a mechanically altered diet or a therapeutic diet. Resident 13's nutritional care plan updated on 9/9/22 revealed resident weight was down by 10.1% in 3 month and 12.2% in 6 months. Resident 13 was at risk for nutritional risk as evidence by chewing/swallowing problems with poor dentition and mechanical soft therapeutic diet. The goals were resident 6 would not have significant weight loss, maintain moist mucous membranes and no tenting of skin, no aspiration/cough while eating, tolerate diet, no discomfort due to diet and skin will remain intact. The approaches were monitor weekly weights, encourage more that 75% of meal intake, with a diet of regular, mechanical soft and thin liquids. It should be noted the physician's dietary order was for regular texture and consistency. Physician's orders revealed the following dietary orders: a. On 1/23/17, regular diet with regular texture and regular consistency. b. On 8/17/22, mighty shake three times a day for a supplement c. On 3/15/18, high protein snacks three times a day Resident weights were as follows: [Note: All weights were in pounds.] a. October 2021 was 186.6 b. April 2022 was 178.8 c. May 2022 was 178.2 d. June 2022 was 175.4 e. July 2022 was 174.2 f. August 2022 weight was refused g. September 2022 was 157.6 h. October 2022 was 162.4 It should be noted that resident 7 lost 3% weight in 1 month, 6.7% in 3 months and 9.1% in 6 months. A form titled Skin/Hydration/Weight Meeting dated 7/22/22 revealed resident 13's weight was 170.4 pounds and weight had decreased 2.1% in 1 week. Resident 7 was on a mechanical soft diet with intake amount refused to 50% to 100% and skin was intact. Resident 7's MD was notified of weekly weights, weight was trending down, resident tended to worry about weight gain, and did not want to gain weight at all. Resident 7 currently was COVID positive. The DM documented Will fortify diet as to not add more volume in suppl, (supplement) etc will follow closely. The note was co-signed by the Registered Dietitian (RD). It should be noted there was no change in resident 13's diet order to fortified. A Skin/hydration/weight Meeting on 9/9/22 revealed that resident had 10.1% weight loss in 3 months and 12.2% in 6 months. Resident 13 was receiving a regular mechanical soft diet. It was documented that the MD was notified of weekly weight and resident 13 was eating fair to poor and refused to eat at some meals. Resident 13 was self directed with meal choices and intake. Resident 13 encourage intake and will continue to monitor. On 10/26/22 at 4:20 PM, an interview was conducted with the DM. The DM stated resident 13's weight was bouncing up and then back down. The DM stated resident 13 did not want to gain weight and he really focused on his weight. 4. Resident 31 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, hyperlipidemia, dementia with behavioral and major depressive disorder. On 10/11/22 at 7:50 AM, an observation was made of resident 31. Resident 31 was observed to be served a pancake, ground meat, hot cereal and grapes. Resident 31 was not served a mighty shake. Resident 31 was observed to be assisted with eating by CNA 2. On 10/12/22 at 10:31 AM, an interview was conducted with resident 31's family member. The family member stated resident 31 had lost weight and her current weight was like 112 or 114. The family member stated resident 31 ate but staff did not give her the time of day to feed her. On 10/18/22 at 12:14 PM, resident 31 was observed in the memory care unit dining room. Resident was observed to be eating cake with her fingers. The cake was crumbled and she was getting small amounts into her mouth. Resident 31's meal ticket was on her plate and resident was observed to pick up her meal ticket and put it between her fingers and raised the meal ticket to her mouth. Resident 31 dropped her meal ticket onto her lap. Resident 31 had rice and a orange/brown substance over the rice. Resident 31 did not have utensils. There were no staff in the dining room. LPN 1 was observed outside the dining room and CNA 1 was in another residents room. On 10/20/22 at 11:49 AM, resident 31 was observed in the memory care unit dining room. Resident 31 was observed to be assisted by CNA 4 with eating. CNA 4 stated resident 31 sometimes received a small chocolate shake with her meals. On 10/24/22 at 11:53 AM, resident 31 was observed in the memory care unit dining room. Resident 31 was observed to place her hands in her cake. CNA 8 was observed to remove resident 31's hands from the cake and clean them off. Resident 31 was not observed to have a mighty shake. On 10/26/22 at 11:46 AM, resident 31 was observed in the memory care unit dining room. Resident 31 was observed to be assisted with eating by the Director of Nursing (DON). Resident 31 was not observed to have a mighty shake. A continual observation was conducted of the memory care unit until 2:36 PM. The DON was not observed to provide mighty shakes. Resident 31's medical record was reviewed. An annual MDS dated [DATE] revealed resident 31 was 115 pounds with no weight loss or gain of greater than 5% in a month or greater than 10% in 6 months. Resident 31 did not have a mechanically altered or therapeutic diet. The MDS revealed resident 31 required limited 1 person assistance with eating. A nutritional care plan dated 10/14/22 revealed resident 31 was at nutritional risk as evidence by history of weight loss, enriched diet and Alzheimer's Dementia. The goals were no significant weight loss, maintain moist mucous membranes or tenting, no aspirate/cough while eating, tolerate diet, no discomfort due to diet and skin remain intact. The interventions were monitoring weekly weights, encourage more than 60%, high protein three times a day. The diet was enriched, minced and moist with thin liquids. The supplements were mighty shakes three times a day and boost breeze daily. Resident 31's weights in the medical record were: [Note: All weights were in pounds.] a. October 2021 was 130.4. b. April 2022 was 116.8 c. May 2022 was 116 d. June 2022 was 117 e. July 2022 was 116.4 f. August 2022 was 115.6 g. September 2022 was 112.8 h. October 2022 was 113.6 A nutritional assessment dated [DATE] revealed that resident 31 continued on enriched, minced and moist food with thin liquids. Resident 31 had a average intake of about 70%. Resident 31 had resource breeze daily, mighty shakes three times a day and high protein snacks three times per day. Resident 31's weight increased 1.2% in the past week. The RD documented that a medication review was requested to possibly add remeron in September and it was not added. The RD documented remeron was not added and the RD will continue to current plan of care and follow-up as needed. Resident 31's CNA documentation regarding the amount of food eaten revealed resident 31 ate 14 times over a 30 day period of time. Resident ate 75-100% 11 times and 51-75% 3 times in the previous 30 days. Resident 31's Medication Administration Record (MAR) revealed Resource Breeze 1/2 box was not administered on 10/3/22, 10/5/22, and 10/14/22. Mighty shakes were not administered on 10/3/22, 10/5/22, and 10/14/22. Mighty Shakes were documented as administered on 10/13/22 by LPN 1 and on 10/26/22 by the DON. On 10/13/22 from 9:30 AM to 11:30 AM, an observation was made of the facility medication pass. LPN (Licensed Practical Nurse) 1 did not administer mighty shakes to residents. LPN 1 stated that he did not pass any of the Mighty Shakes because they were frozen. On 10/26/22 at 2:45 PM, an interview was conducted with the DON. The DON stated that she gave a resident 31 her mighty shake about 8:30 AM and resident 31 did not really drink it. The DON stated that she administered resident 31's noon mighty shake at 2:30 PM. It should be noted that there was a continual observation of the memory care unit from 1:45 PM until 2:36 PM and the DON was not observed to enter the unit during that time. The lunch meal was observed and resident 31 did not receive a mighty shake with her meal. On 10/26/22 at 1:56 PM, an interview was conducted with CNA 1. CNA 1 stated she did not have a mighty shake to feed resident 31 with lunch. On 10/27/22 at 9:36 AM, a phone interview was conducted with resident 31's power of attorney (POA). The POA stated he knew resident 31 was loosing weight because of the way she looked. The POA stated he had not been notified by the facility staff that resident 31 had lost weight. On 10/26/22 at 4:11 PM, an interview was conducted with the DM. The DM stated resident 31 was loosing weight because of her dementia. The DM stated resident 31 ate sandwiches because she did not smash them into things. The DM stated every meal resident 31 needed to be provided with assistance for eating. The DM stated resident 31 was provided snacks three times a day, a box of boost breeze daily, and mighty shakes three times a day. The DM stated resident 31 drank the supplements well. The DM stated there was high protein milk for residents on enriched or fortified foods. The DM stated resident 31 should have more fats and gravies with extra calories. The DM stated the high protein drink consisted of 1 gallon of whole milk, 2 cups powdered milk, sugar and flavor. The DM stated residents were served 8 ounces of the high protein milk. The DM stated resident 31 should be getting the high protein milk with every meal. On 10/26/22 at 11:39 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 31 had lost weight because she was pacing the hallway more. CNA 1 stated most of resident 31's weight loss had experienced it gradually. CNA 1 stated if a residents weight was to low, then the resident received breezes or mighty shakes. CNA 1 stated there were sandwiches available for resident that need more food. CNA 1 stated that sometimes weight were off on the scale so a re-weigh was done. CNA 1 stated if a resident continued to loose weight then there were interventions to prevent more weight loss like sandwiches or supplements. CNA 1 stated resident 31 got a sandwich three times a day. CNA 1 stated she was given a mighty shake with her medications or with her meals. On 10/18/22 at 1:23 PM, an interview was conducted with Cook 1. Cook 1 stated that there were mighty shakes in the freezer in the kitchen. Cook 1 stated the nursing staff had to come ask for the mighty shakes and they were kept in the refrigerator at the nurses station. Cook 1 stated that boost breeze came out with snacks at 10:00 AM, 2:00 PM and 8:00 AM. On 10/18/22 at 1:28 PM, an interview was conducted with LPN 1. LPN 1 stated he went through about 15 mighty shakes per day. LPN 1 stated he was out of the medication pass and the mighty shakes were still frozen on 10/13/22. LPN 1 stated it took about 4 hours for the mighty shakes to thaw. LPN 1 stated if he did not have enough mighty shakes he administered boost breeze to residents. It should be noted during the medication pass on 10/13/22, LPN 1 did not administer boost breeze when he did not have mighty shakes available. On 10/27/22 at 4:15 PM, an interview was conducted with CNA 5. CNA 5 stated resident 31 was not supposed to be fed, but she was just forgetting how to eat. CNA 5 stated resident 31 needed help eating because she did not know how to eat on her own. CNA 5 stated she tried to get resident 31 finger foods and then she could cue resident 31 to eat. CNA 5 stated she needed to be fed foods like soup. CNA 5 stated she was the only CNA for the entire facility from 2:00 PM to 10:00 PM most days. CNA 5 stated that dining rooms had to go unattended at times. CNA 5 stated residents in the main dining room were independent. CNA 5 stated the nurses sometimes helped in the dining rooms. 40334 5. Resident 36 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, anxiety, diabetes mellitus, anemia, intellectual disabilities, and depression. On 10/11/22 from 4:22 AM until 6:04 AM, resident 36 was observed wandering the memory care unit. Resident 36 appeared thin, and paced continuously. On 10/13/22 at 10:30 AM, LPN 1 was observed during medication (med) pass administering medications to resident 36. LPN 1 stated that resident 36 had been asleep and did not receive any medications or supplements before med pass. LPN 1 was observed to provide eight medications and supplements. LPN 1 was not observed to provide resident 36 a mighty shake. LPN 1 stated that he did not pass any of the Mighty Shakes because they were frozen. On 10/22/22 at 10:40 AM until 12:37 PM, resident 36 was observed wandering the hallway in the memory care unit. On 10/24/22 at 11:12 AM until 11:50 AM, resident 36 was observed pacing the hallway in the memory care unit. Resident 36 was observed to ask CNA 4 and CNA 8 for scissors because there were wires on his bed. On 10/31/22, resident 36's medical record review was completed. Resident 36's physician orders included an order for a supplement called at Mighty Shake, three times daily, when resident 36 arose, at noon, and in the afternoon (time unspecified). A diet order for an enriched diet. Resident 36's weights were obtained by the facility. On 9/4/22, resident 36 weighed 120.8 pounds. On 10/16/22, resident 36 weighed 116.4 pounds. On 9/12/21, resident 36 weighed 123.2 pounds. Resident 36 lost 5.6% of his total body weight in one month. On 10/26/22 at 4:08 PM, an interview was conducted with the DM. The DM stated that the fortified and enriched diets were the same, with added calories for people who had weight loss. The DM stated that the high-protein drink for most residents was the Mighty Shake. The DM stated that for resident 36, staff tried to get him finger foods because he would eat a little and walk away. The DM stated that resident 36 walked away his calories. The DM stated that the nurses provided the Mighty Shakes to the residents. The DM stated that there was butter stored on the top of the serving cart, but the butter was not always added. 6. Resident 37 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, DM II, hypokalemia, chronic pain, epilepsy, delusional disorder, dementia, osteoporosis, atherosclerotic heart disease, systemic lupus erythematosus, hypertension, and schizophrenia. On 10/13/22 at 10:30 AM, LPN 1 was observed during medication (med) pass administering medications to resident 37. LPN 1 stated that resident 37 had been asleep and did not receive any medications or supplements before med pass. LPN 1 was observed to provide eight medications and supplements. LPN 1 was not observed to provide resident 37 a mighty shake. LPN 1 stated that he did not pass any of the Mighty Shakes because they were frozen. Resident 37's record review was completed on 10/31/22. Resident 37 had an order for a Mighty Shake, one time a day in the morning. Resident 37's dietary order was for RCS, mechanical soft texture, and regular consistency, with directions for fortification and twice daily high-protein snacks. On 10/20/22 at 10:00 AM, an interview was conducted with LPN 1. LPN 1 stated that residents did not receive Mighty Shakes unless there was an order. LPN 1 stated that the nurses were responsible to get the Mighty Shakes from the freezer and defrost them for the shift. LPN 1 stated that the Mighty Shakes were typically not available early in the morning, because they took a few hours to thaw. On 10/26/22 at 3:51 PM, an interview was conducted with the DM. The DM stated that she purchased the Mighty Shakes as needed. The DM stated that sometimes weights were missed by the staff, but usually it was because the residents had refused. The DM stated that she did not know why the latest week's weights were not available. The DM stated that the last available weights were from 10/16/22. On 10/28/22 at 10:55 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 37 was only calm when staff fed her meals, but staff did not typically feed her, because it was not required. [Note: The Task list for CNAs revealed that resident 37 received assistance with meals one time in the past 30 days, between 10/1/22 and 10/30/22, which was on 10/4/22.] On 10/27/22 at 2:30 PM, an observation was made of the facility medication room. There were 25 Mighty Shakes on a tray in the medication room on the counter. An interview was immediately conducted with the Assistant Director of Nursing (ADON). The ADON stated she had received the mighty shakes that morning and had administered a few with the lunch medication pass. The ADON stated the Mighty Shakes were frozen for the morning medication pass. The ADON stated that residents cannot drink the Mighty Shakes when they're frozen, so they were not administered in the morning. The ADON stated she was thawing the Mighty Shakes on the counter so they could be administered during afternoon medication pass, and the Mighty Shakes should have been refrigerated. 45470 7. Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included muscle weakness, schizophrenia, cognitive communication deficit, conversion disorder, anxiety disorder, chronic kidney disease, psychosis, difficulty in walking, and hyperlipidemia. On 10/13/22 at 9:23 AM, an observation of resident 4 was made. Resident 4 was in bed and observed to have a feeding tube which entered through resident 4's nose. An interview with resident 4 was not conducted due to resident 4's cognitive communication deficit. A review of resident 4's medical record was conducted. Resident 4's MDS dated [DATE] revealed that resident 4 was on a feeding tube. The MDS was marked 51% or more for proportion of total calories the resident received through parenteral or tube feeding. The MDS was marked 51% or more for average fluid intake per day by IV (Intravenous therapy) or tube feeding. Resident 4 had a care plan focus, dated 8/2/21, which stated, The resident requires tube feeding r/t (related to ) chewing problem swallowing problem. The goals were listed as, The resident will be free of aspiration throug [TRUNCATED]

Based on observation, interview, and record review it was determined, for 1 of 33 sampled residents, that the facility failed to provide appropriate treatments and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. Specifically, physician orders to prevent a clogged feeding tube were not followed for a resident who was receiving enteral feeding. Resident identifier: 4. Findings Include 1. Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included muscle weakness, schizophrenia, cognitive communication deficit, conversion disorder, anxiety disorder, chronic kidney disease, psychosis, difficulty in walking and hyperlipidemia. On 10/13/22 at 9:23 AM, an observation of resident 4 was made. Resident 4 was in bed and observed to have a feeding tube which entered through resident 4's nose. An interview with resident 4 was not conducted due to resident 4's cognitive communication deficit. Resident 4's medical record was reviewed. Resident 4's Minimum Data Set (MDS) dated [DATE] revealed that resident 4 is on a feeding tube. The MDS was marked 51% or more for proportion of total calories the resident received through parenteral or tube feeding. The MDS was marked 51% or more for average fluid intake per day by IV (intravenous therapy) or tube feeding. Resident 4 had a care plan focus, dated 8/2/21, which stated, The resident requires tube feeding r/t (related to) chewing problem swallowing problem. The goals were listed as, The resident will be free of aspiration through the review dated, the resident will maintain adequate nutritional and hydration status .weight stable, no s/sx (signs/symptoms) of malnutrition or dehydration through review date, [and] the resident will remain free of side effects or complications related to tube feeding through review date. The interventions/tasks listed were, The resident needs the HOB (head of bed) elevated 45 degrees during and thirty minutes after tube feed. Obtain and monitor lab/diagnostic work as ordered. Reports results to MD (medical director) and follow up as indicated. The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders. The Treatment Administration Record (TAR) document was reviewed from 10/1/22 to 10/12/22. The TAR orders had multiple days with incomplete documentation: a. An order with a start date of 1/10/21 stated, Change syringe and feed bag/tubing with date labeled Q (every) night shift There was no documentation as administered on 10/2/22, 10/3/22, 10/8/22, 10/9/22, 10/10/22, or 10/11/22. It should be noted that this order was blank in the nursing initial section 6 out of 12 times from 10/1/22 to 10/12/22. b. An order with a start date of 4/22/22 stated, Flush feeding tube night shift every 3 hours .every night shift .to prevent clogging of tube. There was no documentation as administered on 10/2/22, 10/3/22, 10/8/22, 10/9/22, 10/10/22, or 10/11/22. It should be noted that this order was blank in the nursing initial section 6 out of 12 times from 10/1/22 to 10/12/22. On 10/18/22 at 10:04 AM, an interview with Registered Nurse (RN) 3 was conducted. RN 3 stated when there were blank area in the nursing initial section on the Behavior Tracking document, the MAR, and the TAR, that meant the nurse did not chart whether the order was completed or not. RN 3 stated that not charting whether orders were completed or not could mean that the orders were not completed. On 10/20/22 at 10:00 AM, an interview with Licensed Practical Nurse (LPN) 1 was conducted. LPN 1 stated that he was aware of a night nurse who, on multiple occasions, was not following the doctor's orders to flush resident 4's feeding tube. LPN 1 stated that on one occasion, LPN 1 came on shift in the morning and discovered that resident 4's feeding tube was clogged from 11:30 PM the night before, and the night nurse in charge of resident 4 did not unclog it, start an IV for hydration, nor inform the doctor that the tube feeding was clogged. LPN 1 stated that he immediately got orders to send resident 4 to the emergency room to unclog the feeding tube. LPN 1 stated that he felt this occasion was neglectful. LPN 1 stated that resident 4 has had the NJ (nasojejunal) tube for almost 2 years. LPN 1 stated an NJ tube was temporary so he should have had a PEG (percutaneous endoscopic gastrostomy) tube placed. LPN 1 stated that the facility had been discussing replacing the NJ tube with a PEG tube for about 2 years. LPN 1 stated he was not sure why the appointment for resident 4 to get a PEG tube was continuously postponed. Resident 4's progress notes revealed multiple occasions where the NJ tube has been clogged: a. On 1/21/22 at 3:36 PM, Resident was taken via w/c (wheelchair) to . hospital at 9:15 [AM] for a replacement of his clogged NJ tube . b. On 3/2/22 at 8:41 PM, Resident NG (nasogastric) tube clogged and was being declogged when it burst with a hole in it. MD notified and orders for a replacement of NG . c. On 4/16/22 at 10:16 AM, NJ tube is clogged. Radiology is unable to replace tube all weekend. Scheduling office is closed so will have to call Monday morning to schedule NJ replacement. MD notified . d. On 5/21/22 at 8:59 PM, In to assist RN with a clogged feeding tube. Feeding tube was unhooked from machine easier as it was reported that he had a shower . e. On 9/22/22 at 4:53 PM, NJ tube became clogged, and resident then pulled the tube out on his own. MD notified and ordered NJ tube replace by [hospital name redacted] radiology . On 10/21/22 at 11:44 AM, an interview with the Director of Nursing (DON) was conducted. The DON reported that on one occasion the night nurse on duty did not start an IV or inform a doctor when resident 4's feeding tube was clogged. The DON stated that when she came on shift in the morning and learned that the feeding tube was clogged, she immediately started an IV. The DON stated that the night nurse should have started the IV and informed the doctor right away. The DON stated that resident 4 was diabetic and it would have been dangerous if resident 4 became dehydrated.

Based on observation, interview and record review it was determined, for 2 of 33 sampled residents, that the facility did not ensure pain management was provided to residents who required such services. Specifically, a resident screamed out in pain when he was repositioned. Another resident went to the hospital and his scheduled pain medication was discontinued when he returned. The resident complained of uncontrolled pain. These examples will be cited at a harm level. Resident identifiers: 14 and 32. Findings include: 1. Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia, chronic obstructive pyelonephritis, severe sepsis, aspiration pneumonitus, supraventricular tachycardia, acute kidney failure, bipolar disorder, epilepsy, thyrotoxicosis and osteoarthritis. Resident 32's medical records were reviewed between 10/11/22 and 10/31/22. Resident 32's care plan dated 7/10/17 indicated that the resident was at risk for pain due to his osteoarthritis, cerebrovascular accident, and migraines. The interventions were to administer analgesia 30 minutes before treatments or care, anticipate the resident's need for pain relief and respond immediately to any complaint of pain, and evaluate the effectiveness of pain interventions. The care plan had not been updated since 7/10/17. Two different pain assessments were located in resident 32's medical record with resident 32's name on it. However, the assessments were blank. Resident 32's physician orders revealed that resident 32 had the following orders: a. Acetaminophen 650 milligrams (mg) every 6 hours as needed. b. Meloxicam 7.5 mg daily for osteoarthritis. The September 2022 Medication Administration Record (MAR) indicated that resident 32 had not received any Acetaminophen during that month. The MAR also indicated that the highest level of pain that resident 32 was reporting was an 8 on 9/14 (twice), 9/15 (twice) and 9/16 (once). No indication was made on the MAR that resident 32 was receiving pain medication prior to cares, as suggested in the care plan. The October 2022 MAR indicated that resident 32 had not received any Acetaminophen during the month of October 2022 as of 10/26/22. The MAR also indicated that the highest level of pain that resident 32 was reporting was a 2. No indication was made on the MAR that resident 32 was receiving pain medication prior to cares, as suggested in the care plan. On 10/12/22 at 11:20 AM, resident 32 was interviewed. Resident 32 stated that he was only in pain when he moved. Resident 32 stated that when he was moved, such as for a brief change, his pain was an 8 on one side of his body, and a 10 on the other side. Resident 32 stated as long as he was in a middle position, he did not have any pain. On 10/26/22 at 10:50 AM, resident 32 was re-interviewed. Resident 32 stated that his pain was shooting from his right leg and going up his left arm. Resident 32 again stated that he was only in pain if he moved. Resident 32 stated that his pain was at an 8 out of 10 when his briefs were changed. On 10/26/22 at 11:04 AM, an observation was made of resident 32's torso area with Certified Nursing Assistants (CNAs) 3 and 4. The resident's brief change was also observed. Resident 32 presented with red to red/purple skin on the left side of his back and bilateral lower extremities below the knees. The skin was peeling (excoriated) with open wounds that were not dressed. There were four small (less than 1 centimeter) open, bleeding areas on resident 32's back, all on the left side of the resident's spine. The skin over the spine also appeared to be peeling and red. CNA 3 stated that the Director of Nursing (DON) would come in later to assess the wound to determine the appropriate dressing/cream. CNA 3 stated that the skin did not blanch and demonstrated that the purple/red areas on resident 32's left side did not blanch. CNA 3 stated that resident 32 had a lot of pain with his brief changes, and that they worked together every day to make sure he had the Calmoseptine cream on his red areas. CNA 4 stated that resident 32's skin appeared better than a month ago. Lotion was applied by the CNAs over resident 32's legs. Resident 32 stated OW! multiple times each time he was rolled during the brief change. The resident also stated that his pain was at a 10 on his left side. Resident 32 stated that his entire left side hurt, and motioned from his head to his foot. Resident stated that the right half of his body was alive and the left side was dead. The CNAs propped resident 32's left leg on a pillow, with the leg turned outward (abducted) from midline, and resident 32's right leg was placed on a pillow with the right heel floated. The right heel did not appear to have any open areas. Resident 32's head was placed on a pillow. Resident 32 stated that he did not have pain after the pillows were placed. On 10/26/22 at 11:24 AM, an interview was conducted with Certified Nursing Assistants (CNAs) 3 and 4. CNA 3 stated that no matter what position they placed resident 32 in, he would move himself back to his favored position due to pain. CNA 3 stated that staff had to coax the resident into showers and brief changes. On 10/25/22 at 10:09 AM, an interview was conducted with Registered Nurse (RN) 3. When asked about resident 32's pain, RN 3 stated that when resident 32 was repositioned by staff, he would complain of pain. RN 3 stated that its been going on a long time that he says he's in pain. RN 3 stated that resident 32 was being administered meloxicam every day for pain relief. RN 3 stated that resident 32 was cognitively impaired and would often say that he wasn't in pain. RN 3 further stated we should probably do a non verbal (pain scale) as well. On 10/31/22 at 8:48 AM, an interview was conducted with the facility Medical Director (MD). The MD stated she was unaware that resident 32 did not move because he was in pain. The MD stated she would address uncontrolled pain if she had been notified. 30563 2. Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cellulitis and abscess of mouth, osteoarthritis in left hip, chronic pain, metabolic encephalopathy, Wernicke's encephalopathy, dementia and psychosis. On 10/20/22 at 12:00 PM, an interview and observation was made of resident 14. Resident 14 asked why he was in more pain and getting more medication than before he left to the hospital. Resident 14 stated he had pain in legs, hands and spine. Resident 14 stated eating hurt and pain kept him awake at night. On 10/26/22 at 12:15 PM, an interview was conducted with resident 14. Resident 14 stated he had pain in his right leg and pain from his shoulder to his toes down his leg on his left side. Resident 14 stated he was not in pain at the hospital but since getting back to the facility he had been in pain. Resident 14 stated in the morning he was woken-up by his pain. Resident 14 stated if he got his pain medication prior to bed, then he was able to sleep. Resident 14 stated without pain killers he did not sleep at all. Resident 14 stated the cold weather made his pain worse. Resident 14 stated he didn't do much because he was in pain. Resident 14 stated if there were activities, he would not go because it hurt for him to walk. Resident 14 stated at the hospital, they were able to control his pain, but he was unable to get the same medications at the facility. At 12:42 PM, resident 14 stated that his back was hurting and he was in pain. Resident 14 stated the pain medication did not last very long. Resident 14's medical record was reviewed. A quarterly Minimum Data Set, dated dated dated [DATE] revealed that resident 14 had received scheduled and as needed pain medication. The MDS revealed resident had pain or was hurting any time in the last 5 days and was almost constantly experiencing pain in over the previous 5 days. The MDS revealed that resident 14's pain limited his day-to-day activities. The MDS revealed resident's worst pain intensity was very severe, horrible in the previous 5 days. A care plan dated 6/10/13 with a target date of 5/3/22 revealed The resident has pain r/t (related to) general pain, arthritis, low back pain. The goal was The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Interventions included The resident will not have discomfort related to side effects of analgesia through the review date; The resident will not have an interruption in normal activities due to pain through the review date ; The resident will display a decrease in behaviors of inadequate pain control (SPECIFY: irritability, agitation, restlessness, grimacing, perspiring, hyperventilation, groaning, crying) through the review date; Resident's pain will be managed at an acceptable level 5 through next review date; The resident's pain is aggravated by: general pain ; The resident's pain is alleviated/relieved by: prn (as needed) medications; Administer analgesia ultram as per orders. tylenal Give 1/2 hour before treatments or care; Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; Evaluate the effectiveness of pain interventions after medication administration; Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition ; Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function; Identify, record and treat the resident's existing conditions which may increase pain LPN and or discomfort; and resident usually does not remember when the nurse has given him a pain pill . ask resident too rate his pain level before and after to determine effectiveness. Resident 14's physician's orders were reviewed prior to discharging to the hospital. The following medications were ordered: a. Start date of 9/24/2020, Gabapentin 100 mg by mouth three times a day for low back pain. b. Start date of 1/5/19, Oxycodone HCL 5 mg. Give 1 tablet by by mouth every 4 hours as needed for pain related to other chronic pain. c. Start date of 1/5/19, Oxycodone HCL 5 mg. Give 1 tablet by mouth two times a day related to other chronic pain and low back pain. Discontinued on 10/13/22. Resident 14 returned from the hospital on 10/13/22 with orders to discontinue the scheduled Oxycodone 5 mg twice daily. The form revealed resident 14 had a neck wound and neck abscess. The nursing phone revealed a notification to the MD on 10/13/22 [resident 14] is back. The MD responded What was he treated for? Any new orders? Nurse responded [resident 14's] discharge orders. sent to the MD. The MD responded Please make sure they get a follow up appt (appointment) for him with the ENT (ear, nose and throat) as per discharge orders. There was no follow up information about the change in pain medication. Resident 14's October 2022 MAR was reviewed. Resident 14 received the scheduled Oxycodone twice daily expect in the evening on 10/5/22. Resident 14's pain scores were 0 to 5 with pain at an 8 one time. Resident 14's pain score after returning from the hospital were 7 on 10/13/22, 10/14/22 and 10/15/22. Resident 14's pain was an 8 on 10/21/22, 10/22/22 and 10/23/22. The October 2022 MAR revealed resident 14 was provided Oxycodone 5 mg on the following days: a. On 10/6/22 at 8:33 PM, with a pain score of 8, b. On 10/15/22 at 9:58 AM, with a pain score of 7, c. On 10/16/22 at 3:51 PM, with a pain score of 6, d. On 10/18/22 at 12:08 PM, with a pain score of 5, e. On 10/20/22 at 11:56 AM, with a pain score of 5, f. On 10/21/22 at 12:24 PM, with a pain score of 6 and the medication was ineffective. g. On 10/21/22 at 7:40 PM, with a pain score of 8, h. On 10/23/22 at 3:50 PM, with a pain score of 8 i. On 10/24/22 at 10:55 AM, with a pain score of 8, j. On 10/25/22 at 11:57 AM, with a pain score of 5, k. On 10/25/22 at 5:22 PM, with a pain score of 5, l. On 10/26/22 at 11:57 AM, with a pain score of 5. According to the Controlled Drug Record for the Oxycodone 10 mg the instructions were take 1/2 tablet by mouth twice daily and 1/2 every four hours as needed. Resident 14 was administered a 1/2 tablet on the following days which there were not documented in the MAR entries with pain scores: a. On 10/13/22 at 9:35 PM b. On 10/14/22 at 6:00 PM c. On 10/18/22 at 9:00 AM d. On 10/15/22 at 6:00 PM e. On 10/14/22 with no time f. On 10/17/22 at 9:10 PM g. On 10/17/22 at 8:30 PM h. On 10/18/22 at 2:00 AM i. On 10/18/22 at 11:00 AM j. On 10/18/22 at 4:30 PM k. On 10/18/22 at 11:30 PM l. On 10/19/22 at 8:00 AM m. On 10/19/22 at 8:00 PM n. On 10/20/22 at 8:50 AM o. On 10/22/22 at 3:30 PM p. On 10/23/22 at 7:00 AM q. On 10/23/22 at 9:00 PM r. On 10/26/22 at 8:30 AM On 10/26/22 at 11:57 AM, an observation was made of resident 14 and the DON. The DON was observed to ask resident 14 if he wanted a pain pill. Resident 14 stated yes. The DON was observed to ask resident 14 what his pain level was and resident 14 stated 8. The DON stated that's a good level. On 10/27/22 at 9:10 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated resident 14 always complained of pain. The ADON stated resident 14 sometimes complained of pain everywhere and other times only in his legs or back. The ADON stated when resident 14 was walking he definitely looked like he was in pain. The ADON stated resident 14 went to hospital and his oxycodone was changed to every 4 hours as needed and the twice daily was discontinued. The ADON stated resident 14 had been getting the as needed quite often. The ADON stated she offered the oxycodone when resident 14 was in pain. On 10/28/22 at 11:26 AM, a interview was conducted with the DON. The DON stated resident 14 complained of pain. The DON stated resident 14 had scheduled and as needed pain medication. The DON stated He is one of those residents that says he's in pain. The DON stated He will say he is after he has had his pain medication. The DON stated resident 14 had not complained of more pain since going to the hospital. The DON stated staff needed to be very careful with him because of his narcolepsy. The DON stated resident 14 stayed up from noon till about 7:00 or 8:00 PM. The DON stated resident 14 slept a lot. The DON stated she was not aware of a change to his pain medication since coming back from the hospital. On 10/31/22 at 10:59 AM, an observation and interview was conducted with resident 14. Resident 14 stated his pain is at an 8 out of 10 and was up all night in pain. Resident 14 stated his pain went straight down his spine. Resident 14 stated if he moved the pain woke him up. Resident 14 stated before going to the hospital, he was not in this much pain. Resident 14 stated the pain was in the same areas but a lot more intense. Resident 14 stated he felt like shit because I can't sleep. Resident 14 stated eating was hard and his eyes felt like they were being ripped out. On 10/31/22 at 8:48 AM, an interview was conducted with the MD. The MD stated she was not contacted regarding resident 14 complaining of pain. The MD stated she was contacted about resident 14's stitches being removed, but that was all. The MD stated she did not know that his scheduled Oxycodone had been discontinued when he returned from the hospital. The MD stated she could address his pain if she was aware of it.

Based on interview and record review the facility did not ensure that 4 of 33 sampled residents were free of significant medication errors. Specifically, a resident was not administered the correct dose of insulin per physician orders resulting in uncontrolled diabetes. This example will be cited at a harm level. In addition, two residents' antibiotics were not administered according to physician orders, and another resident's coumadin was not administered according to physician orders. Resident identifiers: 22, 29, 32 and 94. Findings include: Harm 1. Resident 29 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus with foot ulcer, schizoaffective disorder, neuropathy, generalized anxiety disorder, borderline intellectual functioning, hyperlipidemia and hypomagnesemia. On 10/12/22, resident 29 was observed with a dressing on her right foot. Resident 29 stated that she recently had surgery. On 10/12/22 at 10:17 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that resident 29 often came to the nursing desk to ask the nurses for her medications, but some of the nurses ignored resident 29 and told her to wait. CNA 2 stated that resident 29's family did not provide any assistance to resident 29. CNA 2 stated that resident 29 had a lot of medical needs, and CNA 2 was not sure resident 29 received all the care she needed. On 10/11/22 at 5:05 AM, Registered Nurse (RN) 1 stated that she had not signed out resident 29's narcotic medication. On 10/12/22 at approximately 10:00 AM, resident 29 was interviewed. Resident 29 was observed to be ambulating in a wheelchair and stated that she had an appointment with her surgeon because she had foot issues. On 10/31/22, resident 29's medical record review was completed. Resident 29's physician orders included the following: a. Blood sugar checks before meals and at bedtime were initiated on 11/10/21. b. Bacitracin ointment, 500 units/gram, apply to wound topically, initiated on 11/10/21. c. Bactrim DS tablet, 800-160 MG (milligrams) (Sulfamethoxazole-Trimethoprim), 800 mg by mouth twice daily. d. Lantus solution, 100 units/mL (milliliters), inject 70 units subcutaneously in the morning and 60 units subcutaneously in the evening. e. Humalog solution 100 units/mL, sliding scale f. Clindamycin HCL capsule 300 MG, give 1 capsule by mouth three times a day related to unspecified open wound, right foot g. Doxycycline monohydrate tablet, 150 mg, Give 1 tablet by mouth two times a day for right foot for 14 Days Resident 29's Medication Administration Record (MAR) revealed that resident 29 did not receive the following medications on the following dates: a. In June, 2022, resident 29's Lantus was missed in the afternoon on 6/7, 6/13, 6/27, and 6/30; the Humalog sliding scale was not provided at 4:00 PM on 6/3, 6/13, 6/17, 6/20, 6/24, and 6/30; the Humalog sliding scale was not provided at 9:00 PM, on 6/7, 6/13, 6/27, and 6/30. b. In July, 2022, for resident 29's Lantus 70 units subcutaneously two times a day for diabetes mellitus, was missed on evening shift 7/5 and 7/10; Humalog solution 100 u/ml (Insulin Lispro) checks were ordered for 7:30 AM, 11:00 AM, 4:00 PM, and 9:00 PM. The 4:00 PM check and insulin were missed on 7/1, 7/5, 7/9, 7/11, 7/15, 7/16, 7/18, 7/22, 7/25, 7/29, and 7/30; The blood glucose check and insulin administration were missed at 9:00 PM on 7/5, and 7/10. c. In August, 2022, resident 29's Doxycycline was missed for the PM dose on 8/10, and the morning dose on 8/12 (with no extended doses); Doxycycline monohydrate tablet, 150 mg, Give 1 tablet by mouth two times a day for right foot for 14 Days was missed for the PM dose on 8/28/22; Lantus was not administered for the PM doses on 8/10, and 8/28; Humalog was not provided at 4:00 PM on 8/1, 8/5, 8/10, 8/11, 8/12, 8/15, and 8/22/22; and the 9:00 PM Humalog was not provided on 8/10. d. In September, 2022, resident 29's Lantus was not provided on 9/5, and 9/14; Clindamycin HCL capsule 300 MG, give 1 capsule by mouth three times a day related to unspecified open wound, right foot, subsequent encounter for 10 days, missed 9/14 all 3 doses (Arise, Noon, PM), and noon on 9/16 and the dosing was not extended; Humalog solution 100 unit/mL (insulin lispro) sliding scale was not checked or administered on: 9/5 in the PM; 9/14 all day, 9/16 at noon, and 9/26 at noon. e. In October, 2022, resident 29 did not received the following: Humalog check and administration at noon, missed on 10/5, and 10/17; HumaLOG Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 149 = 0; 150 - 200 = 3; 201 - 250 = 6; 251 - 300 = 9; 301 - 350 = 12; 351 - 400 = 15 Call medical provider if BS is >400, subcutaneously three times a day related to TYPE 2 DIABETES MELLITUS WITH FOOT ULCER, the afternoon Humalog was missed on 10/5, and 10/24. [Note: No charting was recorded that resident 29 refused cares or medications.] Resident 29's nursing notes revealed that resident 29 had a chronic right heel wound on 11/15/21 that became infected, worsened and required antibiotics in April through August. Resident 29 was lethargic in August 2022, and had new ulcers open on her foot. Resident 29 developed osteomyelitis and required a toe and metatarsal bone amputation in September, 2022. Resident 29's wound care note from 10/18/22 revealed that resident 29 had no open areas on her foot. On 10/24/22, resident 29's wound was partially open. On 10/25/22 at 10:09 AM, Registered Nurse (RN) 3 was interviewed. RN 3 stated that resident 29's wound had a bit of dehiscence (opened). Resident 29 was receiving antibiotics, but the wound was looking infected again. RN 3 stated that resident 29 needed to follow up with her surgeon. RN 3 stated there was a small amount of yellow-red drainage, and resident 29 was unable to walk on her foot after her surgery. RN 3 stated that any additional wound care should have been charted in the nursing notes or on the TAR. On 10/24/22 at 12:22 PM, the Medical Director (MD) was interviewed. The MD stated that she was not informed that resident 29's foot had reopened, and there was an area of what appeared to be necrotic tissue. The MD stated that the wound care company handled the wounds, and staff did not have the MD look at anyone's wounds. The MD stated that resident 29 required good control of her diabetes to promote healing and optimal health. 45470 Potential for Harm 2. Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] which included chronic diastolic heart failure, hyperkalemia, chronic kidney disease, anxiety disorder, difficulty in walking, polyneuropathy, major depressive disorder, cellulitis of lower limb, and venous insufficiency. A review of resident 22's medical record was conducted on 10/20/22. According to resident 22's physician's orders, resident 22 was prescribed 100 mg of Doxycycline Monohydrate Tablet two times a day for 10 days which started on 10/16/22 at 3:45 PM. A progress note from 10/16/22 at 3:52 PM stated, .Open areas of BLE (bilateral lower extremities) were larger today with some drainage. MD (Medical director) notified, ordered doxycycline 100mg BID [twice a day] x 10 days. First dose given at 1550 (3:50 PM) . Resident 22's Medication Administration Record (MAR) was reviewed. The MAR revealed that on 10/18/22 in the evening and on 10/19/22 in the morning, the Doxycycline Monohydrate Tablet was not marked as administered or held. On 10/27/22 at 10:06 AM, an interview with RN 3 was conducted. RN 3 stated that it was unclear if the medication was given on 10/18/22 in the evening and 10/19/22 in the morning from looking at the MAR. RN 3 stated that if there was a blank space on the MAR when a medication should have been administered, it meant that the nurse on duty did not indicate if the medication was administered or not, and the nurse did not add a reason as to why the medication was administered or not. RN 3 explained that antibiotics, like Doxycycline Monohydrate Tablets, were tracked on an antibiotic tracking paper in addition to being tracked on the MAR. RN 3 stated that the tracking sheet for Resident 22's Doxycycline Monohydrate Tablet had been turned in since the medication had been discontinued. RN 3 stated that the completed antibiotic tracking sheets were placed in one of the drawers at the nursing station, and she was unaware of where the papers went after that. On 10/27/22 at 10:15 AM, the nursing station drawers were searched for Resident 22's antibiotic tracking sheet. Resident 22's antibiotic tracking sheet was not found. The antibiotic tracking sheet for resident 22 was requested by the facility and the facility was unable to provide it. 22992 3. Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia, chronic obstructive pyelonephritis, severe sepsis, aspiration pneumonitus, supraventricular tachycardia, acute kidney failure, bipolar disorder, epilepsy, thyrotoxicosis and osteoarthritis. Resident 32's medical records were reviewed between 10/11/22 and 10/31/22. Resident 32's hospital discharge orders dated 8/18/22 were reviewed. The discharge orders included a new prescription for Linezolid 600 mg twice a day. The hospital documented that the next dose of the antibiotic was due that same evening. Resident 32's August 2022 MAR was reviewed. The MAR indicated that resident 32 did not receive the Linezolid on the evening of 8/18/22, or the evening of 8/22/22. The MAR indicated that resident 32 received the next dose on 8/23/22, after which the medication was discontinued by the physician. 4. Resident 94 was admitted to the facility on [DATE] with diagnoses that included chronic atrial fibrillation, aortic regurgitation and stenosis, pulmonary hypertension, hypertension, and type 2 diabetes mellitus with both diabetic nephropathy and peripheral angiopathy. Resident 94 was discharged from the facility on 9/6/22. Resident 94's medical record was reviewed from 10/11/22 through 10/31/22. a. Resident 94's hospital discharge orders were reviewed. The orders indicated that resident 94 should continue to be administered Coumadin 5 milligram (mg), one and half tablets every day for a total dose of 7.5 mg a day, and 52.5 mg of Coumadin per week. Resident 94's admission orders to the facility indicated that resident 94 was to be administered Coumadin 5 mg one tablet every day (for a total dose of 35 mg per week). The admission orders were documented as having been transcribed by the DON. Resident 94's Medication Administration Record (MAR) indicated that resident 94 received the 5 mg of Coumadin every day from 5/3/22 through 6/9/22. On 5/24/22, an Anticoagulant Visit Summary was completed for resident 94. The summary indicated that resident 94 had Dosing Instructions to be administered Coumadin 5 mg, one and half tablets every day for a total dose of 7.5 mg a day, and 52.5 mg of Coumadin per week. Despite the dosing instructions provided on 5/24/22, the resident continued to receive only 5 mg of Coumadin daily. On 6/10/22, resident 94's Coumadin dose was changed to 6 mg daily, for a total dose of 42 mg of Coumadin per week. It should be noted that this dose was still less than the prescribed amount listed on the hospital discharge orders. Resident 94's August 2022 MAR indicated that on 8/1/22, the resident's Coumadin was discontinued, and the resident was now being administered Eliquis 5 mg daily. On 10/24/22 at 2:30 PM, an interview was conducted with the DON. The DON stated that when a resident was admitted , either herself or the Assistant Director of Nursing (ADON) would transcribe the admission orders. The DON stated that sometimes facility staff started the paperwork, but then be unable to finish it at the time, and the DON would have to come back to finish it later. The DON stated that there was not a system in place to double check the admission orders for residents, but that we should be doing that. When asked about resident 94's Coumadin transcription error, the DON stated that she would have to look into that. As of exit on 10/31/22, the DON did not provide additional information about resident 94's Coumadin error. On 10/17/22 at 11:38 AM, an interview was conducted with the facility MD. The MD stated that she was unaware of the transcription error from resident 94's admission orders. b. On 5/24/22, an Anticoagulant Visit Summary was completed for resident 94. The summary indicated that resident 94 had had his PT/INR drawn at an outside facility. The resident's INR was listed as 1.6, with a target level of 2.5. The summary included instructions for the resident to have a double dose of Coumadin that day, for a total of 3 tablets, a dose of 10 mg. Review of resident 94's May 2022 MAR indicated that resident 94 did not receive the double dose of Coumadin that day, but instead received only the 5 mg dose.

Based on observation, interview and record review it was determined, for 3 of 33 sampled residents, that the facility did not arrange outside resources in a timely manner for residents. Specifically, a resident was not scheduled for a Percutaneous Endoscopic Gastrostomy (PEG) tube placement and had multiple problems with the Nasojejunal (NJ) tube which was cited at a harm level. In addition, residents were not scheduled for a neurologist appointment and a cardiologist appointment. Resident identifiers: 4, 30 and 34. Findings include: Harm 1. Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included muscle weakness, schizophrenia, cognitive communication deficit, conversion disorder, anxiety disorder, chronic kidney disease, psychosis, difficulty in walking, and hyperlipidemia. On 10/13/22 at 9:23 AM, an observation of resident 4 was made. Resident 4 was in bed and observed to have a feeding tube which entered through resident 4's nose. An interview with resident 4 was not conducted due to resident 4's cognitive communication deficit. On 10/13/22 resident 4's medical record was reviewed. Resident 4's order history revealed that resident 4 began receiving enteral feeding on 12/24/20. On 10/18/22 at 10:04 AM, an interview with Registered Nurse (RN) 3 was conducted. RN 3 stated that resident 4 often had a difficult time with his feeding tube. RN 3 stated that resident 4 frequently pulled out his NJ tube. RN 3 stated that the NJ tube frequently got clogged. RN 3 stated that when the NJ tube had been pulled out or the NJ tube was clogged, the facility informed the doctor and resident 4 needed a doctor's appointment to replace or unclog the NJ tube. RN 3 stated that the facility had been talking about resident 4 getting a PEG feeding tube to replace the NJ feeding tube. RN 3 stated she did not know why that appointment had not been made. A review of resident 4's progress notes revealed multiple issues with the NJ tube. The follow progress notes were: a. On 1/21/22 at 3:36 PM, Resident was taken via w/c (wheelchair) to . hospital at 9:15 (AM) for a replacement of his clogged NJ tube . b. On 3/2/22 at 8:41 PM, Resident NG tube clogged and was being declogged when it burst with a hole in it. MD (Medical Director) notified and orders for a replacement of NG . c. On 4/16/22 at 10:16 AM, NJ tube is clogged. Radiology is unable to replace tube all weekend. Scheduling office is closed so will have to call Monday morning to schedule NJ replacement. MD notified . d. On 5/21/22 at 8:59 PM, In to assist RN with a clogged feeding tube. Feeding tube was unhooked from machine easier as it was reported that he had a shower . e. On 8/16/22 at 9:50 AM, Resident's NJ tube bridel (sic) was loose and tube came out by several inches and back in. f. On 8/18/22 at 7:11 AM, Resident completed pulled out feeding tube. g. On 8/28/22 at 1:20 PM, NOC (night) Nurse informed me during 5:00 [AM] report that resident has NJ feeding tube out at 2330 (11:30 PM) . h. On 9/4/22 at 10:10 AM, Resident pulled out NJ tube at approx (approximately) 1:30 AM per night shift report. MD notified and ordered IV fluids until NJ can be replaced . i. On 9/10/22 at 1:35 AM, .he had his NJ tube replaced on Tuesday. They are talking about placing a G-tube in him soon . j. On 9/22/22 at 4:53 PM, NJ tube became clogged, and resident then pulled the tube out on his own. MD notified and ordered NJ tube replace by [hospital name redacted] radiology . k. On 9/23/22 at 2:29 PM, Resident went to have NJ tube replaced today at 1:15 PM. In apptment [appointment] form, it was written that MD ordered a PEG tube and order attached . New feeding tube may be used. Unable to do a PEG today, and that needs to be scheduled with [hospital name redacted] radiology. Will f/u (follow-up) on Monday 9/26/22 with [hospital name] for PEG placement appointment. l. On 10/10/22 at 6:36 AM, Notified MD that feeding tube was out. MD stated she was not notified and no orders given to place IV for fluids . m. On 10/25/22 at 2:20 AM, resident was agitated and pulled out NG tube at 0030 (12:30 AM) on 10/25/22 . MD notified. A review of the facilities appointment book revealed that resident 4 did not have any upcoming appointments. On 10/20/22 at 10:11 AM, an interview with Licensed Practical Nurse (LPN) 1 was conducted. LPN 1 stated that resident 4 had a history of going to the emergency room to get his NJ tube replaced. LPN 1 stated that resident 4 had the NJ tube for almost 2 years. LPN 1 stated that the facility had been discussing replacing the NJ tube with a PEG tube for about 2 years. LPN 1 stated he was not sure why the appointment for resident 4 to get a PEG tube was continuously postponed. On 10/18/22 at 10:53 AM an interview with the Administrator (ADMIN) was conducted. The ADMIN stated that the facility was working with the hospital to schedule an appointment for resident 4 to get a PEG tube so the NJ tube could be removed. The ADMIN stated that hospital kept rescheduling resident 4. The ADMIN stated that the facility did not keep records of any communication with the hospital regarding resident 4's appointment for the G tube. On 10/24/22 at 2:30 an interview with the Director of Nursing (DON) was conducted. The DON stated that there were issues with the PEG tube appointment. The DON stated that resident 4 was supposed to have a PEG tube over a year ago. The DON stated that resident 4 had been pulling out his NJ tube more frequently and the NJ tube kept getting clogged. The DON stated that she took it upon herself to ask the MD to write an order for a PEG tube for resident 4. The DON stated that it should not have taken this long to get a PEG tube appointment for resident 4. The DON stated that resident 4 still did not have an appointment scheduled for a PEG tube. 40334 Potential for Harm 2. Resident 30 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (MS), neuropathy, insomnia, obesity, chronic pain, and depression. On 10/11/22 at 9:40 AM, resident 30 was observed to be sitting in a wheelchair. Resident 30 stated that she needed to see her neurologist because her MS was flaring. Resident 30 stated that she had made an appointment to see her neurologist, but staff told her that they were unable to transport her, so they canceled the appointment. Resident 30 stated that it took several months to get into her neurologist, and staff had not rescheduled the appointment. On 10/31/22, resident 30's medical record was reviewed. Resident 30's physician and NP (Nurse Practitioner)/PA (Physician Assistant) notes revealed the following: a. On 2/7/22 a new order was initiated that resident 30 should follow up with her neurologist because resident is c/o (complaining of) increased weakness in right arm and leg. b. On 3/24/22 at 7:35 PM, resident 30 is followed by neurology for her MS Continue follow up with neurology. c. On 7/21/22 at 2:16 PM, chief complaint was resident 30's multiple sclerosis. Resident was followed by neurology and .is supposed to have an appt (appointment) in September . d. On 9/22/22 at 4:06 PM, . She is wanting to get into her neurologist . e. On 9/26/22 at 1:07 PM, .requested appt to be made with her neurologist. On 10/24/22 at 2:30 PM, the DON was interviewed. The DON stated that she had made appointments for residents previously, but was told that the previous Administrator (ADM) was responsible to make appointments. The DON stated that it was an issue getting residents into their doctors. On 10/25/22 at 11:14 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that he hated the appointment book. LPN 1 stated that the process did not work. LPN 1 stated that the previous ADM and current ADM had canceled appointments for residents because of transportation issues and the ADM's wanted to schedule the appointments to ensure that someone would be available to take the resident to the appointment. LPN 1 stated that when a resident needed an appointment, staff let the ADM know, filled out a request sheet, and waited for the OK from the ADM to get an appointment for the resident. LPN 1 stated that nurses would cross our fingers that the resident went to an appointment. LPN 1 stated that the system was so broken, the nurses did not know if someone went to an appointment or not. LPN 1 stated that when residents made their own appointments, there would not be transportation, and the appointment would be canceled. On 10/25/22 at approximately 1:00 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that she was not aware of any staff members who made appointments. The ADON stated that the receptionist or front office person would make appointments under the direction of the ADM. The ADON stated that she was aware of several residents who required physician visits, but she was unaware of when they may be scheduled. The ADON stated that the Medical Director (MD) had asked about several appointments, but the ADON stated she was not able to make the appointments, and they would have to be made by the DON or ADM. On 10/25/22 at 1:35 PM, an interview was conducted with the ADM. The ADM stated that she had not made appointments in months, but appointments must have been made by someone because residents went out. The ADM stated that resident 30 had made her own appointment, but they were not able to take her due to staffing. The ADM stated that appointments needed to be coordinated, and sometimes there was no staff available for transportation. The ADM stated that sometimes appointments were written down on post-it notes, and they may have been misplaced. On 10/27/22 at 1:06 PM, an interview was conducted with the MD. The MD stated that she was told the ADM made the appointments with physicians for the residents. The MD stated she had asked the nurses to make follow-up appointments for the residents and the MD stated the nurses told her that appointments had to go through the ADM. 22992 3. Resident 34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included atherosclerotic heart disease, hemiplegia, gout, memory deficit following cerebral infarction, diabetes mellitus, dysphagia, and hyperlipidemia. On 10/11/22, resident 34's medical record was reviewed. Physician progress notes indicated the following: a. On 12/27/21, . he mentioned he has a defibrillator. He does not know who his cardiologist is. Will call patient's sister to see if she knows. b. On 4/25/22, . Still awaiting cardiology appt. c. On 9/12/22, . has defibrillator. Still awaiting cardiology appt. Resident 34's medical record did not indicate that resident 34 had been seen by a cardiologist during his stay at the facility. The facility appointment book was reviewed. The appointment book did not contain any documentation that resident 34 had been scheduled for a cardiology appointment. On 10/24/222, an interview was conducted with resident 34. Resident 34 stated he had not seen a cardiologist since he was admitted to the facility. Resident 34 stated that his defibrillator had shifted and was lower than it once was. Resident 34 stated he was unaware if he had an appointment to see a cardiologist to have his defibrillator checked or not. On 10/24/22, an interview was conducted with the MD. The MD stated that she had been documenting in her progress notes since December 2021 that resident 34 needed an appointment to see a cardiologist. The MD stated that resident 34 had a defibrillator, and that resident 34 should see a cardiologist at least every six months to ensure it was still functioning appropriately and the battery was at a good level. The MD stated that she had put a request in the appointment book on two occasions for resident 34 to see a cardiologist but its not there anymore. On 10/27/22, a follow up interview was conducted with the facility MD. The MD stated that the nurses have told her they can't make any appointments, and that all appointments were made by the facility Administrator (ADM). On 10/24/22 at 2:30 PM, an interview was conducted with the DON. The DON stated that she was aware that resident 34 had a defibrillator, and confirmed she had not made an appointment for resident 34 to see a cardiologist, even though the MD had requested it. When asked why she had not made an appointment for resident 34 to see a cardiologist, the DON stated, I made an appointment before and got my butt chewed, so I don't make them anymore. I'm not allowed to. The DON stated that it was the ADM who was prohibiting her and other nurses from making appointments for residents.

Based on observations, interviews and record review it was determined the facility did not ensure a resident with limited range of motion received appropriate treatment and services to increase their range of motion and to prevent further decrease in range of motion. Specifically, a resident with documentation of a contracture to the right and left hand was not provided with treatment and services to increase their range of motion or to prevent further decrease in range of motion. This finding resulted in a harm deficiency. Resident identifier: 28. Findings include: Resident 28 was originally admitted to the facility on [DATE], with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/30/21 at 8:19 AM, resident 28 was observed at breakfast attempting to hold a cup with her left hand. After three attempts at grasping the cup resident 28 was able to grasp the cup in order to bring it to her mouth. At this time resident 28's right hand was closed and kept close to her body. On 8/30/21 at 11:39 AM, resident 28 was again observed to be able to grab a cup of water independently with the left hand. On 8/30/21 at 11:30 AM, Certified Nursing Assistant (CNA) 2 reported resident 28 was independent with eating meals, but resident 28 needed help in other areas like zipping things or completing tasks that needed fine motor skills. CNA 2 reported she was unaware if resident 28 had any contracture issues to the right or left hands. CNA 2 also reported staff did not use any splints or interventions for preventing contractures with resident 28's hands. On 8/30/21 at 11:38 AM, resident 28's room was examined. No splints or range of motion devices were noted. On 9/1/21 at 12:00 PM, resident 28 was observed at lunch to be unable to grasp a fork with the left hand. Resident 28 placed the fork back onto the table and then using her left hand, resident 28 grasped the meat patty and brought the food to her mouth. On 9/1/21 at 9:20 AM, Licensed Practical Nurse (LPN) 1 stated resident 28 had a contracture to both the left and right hands. LPN 1 stated since starting employment at the facility in January 2021, LPN 1 had noticed resident 28 was suffering from a contracture to the left hand. LPN 1 also stated the contracture to resident 28's right hand had gotten worse and resident 28 was not able to use the right hand at all now. LPN 1 stated in the past he tried to place a rolled up towel within resident 28's right hand, but resident 28's right hand would not open. LPN 1 stated there were no consistent interventions in place to help prevent worsening contracture to resident 28's right or left hands. On 9/1/21 at 11:59 AM, CNA 4 stated they had seen LPN 1 try to place a towel in resident 28's right hand in the past. CNA 4 stated the CNA staff were not doing anything with resident 28's hands to prevent further contracture to the left or right hand. On 9/1/21 a review of resident 28's medical record was completed. The following observations were made within resident 28's medical record: a. A Weekly Note from 5/13/21 stated, Resident . Uses w/c [wheelchair] for mobility, has contractures in both hands. b. A Weekly Note from 7/15/21 stated, Rt. [Right] hand fully closed d/t [due to] contractures and Lt. [left] hand is partially contracted. c. A Weekly Note from 7/22/21 stated, Resident has hand contractures and right hand completely closed. d. A Weekly Note from 8/5/21 stated, Resident has contractures to both hands and Right (sic) hand contracture is completely closed. e. A Weekly Note from 8/26/21 stated, Contractures to both hands and left hand [resident] is still able to use and right hand is completely closed (sic). f. Resident 28's Minimum Data Set (MDS) assessment history was reviewed regarding functional status and Functional Limitation in Range of Motion. MDS records from 6/30/21 indicate, Upper Extremity (shoulder, elbow, wrist, hand) . Impairment on one side. [Note: per nursing documentation resident with contracture to both hands]. g. Occupational Therapy (OT) documentation from therapy services present from 12/10/19 to 3/8/20. OT documentation indicates resident was seen for Contracture; right hand. h. On 08/30/21 at 12:08 PM, resident 28's care plan was reviewed. Within resident 28's electronic care plan, no care plan related to contractures was noted. On 9/1/21 at 9:33 AM, the Director of Nursing (DON) reported having noticed resident 28's left hand contracture seemed worse the other day. The DON reported because of working as a floor nurse the DON was not always able to observe how all the residents were doing, unless they were on the DON's workload that day. The DON reported there were no interventions being done with resident 28's left or right hands to prevent the contractures from getting worse. The DON also stated being unaware if resident 28 had received any OT services for the hand contractures at this time. On 9/1/21 at 12:47 PM, an OT therapist for the facility was interviewed. The OT therapist stated resident 28 had not received therapy services in, quite a while. The OT therapist reported around the 1st of August 2021, the OT department had received a referral to look into resident 28's contractures. The OT therapist reported resident 28 had not been added to the therapy case load following receipt of the referral around 8/1/21 because one of the OT therapists was on vacation.

Based on interview and record review, the facility did not ensure that 1 of 30 sample residents maintained acceptable parameters of nutritional status. Specifically, a resident who was exclusively tube fed lost weight without timely interventions to prevent further weight loss. The findings were cited at a harm level. Resident identifier: 24. Findings include: Resident 24 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 24's medical record was reviewed on 8/29/21. Resident 24's Nutritional Assessment was reviewed. The Nutritional Assessment indicated that the facility Dietary Manager (DM) completed the assessment on 12/28/20, which was 4 days after resident 24 was readmitted . The Assessment further indicated that the facility Registered Dietitian (RD) did not review the Assessment until 1/15/21, approximately 3 weeks after resident 24 was readmitted . The Assessment indicated that resident 24 weighed 161.6 pounds (lbs). The Assessment indicated that resident 24 was receiving an enteral tube feeding of [MEDICATION(S)] with Fiber for 65 milliliters (ml) an hour for 24 hours a day. The Assessment also indicated that resident 24 had experienced a recent significant weight change. The Assessment indicated that resident 24 was not eating any food by mouth, and was exclusively tube fed due to a swallowing difficulty. The Assessment indicated that resident 24's estimated calorie needs to be between 1470 and 1838 calories a day. The Assessment indicated that resident 24's tube feeding formula would provide 1560 calories a day. Resident 24's care plan was reviewed. Review of the care plan indicated that it was not developed until 1/15/21, approximately 3 weeks after resident 24 was admitted . The care plan indicated that the facility was to monitor resident 24's weights every week. Review of resident 24's graphed weight records revealed the following weights: a. 1/3/21 - 157.1 lbs. b. 2/7/21 - 155.8 c. 3/7/21 - 157.6 d. 4/4/21 - 150.8 e. 5/2/21 - 150.4 f. 6/6/21 - 148.2 g. 7/4/21 - 146.2 On 8/31/21 at 1:30 PM, an interview was conducted with the DM. The DM stated that weights were taken and recorded on a graph the first Sunday of every month. Review of resident 24's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/5/21, resident 24's tube feeding rate was increased to 75 ml an hour for 24 hours. It should be noted that between 1/3/21 and 7/4/21, resident 24 had lost approximately 11 lbs. On 7/3/21, the RD documented that resident 24's weight was overall trending downward, although no acute significant loss. Resident weight upon initiation of TF (tube feeding) Jan (January) 2021 161.6 [lbs], currently 144 [lbs], [decrease] 10.9 [percent] [in] 7 months. RD to cont (continue) to watch [and] f/u (follow up)PRN (as needed). The RD recommended that resident 24's tube feeding rate be increased to 75 ml an hour for 24 hours. Review of weekly weights provided by the DM revealed the following weights: a. 7/11/21 - 146.0 b. 7/18/21 - 143.8 c. 7/25/21 - 143.0 d. 8/1/21 - 142.8 e. 8/8/21 - 142.0 f. 8/15/21 - 141.8 g. 8/22/21 - 139.8 Review of resident 24's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/30/21, resident 24's tube feeding rate was increased to 85 ml an hour for 24 hours. It should be noted that between 7/4/21 and 8/22/21, resident 24 had lost approximately 6.4 lbs. On 8/29/21, the RD documented that resident 24's weight was dropping, and that the trend downward not desired. The RD also documented that resident 24 had lost 2.2 percent of his body weight in one month. The RD recommended that resident 24's tube feeding rate be increased to 85 ml an hour for 24 hours. Resident 24's care plan revealed that despite resident 24's weight loss and multiple changes in tube feeding rate, the care plan was not updated after 4/15/21. Review of resident 24's August 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/31/21 at 1:00 PM, an interview was conducted with the DM. The DM stated that she was aware of resident 24's weight loss, and that the RD had recently increased the rate of resident 24's tube feeding. The DM stated that she did not know why resident 24 was losing weight. The DM further stated that she was not involved in making decisions about tube feeding recommendations. On 9/1/21 at 8:42 AM, an interview was conducted with the facility RD. The RD stated that she participated in the skin and weight meetings, and that she was in weekly communication with the DM. The RD stated that she was responsible for evaluating the residents receiving tube feedings to determine if their needs were being met. The RD stated that resident 24 had experienced a general change of condition. The RD stated that she thought that resident 24 was receiving some of his calories by mouth, and that there were other things happening. The RD stated that she had recently increased the tube feeding rate for resident 24, and that she was thinking about changing the formula to a 1.1 or 1.2 calorie formula. The RD stated that she was going to wait to change the resident's formula to correct his weight loss until after the survey was over so that she didn't shake things up for facility staff. On 9/1/21 at 9:30 AM, an interview was conducted with the facility Director of Nursing (DON). The DON confirmed that resident 24 was not receiving any food by mouth. When asked about resident 24's tube feeding, the DON stated we are aware that he is losing weight. My assumption would be that the RD may not be coming in because of COVID.

Based on observation, interview, and record review it was determined, for 1 of 4 sample residents, that the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, facility staff did not have a timely follow through of physician's orders [REDACTED]. Resident identifier: 1. Findings include: Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/16/19 resident 1's medical record was reviewed. Nursing progress notes revealed the following entries: a. 7/30/2019 19:10 FALL MONITORING Late Entry: Note Text: Pt. (patient) was ambulating from the MDR (main dining room) to her room using her walker. A CNA (Certified Nursing Assistant) was behind her with the 02 (oxygen) concentrator. (Resident 1) went into her room and stated that she tried to move something off her bedside table when she tipped too far forward and fell on her knees. She then sat on her buttocks and that is when the CNA walked into the room. Pt. states she doesn't hurt anywhere but her knees. No redness or abrasions noted. Pt. assisted to her feet and she was able to go into the bathroom without difficulty but with assist (assistance) x (times) 1. MD and family were notified. V/S (vital signs) taken and are stable. Will continue to monitor. b. 7/31/2019 07:08 Orders - Administration Note Note Text: [MEDICATION NAME] HCl ([MEDICATION NAME]) Tablet 50 MG (milligrams) Give 50 mg by mouth as needed for pain TID (three times daily) resident c/o (complains of) knee pain. c. 7/31/2019 10:14 FALL MONITORING Note Text: Resident is engaging in her regular activities. Resident c/o knee pain this morning and received PRN (as needed) [MEDICATION NAME]. Effective for her knee pain. Resident is ambulating without difficulty. Will continue to monitor. d. 7/31/2019 16:23 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID resident requests for knee pain. e. 7/31/2019 20:21 FALL MONITORING Late Entry: Note Text: Pt. states her knees remain sore but she has been able to ambulate to and from the MDR. Nurse explained that we would check her every shift to make sure she was doing ok. No redness or abrasions noted. WCTM (will continue to monitor). f. 8/1/2019 00:04 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID. g. 8/1/2019 06:45 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID resident requests for pain in knees. h. 8/1/2019 15:25 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID resident c/o knee pain. i. 8/1/2019 23:04 Weekly Note Late Entry: Note Text: Resident is alert and oriented x 3 while awake. Speech is slow but clear. Usually able to understand verbal content and usually able to make needs known verbally. Takes a while to answer a question and forgetful. Has short term memory loss. Pleasant and cooperative with nursing interventions. Does have a worried look on her face when up and about. She verbalizes fears about her medications and shows a little paranoia a few times weekly. ADL (activities of daily living) assist of 1 extensive with all ADL's except ambulating and eating are supervision. Ambulates with a FWW (front wheeled walker) with a steady gait, unsteady without. Wears 02 via nc (nasal cannula) cont. (continue) at 4-5 l(liters)/min (minute) to keep 02 sats (saturations) >(greater than) 90%. Skin: C/D/I (clean, dry, intact). Does have mild rash on face in which (s)he has [MEDICATION NAME] cream applied prn and is helpful to decrease rash. Taking meals in MDR AND EATING 50-100% of RCS mechanical soft diet. Taking medications as prescribed. Blood sugars have been decreasing. C/o back and knee pain r/t (related to) recent fall cautiously give narcs (narcotic pain medication) d/t (due to) renal conditionWCTM (sic). j. 8/3/2019 07:00 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID resident requests for pain in knees. k. 8/4/2019 01:01 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 5 MG Give 1 tablet by mouth every 6 hours as needed for Pain every 6hrs prn. l. 8/4/2019 07:05 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID resident c/o knee pain. m. 8/4/2019 09:06 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID. n. 8/5/2019 13:00 Orders - Administration Note Note Text: Bengay Greaseless Cream 10-15 % Apply to affected area topically as needed for pain up to TID resident c/o knee pain. o. 8/6/2019 18:00 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 5 MG Give 1 tablet by mouth every 6 hours as needed for Pain every 6hrs prn. p. 8/6/2019 18:28 Social Service Note Late Entry: Note Text: IDT meeting with resident, she stated that she is doing fine, likes MVHS and the staff, she likes the food, stated that her knees and lower back were hurting. (Reported pain to the RN (Registered Nurse), she stated that resident recently had a fall and was being given medication for comfort). No other concerns at this time. q. 8/6/2019 22:43 Orders - Administration Note Note Text: Bengay Greaseless Cream 10-15 % Apply to affected area topically as needed for pain up to TID. r. 8/6/2019 22:4 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID. s. 8/7/2019 00:19 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 5 MG Give 1 tablet by mouth every 6 hours as needed for Pain every 6hrs prn. t. 8/7/2019 16:42 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 5 MG Give 1 tablet by mouth every 6 hours as needed for Pain every 6hrs prn pain to knee after ambulating hallway. u. 8/10/2019 07:15 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID resident c/o knee pain . v. 8/10/2019 09:25 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID. w. 8/11/2019 07:00 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID resident c/o knee pain. x. 8/11/2019 09:48 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID. y. 8/12/2019 19:28 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID. z. 8/13/2019 00:17 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID. aa. 8/13/2019 07:30 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID resident requests for knee pain. bb. 8/17/2019 08:02 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID Given per request d/t c/I back and knee pain. cc. 8/17/2019 09:30 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID. dd. 8/17/2019 15:38 Orders - Administration Note Note Text: [MEDICATION NAME] Tablet 325 MG Give 2 tablet by mouth every 4 hours as needed for pain/fever *NTE (not to exceed) 3gm (grams) in 24 hours of APAP (acetyl-para-[MEDICATION NAME]) from all sources. Given per request d/t c/o back and knee pain ee. 8/18/2019 16:31 Health Status Note Note Text: PAIN: MD in to assess patient on Friday 8/1/2019. Does report pain to knees and lower back. Resident has been educated to ask nurse/staff for pain meds when in pain. This nurse asked the resident this am and was given a [MEDICATION NAME] and has been in no pain all day. Remind patient to ask for pain meds when in pain. ff. 8/18/2019 16:33 Health Status Note Note Text: *Correction* MD in to assess patient on Friday 8/16/2019. gg. 8/20/2019 07:00 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID resident requests for pain in knees and back . hh. 8/21/2019 09:15 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID resident c/o knee and back pain. ii. 8/21/2019 19:15 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID Given d/t c/o back and knee pain. jj. 8/26/2019 20:10 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID Given per request d/t c/o knees and back pain. kk. 8/27/2019 19:00 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID. ll. 8/28/2019 13:01 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 5 MG Give 1 tablet by mouth every 6 hours as needed for Pain every 6hrs prn. mm. 8/29/2019 23:34 Weekly Note Late Entry: Note Text: Resident is alert and oriented x 3 while awake with some intermittent confusion at times. Poor short memory and answers questions slowly. Speech is clear, usually able to make needs known verbally and usually understands verbal content. Pleasant and cooperative with nursing interventions. Takes her medications per MD orders. Requests for pain medications in AM and HS for back, knee and peripheral pain and effective with [MEDICATION NAME] or [MEDICATION NAME] 5 mg prn nn. 8/30/2019 13:30 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID resident c/o pain in back and legs. oo. 8/30/2019 14:12 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID. pp. 8/30/2019 15:56 New Order Note Text: Resident continues to c/o pain in both knees. (Facility Nurse Practitioner) notified and ordered an X ray with sunrise view. Called into (Name of mobile radiology) who will send a tech. qq. 8/31/2019 09:16 New Order Note Text: X-ray results reported to NP (Nurse Practitioner). Negative for fracture on right knee. Left knee shows probable fractures of the upper pole of patella. NP ordered ortho consult. Appointment requested in appointment book. rr. 9/2/2019 07:56 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID Given per request d/t c/o back and knee pain. ss. 9/5/2019 18:46 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID Given per request d/t c/o back and knee pain. tt. 9/9/2019 19:35 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID Given per request d/t c/o back and knee pain. uu. 9/11/2019 10:18 Orders - Administration Note Note Text: Bengay Greaseless Cream 10-15 % Apply to affected area topically as needed for pain up to TID c/o ache to r knee. vv. 9/12/2019 11:25 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID c/o knee and back pain. ww. 9/14/2019 07:15 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID Given per request d/t c/o back and knee pain. xx. 9/15/2019 06:52 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID Given per request d/t c/o back and knee pain. yy. 9/15/2019 13:56 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 5 MG Give 1 tablet by mouth every 6 hours as needed for Pain every 6hrs prn Given per request d/t c/o knee pain. zz. 9/16/2019 19:30 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 5 MG Give 1 tablet by mouth every 6 hours as needed for Pain every 6hrs prn Given per request d/t c/o knees and back pain. aaa. 9/18/2019 08:50 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 5 MG Give 1 tablet by mouth every 6 hours as needed for Pain every 6hrs prn. bbb. 9/20/2019 11:40 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID c/o generalized pain. ccc. 9/22/2019 12:00 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID c/o pain in back and knees. ddd. 9/22/2019 18:48 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID Given per request d/t c/o legs, knees and back pain. eee. 9/23/2019 12:05 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID. fff. 9/24/2019 09:24 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 5 MG Give 1 tablet by mouth every 6 hours as needed for Pain every 6hrs prn. ggg. 9/24/2019 19:05 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 5 MG Give 1 tablet by mouth every 6 hours as needed for Pain every 6hrs prn Given for c/o back and knee pain. hhh. 9/25/2019 01:17 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID Given per request d/t c/o back and knee pain. iii. 10/1/2019 07:24 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 5 MG Give 1 tablet by mouth every 6 hours as needed for Pain every 6hrs prn. jjj. 10/1/2019 18:50 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID Given per request d/t c/o back and knee pain. kkk. 10/1/2019 23:15 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 5 MG Give 1 tablet by mouth every 6 hours as needed for Pain every 6hrs prn Given per request d/t c/o back and knee pain. lll. 10/5/2019 11:00 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID c/o knee and back pain. mmm. 10/7/2019 18:46 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 5 MG Give 1 tablet by mouth every 6 hours as needed for Pain every 6hrs prn Given per request d/t c/o back and knee pain. nnn. 10/7/2019 23:06 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID Given per request d/t c/o back and knee pain. ooo. 10/12/2019 07:00 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID Given per request d/t c/o back and knee pain. ppp. 10/12/2019 10:27 Orders - Administration Note Note Text: [MEDICATION NAME] Tablet 325 MG Give 2 tablet by mouth every 4 hours as needed for pain/fever *NTE 3gm in 24 hours of APAP from all sources. Given per request d/t c/o back and knee pain. qqq. 10/13/2019 07:51 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID Given per request d/t c/o back and knee pain. rrr. 10/13/2019 21:02 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 50 MG Give 50 mg by mouth as needed for pain TID. sss. 10/14/2019 14:58 Orders - Administration Note Note Text: [MEDICATION NAME] HCl Tablet 5 MG Give 1 tablet by mouth every 6 hours as needed for Pain every 6hrs prn. ttt. 10/14/2019 16:39 Orders - Administration Note Note Text: PRN Administration was: Ineffective. Physician and Nurse Practitioner Progress Notes revealed the following entries: a. 8/16/2019 11:07 physician progress notes [REDACTED].>Late Entry: Note Text: Recertification visit s: (Resident 1) has not had any new illnesses. She had a fall 7/31 and has had some knee pain but pain meds help. She forgets to ask for them 4. OA - Nursing staff will ask patient if she is having pain as she doesn't remember to ask . b. 10/4/2019 09:11 physician progress notes [REDACTED].>Late Entry: Note Text: s: (Resident 1) continues to report having bilateral knee pain. She takes pain meds which helps. o: no obvious abnormalities of either knee A/P Bilateral knee pain - She is being referred to ortho. Will try topical [MEDICATION NAME]. c. 10/8/2019 10:41 NP/PA PROGRESS NOTE Note Text: REcertification visit. Paranoid [MEDICAL CONDITION], is able to be in main patient population. Blood sugars tracked, trends reviewed. AIC 7, on insulin as well as oral meds. Wt well above ideal. Complains of back and right knee pain, multiple opioids available An x-ray report dated 8/30/19 revealed There is a left knee replacement. Linear lucencies through the upper aspect of the patella Impression: Probable fractures of the upper pole of patella. The x-ray report revealed that the NP was notified on 8/31/19 of the x-ray results and ordered an ortho consult. The nursing progress note dated 8/31/19 revealed that the request had been placed into the appointment book for an ortho consult for probable fractures in the left knee. The request form in the appointment book revealed that there was no date on the request and was situated above a request for another resident dated 9/21/19. Medication Administration Records for resident 1 revealed the following pain medication administrations: (MONTH) 2019: 5/8/19 - [MEDICATION NAME] 50 mg - pain level 5, 5/9/19 - [MEDICATION NAME] 5 mg - pain level 6, 5/13/19 - [MEDICATION NAME] 50 mg - pain level 7, 5/16/19 - [MEDICATION NAME] 5 mg - pain level 5, 5/19/19 - [MEDICATION NAME] 50 mg - pain level 7, 5/21/19 - [MEDICATION NAME] 50 mg - pain level 7. (NOTE: Resident 1 received [MEDICATION NAME] 50 mg 4 times and [MEDICATION NAME] 5 mg 2 times.) (MONTH) 2019: 6/1/19 - [MEDICATION NAME] 50 mg - pain level 6, 6/2/19 - [MEDICATION NAME] 50 mg - pain level 6, 6/5/19 - [MEDICATION NAME] 50 mg - pain level 7, 6/11/19 - [MEDICATION NAME] 50 mg - pain level 7, 6/13/19 - [MEDICATION NAME] 50 mg - pain level 4, 6/19/19 - [MEDICATION NAME] 50 mg - pain level 8, 6/20/19 - [MEDICATION NAME] 50 mg - pain level 7, 6/23/19 - [MEDICATION NAME] 50 mg - pain level 5. (NOTE: Resident 1 received [MEDICATION NAME] 50 mg 8 times did not receive [MEDICATION NAME] in June.) (MONTH) 2019: 7/1/19 - [MEDICATION NAME] 50 mg - pain level 6, 7/3/19 - [MEDICATION NAME] 5 mg - pain level 9, 7/13/19 - [MEDICATION NAME] 5 mg - pain level 8, 7/14/19 - [MEDICATION NAME] 50 mg - pain level 7, 7/16/18 - [MEDICATION NAME] 50 mg - pain level 7, 7/20/19 - [MEDICATION NAME] 50 mg - pain level 6, 7/24/19 - [MEDICATION NAME] 50 mg - pain level 7, 7/25/19 - [MEDICATION NAME] 50 mg - pain level 9, 7/30/19 - [MEDICATION NAME] 5 mg - pain level 8, 7/31/19 - [MEDICATION NAME] 50 mg - pain level 6, 7/31/19 - [MEDICATION NAME] 50 mg - pain level 7. (NOTE: Resident 1 received [MEDICATION NAME] 50 mg 8 times and [MEDICATION NAME] 5 mg 3 times.) (MONTH) 2019: 8/1/19 - [MEDICATION NAME] 50 mg - pain level 7, 8/1/19 - [MEDICATION NAME] 50 mg - pain level 7, 8/3/19 - [MEDICATION NAME] 50 mg - pain level 7, 8/4/19 - [MEDICATION NAME] 50 mg - pain level 7, 8/4/19 - [MEDICATION NAME] 5 mg - pain level 5, 8/6/19 - [MEDICATION NAME] 50 mg - pain level 7, 8/6/19 - [MEDICATION NAME] 5 mg - pain level 7, 8/7/19 - [MEDICATION NAME] 5 mg - pain level 5, 8/7/19 - [MEDICATION NAME] 5 mg - pain level 7, 8/10/19 - [MEDICATION NAME] 50 mg - pain level 7, 8/11/19 - [MEDICATION NAME] 50 mg - pain level 7, 8/12/19 - [MEDICATION NAME] 50 mg - pain level 7, 8/13/19 - [MEDICATION NAME] 50 mg - pain level 7, 8/17/19 - [MEDICATION NAME] 50 mg - pain level 9, 8/20/19 - [MEDICATION NAME] 50 mg - pain level 7, 8/21/19 - [MEDICATION NAME] 50 mg - pain level 7, 8/21/19 - [MEDICATION NAME] 50 mg - pain level 9, 8/26/19 - [MEDICATION NAME] 50 mg - pain level 8, 8/26/19 - [MEDICATION NAME] 5 mg - pain level 10, 8/27/19 - [MEDICATION NAME] 50 mg - pain level 7, 8/30/19 - [MEDICATION NAME] 50 mg - pain level 7. (NOTE: Resident 1 received [MEDICATION NAME] 50 mg 16 times and [MEDICATION NAME] 5 mg 5 times.) (MONTH) 2019: 9/2/19 - [MEDICATION NAME] 50 mg - pain level 8, 9/5/19 - [MEDICATION NAME] 50 mg - pain level 9, 9/9/19 - [MEDICATION NAME] 50 mg - pain level 9, 9/12/19 - [MEDICATION NAME] 50 mg - pain level 7, 9/14/19 - [MEDICATION NAME] 50 mg - pain level 9, 9/15/19 - [MEDICATION NAME] 50 mg - pain level 9, 9/15/19 - [MEDICATION NAME] 5 mg - pain level 9, 9/16/19 - [MEDICATION NAME] 5 mg - pain level 9, 9/18/19 - [MEDICATION NAME] 5 mg - pain level 9, 9/20/19 - [MEDICATION NAME] 50 mg - pain level 7, 9/22/19 - [MEDICATION NAME] 50 mg - pain level 7, 9/22/19 - [MEDICATION NAME] 50 mg - pain level 8, 9/23/19 - [MEDICATION NAME] 50 mg - pain level 6, 9/24/19 - [MEDICATION NAME] 5 mg - pain level 9, 9/24/19 - [MEDICATION NAME] 50 mg - pain level 7, 9/25/19 - [MEDICATION NAME] 50 mg - pain level 9. (NOTE: Resident 1 received [MEDICATION NAME] 50 mg 11 times and [MEDICATION NAME] 5 mg 5 times.) (MONTH) 2019 10/1/19 - [MEDICATION NAME] 50 mg - pain level 9, 10/1/19 - [MEDICATION NAME] 5 mg - pain level 8, 10/5/19 - [MEDICATION NAME] 50 mg - pain level 7, 10/7/19 - [MEDICATION NAME] 50 mg - pain level 8, 10/7/19 - [MEDICATION NAME] 5 mg - pain level 7, 10/12/19 - [MEDICATION NAME] 50 mg - pain level 9, 10/13/19 - [MEDICATION NAME] 50 mg - pain level 8, 10/13/19 - [MEDICATION NAME] 50 mg - pain level 8, 10/14/19 - [MEDICATION NAME] 50 mg - pain level 10, 10/16/19 - [MEDICATION NAME] 50 mg - pain level 8. (NOTE: Resident 1 received [MEDICATION NAME] 50 mg thus far in (MONTH) 6 times and [MEDICATION NAME] 5 mg 4 times.) On 10/16/19 at 1:59 PM, an interview was conducted with the facility Administrator. The facility Administrator stated that administration was responsible for making appointments that were placed in the appointment book and that it was a combined effort between administrative staff to get the appointments made. The facility Administrator stated that he did not know when the appointment request for an ortho consult had been placed into the appointment book, but, that the appointment for the ortho consult had not yet been made. The facility Administrator stated that he would look into the matter. On 10/16/19 at 2:10 PM, an interview was conducted with the facility Administrator. The facility Administrator stated that they had had a lot of changes in staffing and that training was the reason for not making the ortho appointment for resident 1. The facility Administrator stated that that was no excuse, because in the end, I am still the Administrator and it's my fault that the appointment had not been made. The facility Administrator stated that he was unaware that resident 1's x-ray showed a probable fracture. The facility Administrator stated that he had had the facility Ombudsman in several times to talk with him regarding resident 1's pain and the need for an appointment. On 10/16/19 at 2:31 PM, an interview was conducted with the facility Administrator. The facility Administrator stated that he had made the appointment for resident 1 and that she was to see the orthopedic specialist on 10/21/19 at 10:30 AM. (NOTE: This appointment was made approximately 79 days after resident 1's fall and 69 days after the order was given for the ortho consult Additionally, the first request for the ortho consult was made on 8/31/19. The second request was made for the ortho consult on 10/4/19.) On 10/16/19 at 3:35 PM, an interview was conducted with resident 1. Resident 1 stated that after her fall, she had more pain and that the pain was sharp. Resident 1 stated that the pain was in her knees. Resident 1 stated that she was still waiting to see the doctor for her pain in her knees. Resident 1 stated that she was having a difficult time walking and that she had pain in her knees whenever she walked. Resident 1 stated that her current pain level was 8 and that she in need of a pain pill. Resident 1 stated that the [MEDICATION NAME] will take the edge off but did not completely take away the pain in her knees. Resident 1 stated that the [MEDICATION NAME] worked a little better, but that the pain was still not completely gone when she would take the medication. On 10/16/19 at 3:40 PM, an interview was conducted with the facility Administrator. The facility Administrator stated that he did not think that resident 1 had been complaining of pain after the fall and that was the reason for the delay for an x-ray of her knees. On 10/16/19 at 4:00 PM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that resident 1 had a difficult time expressing herself and did not remember to ask for medications, more particularly before her fall as she was in a fog and her psychiatrist changed her medications to [MEDICATION NAME] which helped her a lot. The facility DON stated that post fall, resident 1 was able to inform staff of her pain but would forget to ask for pain medication. The facility DON stated that if resident 1 had informed facility staff of her pain level, she would be given a pain medication. The facility DON stated that she had communicated weekly with resident 1's physician asking her to please see resident 1 because she was experiencing increased pain after the fall. The facility DON stated that she had communicated by text message with resident 1's physician on 8/13/19 and told her that she needed to see resident 1. The facility DON stated that she did not know why there was a delay in ordering an x-ray for resident 1 other than they talked with the Nurse Practitioner rather than with the physician. The facility DON stated that she had communicated again with resident 1's physician on 8/18/19 and documented that she had again asked for the physician to please see resident 1 related to the increased pain after the fall. The facility DON stated that resident 1's physician did see her and ordered for staff to ask resident about her pain and offer pain medications more frequently. The facility DON stated that resident 1 should have had the ortho consult appointment made sooner so that determinations could have been made regarding resident 1's patella fracture. (NOTE: Resident 1's [MEDICATION NAME] was added on 6/11/18 not in 2019 per the interview with the facility DON. Additionally, the facility DON was unable to produce any documentation that she had communicated with resident 1's physician prior to 8/18/19.) On 10/17/19 a telephone interview was conducted with the facility Ombudsman. The facility Ombudsman stated that on 8/6/19, the facility Administrator reported that resident 1 had been seen the her physician and that she had had an x-ray that was negative for a fracture. (NOTE: Resident 1's x-ray was not ordered until 8/30/19 and was positive for a Left Patella fracture.) The facility Ombudsman stated that they had visited with the facility Administrator 9 times to talk about resident 1's increased pain after her fall, including 8/6/19, 8/13/19, 8/30/19, 9/11/19 and 10/1/19. The facility Ombudsman stated that each time she was told that the appointment had not been made for resident 1 but that she was on pain medication and that he would make the the appointment for resident 1.

Based on interview, observation and record review it was determined that the facility failed to provide residents with adequate supervision to prevent accidents. (Residents 10, 12, 13, 19, 27, 32, 56). The deficient practice for residents 12, 13, and 32 was found to have occurred at an Immediate Jeopardy level. The deficient practice identified for residents 10, 19, 27, and 56 was found to have occurred at a potential for harm and will not be included in the Immediate Jeopardy. NOTICE: Notice of Immediate Jeopardy was given verbally to the Administrator on 10/21/15 at 3:30 PM. The Administrator was asked to develop an immediate plan to ensure residents' safety related to accident prevention. PLAN: On 10/23/15 at 2:50 PM, the Administrator provided the surveyor management with a written plan of action to remove the immediate jeopardy to residents in the facility. The written plan dated 10/23/15 stated the following: Mountain View Health Services, 5865 South Wasatch Drive, South Ogden, Utah . This correspondence is to serve as an allegation of the removal of immediate jeopardy at Mountain View Health Services. I allege the removal of immediate jeopardy as of October 23, 2015. The measure to remove immediate jeopardy was completed at 2:30 p.m. The following is an overview of the steps the facility has implemented regarding this issue. Policy regarding Wandering/ Elopement was revised and updated. Checklist and guide for steps to follow, has been updated. Post - elopement checklist has been updated. Each client residing at Mountain View, has received a wandering assessment. The assessment is the wandering assessment already located inside the facility's medical records software, Point Click Care. The assessment included a scoring mechanism, and has scored each client as low, moderate, and high risk for wondering. Each client was then scored on a separate piece of paper, with indications regarding need to proceed with care planning. This Wandering & Elopement Risk Evaluation form, has the point click care score noted, and the L.C.S.W. (Licensed Clinical Social Worker), and the R. N. (Registered Nurse), then evaluated each client, and documented factors that may mitigate the risk of elopement, including history of exit seeking, mobility issues, etc. Each client--except for the few clients considered 'zero risk' then had their care plan reviewed and updated as necessary--this includes the ones considered low risk for elopement. These care plans will be reviewed and updated at the regularly scheduled, quarterly, care plan review date for the client. Low risk clients, who have cognitive impairment, also received a care plan, with specifics for treatment. Behaviors indicating preference such as ' likes to sit in front porch', with actions for staff to take, are indicated in the care plan. Low risk clients with minimal to no cognitive impairment, the focus is on education regarding leaving facility; client's responsibility to sign out properly prior to leaving, and communicating with care staff the intention to leave, prior to leaving; and how to report and sign -in upon return. The education piece is for all staff on identified risk clients, review of the care plans/ intervention, and steps to follow in helping prevent wandering, as well as to what steps to follow in case of wandering/elopement. As of today's date, the facility has met compliance with this issue. On 10/26/15 the surveyors confirmed the removal of the immediate jeopardy situation as of 10/23/15. Deficient practice with potential for more than minimal harm remained for the risk of injury to residents. Findings include: Immediate Jeopardy: A. Resident 13 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/21/15 at approximately 7:05 AM, resident 13 was observed to be sitting in a standard chair next to the front door of the facility. Resident 13 was dressed in a light nightgown with tennis shoes. Resident 13 stood up and exited the front door of the facility. Resident 13 proceeded to walk south towards the road in front of the facility. On 10/21/15 at approximately 7:30 AM, resident 13 was interviewed. Resident 13 stated, I'm tired of being treated like a red headed step child. Resident 13 stated that her newspaper was taken away from her and was told that she Didn't pay for it. Resident 13 then stated, I'm just going to slit my throat and get it over with. Resident 13's medical record was reviewed on 10/21/15. Review of the annual Minimum Data Set (MDS) Assessment completed on 9/10/15 revealed that resident 13 had delusions. A Care Area Assessment (CAA) triggered for behaviors, psychosocial and dementia. The facility staff documented that a care plan would be developed related to resident 13 cognitive process and eloping. The care plans developed for resident 13 were reviewed. On 7/6/13, the facility staff developed care plan which documented, The resident is an elopement risk/wanderer r/t (related to) Impaired safety awareness, History of attempts to leave facility unattended *When (resident 13) becomes agitated, (most often d/t (due to) newspaper or changing clothing) she will yell at staff and then leave the facility Does return, time varies as to how long it takes for (resident 13) to return. Staff member has always accompanied (resident 13) when (resident 13's) impaired cognition and inability to know where facility is located. The goal developed included, The resident will not leave facility unattended through the review date. The intervention developed to achieve the goal included, The resident's triggers for wandering/eloping are not having her newspaper or taking another resident's newspaper, being asked to change clothing. The resident's behaviors is de-escalated by medication, walking, resolving problem. The physician's orders [REDACTED]. On 4/27/13 an order was received instructing the staff that resident 13, MAY NOT LEAVE FACILITY UNLESS ACCOMPANIED BY AUTHORIZED FACILITY STAFF OR HER FAMILY. On 9/13/15 an Elopement Risk Assessment was completed for resident 13. The facility staff documented that resident 13 was oblivious to her own safety needs, had a history of [REDACTED]. The facility staff further documented that resident 13 had a potential for elopement when she was angry. On 10/8/15 at 10:24 AM, the facility Resident Advocate (RA) documented, Activities director was gathering residents to go (shopping). This client was asked to change her clothes a few times by different staff members to look presentable. she was out front waiting for the van, when staff noticed she hadn't changed yet, RA went out and asked her if she was going to change, client yelled and said i have changed 3 times and i'm going to slit my throat and find a bridge to jump off of. she started walked (sic) down the street. RA got in facility van, to pick her up. she had walked all the way across (a busy four lane road) over by (a donut shop). she yelled as (sic) RA and said she wasn't going to get in the (expletive deleted) van and going back to (expletive deleted) RA finally walked her towards van where client had finally calmed down and was willing to get into the van. she was brought back to facility and when we pulled up she yelled well hello prison gates and slammed the van door. she ended up walking into facility yelling and finally calmed down and went to her room. (Note: Resident 13 walked three tenths of a mile unattended across a busy road.) On 10/20/13 at approximately 3:15 PM, RN 1 was interviewed. RN 1 stated that a Elopement Risk Assessment was completed at the time of admission. RN 1 stated that the Elopement Risk Assessment was based on the nurses judgment and that there were no instructions on how to fill out the form, or legend on determining a resident's elopement risk. On 10/21/15 at 10:01 AM, an interview was conducted with CNA 1. CNA 1 stated she had worked at the facility for three weeks. CNA 1 stated if she could not find a resident she would inform the nurse, who would then use their walkie talkies to inform all staff, and then begin to search for the resident. CNA 1 stated resident 13 Gets bored and likes to walk, but she was not allowed to walk in front of the building. CNA 1 stated she would be concerned if resident 13 went out of the front doors, and CNA 1 stated she would Go after resident 13. CNA 1 stated she could not find resident 13 this morning when she was checking blood pressures. CNA 1 stated it was About ten to Seven when she could not find resident 13. CNA 1 stated she told RN 2 that she could not find resident 13 and continued to help assist in getting residents up for the day. CNA 1 stated she did not hear RN 2 on the walkie talkies informing staff that resident 13 was missing. CNA stated she did not know what RN 2 did with the information that resident 13 was missing. CNA 1 stated she did see resident 13 in the dining room after she assisted in getting residents up for the day, but did not know the time she observed resident 13 in the dining room. On 10/21/15 at 10:14 AM, an interview was conducted with RN 3. RN 3 stated she had not been made aware during her shift that resident 13 had been missing. RN 3 stated she would be concerned if resident 13 was out of building. On 10/20/15 at 3:45 PM, an interview was conducted with the Business Office Manager (BOM), who is also the facility owner. The BOM stated that the Elopement Risk Assessment was based on the nurse's judgement as to whether a resident was at risk or not. On 10/21/15 at 12:03 PM, an interview was conducted with the facility Administrator. The Administrator stated resident 13, Is not at risk (for elopement), if she wants to sit on the front porch, she can absolutely. The Administrator stated resident 13 sits and waits for the paper almost every day and sometimes she sits outside to wait. The Administrator further stated resident 13, Knows what she is doing and that if she gets Mad she will go to the street but she usually comes right back. The Administrator stated I can see our documentation doesn't match my feelings. The Administrator then stated as a General rule of thumb that a resident who was on Memory Lane was exit seeking but if a resident was not on Memory Lane he was not concerned with them being exit seeking. On 10/21/15 at 12:27 PM, an interview was conducted with the BOM. The BOM stated resident 13, Always goes out front and that she would not call that leaving the facility. The BOM stated she was not aware of the incident on 10/8/15 when resident 13 left the facility and was found at a local doughnut shop. The BOM stated she would consider that an elopement. The BOM stated it was normal behavior for resident 13 to become upset in the morning and that she was not concerned about resident 13 behavior this morning. The BOM stated resident 13 could not get to the busy road in three minutes and did not know why facility staff would document that. The BOM also stated she would assume the activity director followed resident 13. The BOM stated some residents who are on the facility main floor were elopement risks. The BOM stated she considered the sidewalk in front of the facility, facility property and if a resident was found walking on the sidewalk it would not be considered an elopement. The BOM stated Professional judgement was used by facility nurses when determining if a resident was an elopement risk or not when completing the facility elopement assessment. The BOM stated facility nurses should reassesses a resident for elopement risk quarterly and if a resident eloped. The facility Wandering/Elopement policy and procedure was reviewed and documented: Purpose(s) To provide a safe environment for all residents, in particular those assessed as at risk for elopement, exit seeking and/or wandering. To provide for an assessment and plan to prevent elopement. To establish a culture of safety with regards to care of residents at risk for elopement, exit seeking and/or wandering. Standards Residents are identified as at risk for elopement/exit seeking and/or wandering at the time of admission inquiry and immediately at the time of admission. (See definition for wandering and elopement/exit seeking). An elopement/exit seeking/wandering assessment, is completed at the time of admission that identifies the resident's profile; usual routine (if known); what to observe for; usual trends; type and amount of supervision required; other successful interventions to attempt; contact information and the resident's picture. A complete assessment of behaviors and mood are part of the admission comprehensive assessment and are updated quarterly. The resident's care plan identifies the resident risks and contains code green documentation specifics. When a resident is found outside the facility in an unsecured area without supervision - General standards: a. The unit nurse is notified. b. A head count is performed. c. The facility Director of Nursing and Administrator are notified. d. The family is notified. e. The physician is notified. f. The State hotline number is called. g. An incident report and investigation are completed; the resident is place (sic) on alert monitoring; and documentation is found on the 24-hour report. h. The resident is placed on every 15 minute checks or one to one monitoring until an effective safety plan can be implemented. When a resident is missing - General standards: a. The unit nurse is notified and all shift personnel search all areas inside the facility and outside the premises. b. A head count is performed. c. Staff, residents and visitors are interviewed to determine when the resident was last seen and what the resident was wearing (Type of clothing and colors). d. The facility Director of Nursing and Administrator are notified. e. The family is notified. f. The physician is notified. g. The State hotline number is called. h. The police are notified. i. An incident report and investigation are completed. j. When the resident is found, the resident is placed on every 15 minute checks or one to one monitoring until an effective safety plan can be implemented. The resident is placed on alert monitoring; and documentation is found on the 24-hour report. Definitions: Wandering: Locomotion with no discernible, rational purpose; the resident is oblivious to his or her physical or safety needs; with the possibility of exiting the building and entering an unsecured area inside or outside the building without conscious knowledge on behalf of the resident and therefore putting his or herself in danger. Elopement: A resident exiting a building into an unsecured area without direct supervision who has been deemed not safe to do so. Exit Seeking: A resident who attempts to exit the building through any door to the outside of the building in unsecured areas deemed to be unsafe for this resident without supervision. Exit seeking can be evidenced by actual attempts or verbal statements by the resident of plans to attempt to exit. (Note the Wandering/Elopement policy was developed November 2008 and had not been reviewed or revised.) B. Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 32's medical record was reviewed on 10/21/15. On 8/18/15 an Elopement Risk Assessment was completed for resident 32. The facility staff documented that resident 32 was, NOT a potential risk for elopement . Review of the quarterly Minimum Data Set (MDS) assessment completed on 8/8/15 revealed that resident 32 had a Brief Interview Mental Status score of 6. Resident 32's quarterly MDS also revealed resident 32 exhibited wandering 1 to 3 days during the assessment period. (Note: A score of 0-7 on the BIMS assessment reveals severe cognitive impairment.) The care plans developed for resident 32 were reviewed. On 8/18/15, the facility staff developed care plans which revealed, The resident has a behavior problem wandering in and out of peoples rooms, bathrooms r/t (related to) senile dementia, confusion. Interventions listed included the following, .make sure room is labeled clearly with name on it . redirect patient out of peoples rooms . Resident 32's care plan also revealed, The resident has impaired cognitive function/dementia or impaired thought processes r/t Short term memory loss, Long term memory loss. The interventions listed included the following, .Cue, reorient and supervise as needed . A physician order [REDACTED]. On 8/8/15 a facility nurse documented, At 1410 (2:10 PM), pt in another residents room. Other resident became angry and chased resident out of room . Resident is confused and was at one time in the same area of his old room. Pt might have gotten confused as to which room he was going to. On 8/14/15 a social service note revealed the following information, LCSW met with resident due to residents increase in behaviors. Resident is wandering into other residents rooms (the ones adjacent to his own). He has had several episodes of becoming agitated and combative with other residents and staff. Met with RA and discussed possibility of placing him on in SNU (Special Needs Unit). At this time it was decided to offer to place him in a single room closer to the nurses station with his own bathroom and see if it reduces conflict . On 9/5/15 at 10:36 PM, a facility nurse documented, Res (resident) found outside facility wandering down Harrison Blvd (boulevard) by (Name of facility staff) CNA (Certified Nursing Assistant). Confused, disoriented, states he was depressed, no one would talk to him. Then he started giggling. An incident report dated 9/5/15 at 6:00 PM, revealed the following information, Res left facility, found on wasatch Drive adjacent to facility. The following step taken to prevent recurrence was listed, remind client to sign out. On 9/8/15 at 12:31 PM, a social service note revealed the following information, Administration got report this morning of client leaving facility on 9-5-15. Report RA got from CNA was that they were getting residents settled for dinner and they went to get (name of resident 32) and thought he would be out in the smoking prohibited area. when they discovered that he wasn't. all staff searched facility and grounds. CNA on staff at the time went up on wasatch dr (drive), and walked north towards the 4 way stop. that is where she found client. he was walking back and CNA asked why he left. he said he was depressed and had noone (sic) to talk to and then he smiled. CNA told him any of the staff members are here if he needs to talk. client then told CNA he had been up on Harrison BLVD walking around, client was only gone a total of 3-5 min. so CNA doubts he was up on Harrison at all. On 9/8/15 at 3:04 PM, a social service note revealed the following information, Report from CNA (name of CNA) regarding 9-5-15 incident also reported the same statement as CNA (name of another CNA). Client was not on Harrison Blvd, he was found up on the corner, north of the facility about 1/4 block down. only gone for about 3-5 min (minutes). On 9/7/15 at 7:55 PM, a facility nurse documented, Resident left facility, Found wandering on (Name of street) Found by staff. No injuries noted. On 9/7/15 at 9:31 PM, a facility nurse documented, PT TO LEAVE FACILITY ACCOMPANIED BY STAFF ONLY. everyday and night shift Left facility, found wandering approx. (approximately) a block away. An incident report dated 9/7/15 at 6:00 PM, revealed the following information, Res left facility found by staff Behind facility in Alley. The following step taken to prevent recurrence was listed, educated client to sign out when leaving facility. On 9/8/15 at 3:07 PM, a social service note revealed the following information, 9-7-15 Report from CNA: client went out without letting staff know. he was found down the alley way by facility, walking back. CNA (Name of CNA) saw him and asked where he had been, he was gone for about 15-20 min, according to CNA. client told CNA he went to (name of gas station) to buy cigarettes. but the only cigarettes CNA found on client was the one he was smoking. Client does have a history of walking to the store to buy his own cigarettes. On 9/11/15 at 3:22 PM, a facility nurse documented, Resident was found walking back to facility. He was asked where he went and he just laughed. The C.N.A stated that he look (sic) all over for him and couldn't find him. 3 minutes later he was almost to the parking lot walking towards the building. (Note: An incident report could not be found in regards to resident 32's elopement on 9/11/15.) On 9/27/15 at 7:45 PM, a facility nurse documented, Resident is alert able to make needs known. Able to understand verbal content. Words garbled, confusion, agitation at times . Allowed by Administration to leave facility and go to (Name of gas station) to buy cigarettes. On 10/21/15 at 10:01 AM, an interview was conducted with CNA 1. CNA 1 stated she was unsure if resident 32 was safe to go out in front of the building. On 10/21/15 at 10:14 AM, an interview was conducted with RN 3. RN 3 stated most of the high risk elopement residents had a room on Memory Lane. RN 3 stated resident 32 had been found on Washington blvd but hadn't gotten out of the facility since. RN 3 stated she was unaware of the date. On 10/21/15 at 10:15 AM, and interview was conducted with RN 2. RN 2 stated that resident 32 worries me. We thought about placing him in the SNU for a while but we were worried that he would be violent so we just have to watch him. RN 2 also stated that resident 32 has good days and bad days, and if resident 32 was having a bad day, then he gets confused and wanders. On 10/21/15 at 12:03 PM, an interview was conducted with the facility Administrator. The Administrator stated there was a Weekend nurse who thought resident 32 was eloping when he left the building to go to a local gas station to buy cigarettes, but that he did not agree with this determination, and the nurse was mistaken. The Administrator stated he had assessed resident 32 himself and had followed him across the street to the local gas station where resident 32 bought cigarettes. The Administrator stated in his opinion resident 32 was not an elopement risk, and that resident 32 was just forgetting to sign out. The Administrator stated he did not know why there was an order stating that resident 32 could not leave the facility unless attended by facility staff. On 10/21/15 at 12:27 PM, an interview was conducted with the BOM. The BOM stated resident 32 does leave the facility unattended to buy cigarettes. The BOM stated she was not aware there was a physician order [REDACTED]. On 10/21/15 at 9:50 AM, an interview was conducted with CNA 2. CNA 2 stated she had worked at the facility for two years. CNA 2 stated resident 13 and resident 32 were not allowed to go out in front of the building because they were at high risk to wander. CNA 2 stated both residents could walk in the back of the building because it was fenced in and they would not be able to get out without staff. CNA 2 stated she would be concerned if resident 13 went out the front doors, and she would immediately go and get her and bring her back in the facility. CNA 2 stated the CNA assigned to each high risk wander resident was responsible to check on them every 30 to 60 minutes and if they were not able to locate them the CNA would notify the nurse and then go look for them. C. Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 12's medical record was reviewed on 10/21/15. The care plans developed for resident 12 were reviewed. On 9/25/14, the facility staff developed care plans which revealed, The resident will often harm self by scratching open wounds into skin/reopen old wounds r/t resident reporting 'karen, joe (and) thomas' are trying to harm her. An intervention listed on resident 12's care plan was, .Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. On 3/25/15 a Crisis Evaluation was completed for resident 12 and revealed the following information, .Pt was sent to the ER (emergency room ) by (name of local mental health service) program after she kept trying to scratch and harm herself. Per medical hx (history) pt has been diagnosed with [REDACTED]. Pt had a recent inpatient hospitalization at (name of local hospital) for disorientation, self harming urges, passive suicidal ideation and anxiety. Met with pt who states she is Karen and she wants to hurt (name of resident 12). Pt kept trying to scratch and dig at herself and had to be put in mechanical restraints to stop her from harming herself. Pt reports that (name of resident 12) is stupid, ugly, and has been bad. She wanted to be left alone so she could do what she wanted. When I asked her what she wanted to do she stated she would let 'Joe' out so he could kill (resident 12). Pt continues to try and harm herself by scratching herself until she bleeds and trying to dig her skin with her fingernails . On 9/10/15 at 3:51 PM, the facility RA documented the following, client came into RA office saying she cant keep 'Karen' from coming out and scratching her arm, and 'thomas' wants to go out the front door and leave. and she cant keep fighting these any longer. RA and client called (name of crisis worker), crisis worker at (name of local mental health service) and client spoke w/ (with) her and released some of her fears and worries. crisis worker told her to put an ice pack on her forehead and relax. RA helped client get ice pack and get settled and relaxed in her room. will continue to follow. On 9/10/15 at 4:24 PM, the facility RA documented the following, first crisis worker we spoke w/ told client if ice pack doesn't work to call back. RA checked on client 5-7 min after she tried ice pack and she said it was hurting more and making her 'personalities come out more and making them more mad' RA brought client back into office and we called crisis line back. client spoke w/ (name of crisis worker), crisis worker. client told (name of crisis worker) that she has '3 bad personalities. karen, john and thomas.' (name of crisis worker) told client to try squeezing a rubber ball and listening to some music. client went back to her room to try these techniques. On 9/11/15 at 10:38 AM, the facility RA documented the following, client came into RA office. said nothing is working that the crisis worker had her try last evening. as she sat in my office, and i tried to get the crisis dept (department) back on the phone for her, client closed her eyes as if she was in a trance, and scratched her hand nonstop until it bled. looked very deep. RA finally got her to stop and she 'snapped out' of it and came to. nursing bandaged wound and after cleaning it, nurse said it wasn't as deep as it looked once it was cleaned out. RA lft (left) message for (name of local mental health service) to call back. Administration is working on send (sic) her to (name of local hospital) psych. just waiting for a call back from (name of crisis worker) at (name of local mental health service) so that they can be on board with what is going on this morning. On 9/11/15 at 1:26 PM, the facility RA documented the following, spoke w/ (name of worker at local mental health service) at (name of local mental health service), she lft a msg (message) for (name of staff) to call, if she didn't call by 1:00 RA was to contact (name of staff) with (name of local mental health service) he said that they advise us not to send client to hospital. they feel they wont do anything for her and that client is doing these things for some attention. he advised RA to not give client the attention that she is seeking. that is why she is doing the things she does. but at the same time to try some techniques to help her with, if she is willing to try them. one is hold an ice cube in her hand for 30 seconds, that will get her mind off of her 'personalities' #2 is intense exercise if feasible. and #3 is have her do paced breathing (counting breaths). nursing and administration notified. On 9/13/15 at 2:19 AM, a late nursing note entry for 9/11/15 at 8:00 PM revealed the following information, Elderly male visitor approached the nurses station to inquire if were missing a pt. He stated a female pt was next door to his house and had been sitting under a carport for about an hour and a half. Facility checked and found (resident 12) missing. CNA sent to the location to bring pt. back to the facility. CNA called facility and reported pt. refused to return. CNA stated she called the police department to assist. Administrator also notified. About a half hr (hour) later the CNA and pt. returned to the facility. Pt was very angry and stated she wanted to kill herself. She refused O2 (oxygen), meds (medications), and insulin. A police officer arrived about an hr later and spoke to the pt. Sharp metal was removed from the patients pocket with the help of the officer. Pt. then dug at her arms and face with her long nails causing them to bleed. Areas cleansed and gauze dressing applied. She finally calmed down and went to sleep. RN (Registered Nurse) attempted to call pt's daughter but phone was out of service. (Note: An incident report could not be located regarding resident 12 and the incident above.) On 9/18/15, a Summary of recent behavior written by the facility contracted LCSW revealed the following information, (Resident 12) has become increasingly suicidal and self-destructive. During the past week she left the building during the rain and was found under a neighbors carport. She reported to staff that one of her alter personalities had taken her there with the intent to die. She has been scratching her arms and face until they bleed, and after bandaged is reopening them. She reports that she wants to die and intends on doing it as soon as she can. Today she reports that one of her personalities has a coke can that he has 'torn to pieces' and 'sharpened the edges'. She reports she has it hidden in her room. She refuses to allow staff to search for pieces of the can. As per resident, she intends on using it as soon as she has the chance. It is not safe for her to remain outside of a hospital setting at this time. (Note: Resident 12 was discharged to a local hospital on [DATE].) On 10/21/15 at 12:03 PM, an interview was conducted with the facility Administrator. The Administrator stated resident 12 was alert and oriented times three and if she left the building without signing out it was An education issue with resident 12. The Administrator confirmed resident 12 had self-harm behaviors. The Administrator stated when resident 12 began experiencing self-harm behaviors on 9/10/15 the facility Begged the mental health service who saw her to have resident 12 blue s

Based on observation, interview, and record review, it was determined that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 3 of 33 sample residents. Specifically, there was an extended period of time before treating a resident with a change of condition, a resident did not receive pain medication as ordered, and a facility staff member failed to assess a resident's abdominal hematoma and manage his pain. Resident identifiers: 43, 53, and 58. Findings include: 1. Resident 43 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 43's medical record was reviewed on 10/19/15. Resident 43's medical record review revealed a Progress Note dated 5/12/15 which stated, Gait is usually steady Usually compliant with cares, occasionally gets agitated with people . A Progress Note dated 5/20/15 stated, Resident very confused and disoriented. Wandering up and down hall Will notify oncoming nurse of new behavior. A Progress Note dated 5/25/15 stated, Exhibiting delusional, paranoid behaviors at times this shift. Unable to obtain UA (urinalysis) . (Note: This was five days after first noted change of behavior.) A Progress Note dated 5/26/15 and timed 11:46 AM stated, .today pt (patient) is in abd (abdominal) pain, restless, confused and running into walls. ill. notified (name of physician) .unsteady on feet today. has (sic) sob (shortness of breath) with exertion today . (Note: This was six days after the first noted abnormal behavior.) A Progress Note dated 5/26/15 and timed 2:50 PM stated, Positive UA, cx (culture) pending. Dr. (name of physician) notified, awaiting orders to tx (treat) UTI (urinary tract infection). A Progress Note dated 5/26/15 and timed 8:11 PM stated, Order from Dr. (name of physician);[MEDICATION NAME]([MEDICATION NAME]) 500 mg (milligrams) po (by mouth) bid (twice a day) for 3 days for UTI. (Note: This was 5 hours and 21 minutes after the laboratory results were received.) A Progress Note dated 5/26/15 and timed 8:31 PM stated, .took only a minimal amount of Med Pass (nutritional supplement drink) with abx (antibiotic). After then she didn't open her mouth. Resident didn't eat dinner even though a staff (sic) tried to feed her with encouragement. She refused to open her mouth. Resident looks lethargic. Will continue to monitor. A Progress Note dated 5/27/15 and timed 10:34 AM stated, Resident was difficult to arouse to get to take antibiotic. Resident did take meds (medications), not opening mouth well, would not take fluids. Resident has been sleeping all morning . A Progress Note dated 5/27/15 and timed 5:27 PM stated, Resident lethargic and verbally non responsive. Resident not opening eyes or speaking. Resident crying out when touched. MD (medical doctor) notified of labs (laboratory tests) and residents (sic) decline in physical status. Resident sent to (name of local hospital) via ambulance. Family notified. (Note: This was seven days after abnormal behavior was first noted.) A History and Physical from the local hospital where the resident was transported to was dated 5/27/15 and stated, The conclusion from the ER (emergency room ) staff [MEDICAL CONDITION] with acute urinary tract infection and acute [MEDICAL CONDITION] or perhaps acute or [MEDICAL CONDITION] and [MEDICAL CONDITION] and quite severe [MEDICAL CONDITION] IMPRESSION .4. Marked [MEDICAL CONDITION], most likely due to dehydration . The Director of Nursing (DON) was interviewed on 10/26/15 at 3:35 PM. The DON stated that if a resident became lethargic, a prudent nurse would call the doctor sooner. The Business Office Manager (BOM), who is also the facility owner was interviewed on 10/28/15 at 9:05 AM, but was unable to provide further information. 2. Resident 58 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 58's medical record was reviewed on 10/22/15. Review of the hospital History and Physical revealed that resident 58 had a Right large flank hematoma and that resident 58 was on anticoagulation therapy. Review of the initial admission orders [REDACTED] a. [MEDICATION NAME] 5 mg (milligrams) every day; and b. [MEDICATION NAME] 60 mg twice a day subcutaneously that was to be discontinued when the INR (International Normalized Ratio) was greater than 2.0. Additionally, resident 58's admission orders [REDACTED]. Review of the initial nursing assessment that was completed on 7/6/15 revealed that the facility nurse assessed resident 58 has having had a large bruise on his right side and hip. Resident had excruciating pain upon admission. Review of the electronic progress notes documented the following entries: a. 7/7/15 at 5:47 AM: .Resident awake and oriented X (times) 3 (person, place, and time).admitted with a sp (status [REDACTED]. He has a (sic) a dominal binder to put around his abdomen until it becomes soft. Rt side of abd (abdomen) is more swollen and distended on the rt. b. 7/8/15 at 4:24 AM: .No s/s (signs or symptoms) of bleeding while taking [MEDICATION NAME] and [MEDICATION NAME] injections. Bruising on left (sic) side and abd getting softer but wearing binder. (Note: Review of the Daily Medicare Skilled Nursing Assessment revealed the facility licensed staff did not assess resident 58's abdominal hematoma from 7/9/15 to 7/12/15.) c. 7/13/15 @ 1:25 AM: .Hematoma on rt side of abd increasing in size and pain, md (medical doctor) notified and sent to hospital @ (at) 2145 (9:45 PM) 7/12/15. [MEDICATION NAME] held per MD order. (Note: The licensed professional staff did not assess resident 58's abdomen or hematoma for four days prior to him being sent to the hospital.) d. 7/13/15 at 4:24 AM: Resident c/o (complained of) increased rt abdominal pain this evening. VS (Vital Signs) taken at 1930 (7:30 PM) P (Pulse) 78, r (respirations) 18 02 (oxygen) sats (saturations) 99% on room air 07/12/15. Resident med (medicated) with [MEDICATION NAME] after calling MD assistant. She said to monitor resident closely. Rt side of abdomen with increased hardness, pain and swelling. Pain rated 9/10. She stated to put ice on it to decrease pain and monitor side draw line around swollen area. This I did. I also gave his (sic) a [MEDICATION NAME] at 1951 (7:51 PM). These were not effective. She said he could have [MEDICATION NAME] q (every) 4 hrs (hours) prn (as needed). After 1 hr (hour) res (resident) c/o (complains of) severe pain on rt side and meds were not effective. He was c/o nausea and med (medicated) with [MEDICATION NAME] at 2000 (8:00 PM) and helpful. His wife in visiting and talked with res and wife and both stated that they would like him sent to (local hospital) ER (emergency room ). MD assist (assistant) notified with order to send via ambulance. Review of the local hospital emergency records revealed that resident 58 was admitted with a worsening hematoma. The ER physician documented, .had an acute onset of increased pain over the right side of his body. family member who is with the patient reported that she had never seen him in such great pain; the patient said that he felt like he would prefer to die if the pain not be (sic) controlled. He felt like the hematoma had increased in size over the right side of his abdomen. 3. Resident 53 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 53's medical record was reviewed on 10/22/15 and revealed physician's orders [REDACTED]. Resident 53's Medication Administration Records (MAR) for March through July 2015 were reviewed and revealed that the [MEDICATION NAME] was documented as administered, according to the physician's orders [REDACTED]. The Controlled Drug Records for resident 53's [MEDICATION NAME] were reconciled with the MARs. For the following dates, the [MEDICATION NAME] was documented as given, but no [MEDICATION NAME] was signed out on the Controlled Drug Records: 3/6/15, 3/27/15, 5/2/15, 5/17/15, 5/29/15, and 7/1/15. Registered Nurse (RN) 4's initials were recorded each of these dates on the MAR. Resident 53's Progress Notes were reviewed. There was no documentation which explained the discrepancy. RN 4 was interviewed on 10/26/15 at approximately 2:15 PM. RN 4 stated she did not know why there would be a discrepancy between the MAR and the Controlled Drug Records. The Emergency Drug Kit Log Book was reviewed on 10/26/15 at 2:22 PM. There were no withdrawals of [MEDICATION NAME]es documented for resident 53 in the past year. Resident 53's family member was interviewed on 10/26/15 at 2:32 PM. The family member stated that frequently resident 53's patches had, old dates on them or she, had no patch on at all. The BOM was interviewed on 10/27/15 at 11:03 AM. The BOM stated it didn't make sense why the MAR would not match the Controlled Drug Records.

Based on interview, observation and record review, the facility did not prevent 2 of 33 sample residents from developing pressure sores while in the facility. In addition, after developing the pressure sore, one of the residents did not receive appropriate treatment. Resident identifiers: 8 and 21. Findings include: 1. Resident 21 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 21's medical record was reviewed on 10/20/15. Resident 21's Admission Minimum Data Set (MDS) assessment dated [DATE] was reviewed. The MDS revealed that resident 21 was at risk for developing pressure ulcers, but that at the time of the MDS Assessment, he did not have any unhealed pressure ulcers. The MDS also revealed that resident 21 required extensive assistance from two or more staff members for bed mobility, transfers, dressing, and toilet use. Resident 21's Quarterly MDS assessment dated [DATE] was reviewed. The MDS revealed that resident 21 was at risk for developing pressure ulcers, but that at the time of the MDS Assessment, he did not have any unhealed pressure ulcers. The MDS also revealed that resident 21 required extensive assistance from two or more staff members for bed mobility, transfers, dressing, and toilet use. A care plan dated 6/2/15 revealed that resident 21 was at risk for pressure ulcer development related to immobility, and that facility staff were to follow facility policies/protocols for the prevention/treatment of [REDACTED]. A Braden Scale Pressure Sore Risk was completed for resident 21 on 5/19/15 and one illegible date. Both scores were 15, which according to the key, indicated that resident 21 was at low risk for developing pressure sores. A Malnutrition/Dehydration Pressure Sore Risk Assessment was completed for resident 21 on 5/19/15 and one illegible date. Both scores were 11, which according to the key, indicated that resident 21 was at high risk for developing pressure sores, and had an additional high nutrition risk. A Nursing Monthly assessment dated [DATE] documented that resident 21's skin, although dry, was intact. A nurses progress note for resident 21 dated 9/27/15 documented that the resident was wheelchair bound, but his skin was clean, dry, and intact except for skin tears on his forearms. A nurses progress note for resident 21 dated 10/3/15 documented that the resident had developed a stage II (pressure ulcer) to left upper buttocks. 2 cm (centimeters) in length. A nurses progress note for resident 21 dated 10/11/15 documented that resident 21 had a stage II DQ (decubitus) (ulcer) on his left upper buttocks. Despite the development of the stage II pressure ulcer, resident 21's care plan had not been updated with specific treatment plan objectives and goals. On 10/27/15, resident 21 was continuously observed for nearly three hours. a) At 8:50 AM, resident 21 was observed to be sitting in his wheelchair near room [ROOM NUMBER] in the Special Needs Unit (SNU). b) At approximately 9:00 AM, resident 21 was wheeled out to the patio area adjacent to the SNU. During resident 21's time outside, he was not repositioned in his wheelchair. c) At 9:16 AM, resident 21 was wheeled back inside the SNU from the smoking area in the adjacent patio area, and again was observed to be seated in his wheelchair near room [ROOM NUMBER]. d) At 11:17 AM, resident 21 was wheeled into his room by Registered Nurse (RN) 2, so that she could check his blood glucose level. RN 2 stated that she would return to administer his insulin. e) At 11:30 AM, resident 21 was still in his room, and RN 2 had not returned. A Certified Nursing Assistant (CNA) entered resident 21's room, and wheeled him in to the dining room to eat lunch. During the continuous observation made from 8:50 AM to 11:30 AM, a period of 2 hours and 40 minutes, resident 21 was not repositioned in his wheelchair, or assisted into a different seat/bed. In addition, resident 21 was not observed to attempt to reposition himself. On 10/28/15 at 10:05 AM, an interview was conducted with Certified Nursing Assistant (CNA) 14. CNA 14 stated that resident 21 can't move much when in bed, and could not reposition himself when in his wheelchair. CNA 14 also stated that staff were responsible for repositioning resident 21 every two hours to prevent skin breakdown. On 10/28/15 at 10:07 AM, an interview was conducted with CNA 7. CNA 7 stated that resident 21 was not coherent enough to help with transfers and repositioning. CNA 7 stated that resident 21 could move a little when in bed. CNA 7 also stated that resident 21 required the assistance of two staff when transferring from his bed to his wheelchair. CNA 7 stated that resident 21's call light automatically rang every two hours to remind staff to reposition the resident. CNA 7 also indicated that resident 21 had a CNA Communication Sheet posted on the inside of his closet door. The communication sheet was observed and indicated that resident 21 required the assistance of two people for both bed mobility and transfer. The communication sheet also indicated that resident 21 was supposed to have his brief checked and changed every two hours. On 10/28/15 at 10:15 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that she was aware resident 21 had a sore on his buttocks but was unaware if it had been staged or not. RN 3 stated that she had seen resident 21's wound the previous week while discussing the possibility of changing treatments, as the treatment at that time did not seem to be helping resident 21's wound improve. On 10/28/15 at 10:30 AM, an interview was conducted with the facility owner regarding resident 21 and the facility's skin and wound policy. The owner stated that resident 21 was supposed to be repositioned every two hours, and the facility had programmed resident 21's call light to automatically ring every two hours in order to remind staff to reposition him. The owner further stated that a facility staff member had recently approached her as resident 21's wound was getting worse. The owner, who was not licensed as a nurse or CNA, stated that she would look at and assess residents' wounds to help licensed nurses determine what further treatment was necessary or whether the residents should be seen at the local wound clinic. 2. Resident 8 was admitted to the facility on [DATE] and re- admitted on [DATE] with [DIAGNOSES REDACTED]. On 10/21/15 at 10:45 AM resident 8 was observed in a room of the facility that had been designated for podiatry visits that day. The resident was sitting in her wheelchair, without a pressure relieving device. A soiled and saturated dressing was observed on her right foot, on the lateral distal aspect. On 10/21/15 at 11:00 AM an interview was conducted with the podiatrist. The podiatrist stated that resident 8 was being seen for nail care, but not wound assessment or treatment. The podiatrist stated that she was unaware that resident 8 had a wound on her foot. The podiatrist further stated that if there was a concern with wounds, the facility normally would add the pertinent information onto the list that was provided to the podiatrist. Resident's 8 medical record was reviewed on 10/26/15. Review of the MDS Assessment completed on 5/7/15 revealed that the facility assessed the resident at risk for pressure ulcers but did not currently have any pressure ulcers. The MDS assessment on 8/21/15 documented that resident 8 was at risk for pressure ulcers and did not have any pressure ulcers. MDS documentation on the above dates assessed the resident as requiring 1 person assistance for bed mobility and transfers, ambulation/locomotion. On 6/19/13 the facility developed a skin integrity care plan. The resident has potential for pressure ulcer development r/t (related to) Immobility, hx (history) of pressure ulcer on foot. The goal that was developed was: The resident will have intact skin, free of redness, blisters or discoloration by/through review date. The target date was documented as 5/17/15. The approaches that were developed to achieve the goal included: 1) Administer medications as ordered. Monitor /document for side effects and effectiveness. 2)Administer treatments as ordered and monitor for effectiveness. 3)Educate the resident/family/caregivers as to causes of skin breakdown; including: transfers/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. 4) (Initiated 7/6/2013) : Float heels 5) If the resident refuses treatment, confer with the resident, IDT (Interdisciplinary Team) and family to determine why and try alternative methods to gain compliance. Document alternative methods. On 8/24/14 and on 9/20/14 the facility staff documented on the Malnutrition/ Dehydration- Pressure Sore Risk Assessment a score of 19 for resident 8. The tool's score key reads: Total score of 8 or higher (equals) HIGH SKIN RISK. The facility form named: skin condition sheets were reviewed. The last entries were dated 7/16/15 and 7/24/15. On 7/16/15 the skin condition sheets documented .Continues to have wound to R (right) lateral foot & (and) is receiving routine dsg (dressing) (changes) to this. Area to buttocks continue to be red & these open one (sic) getting (sic) cream applied. On 7/24/15 the skin condition sheets it was documented: Buttocks red bilaterally (with) small open area to L ( left) & R (right) buttock. Wound to R lateral foot (with) (dressing) (change) q (every ) 3 days. Cream applied to buttocks. Encourage repositioning. (Note: resident 8 was a 1 person assist with repositioning.) A Skin/wound note dated 7/30/15 documented on the electronic record stated Resident has area of redness to both buttocks that are healing and showing less red. Area to right lateral foot that receives routine dressing changes. No other areas of concern noted. A weekly note dated 8/6/15 documented the following: .continues to have wound to right lateral foot that is getting routine dressing changes. Has some redness in panas (sic)area that is receiving cream. Buttock continue to have discolored area, but no new open areas at this time. On 8/11/15 an order was entered as follows: Cleanse right lateral foot wound, then apply abx (antibiotic) ointment and [MEDICATION NAME] Q 3 days (use contact precautions, bio bag for soiled dresg (dressing) and gloves. On the 8/13/15 weekly note RN 4 documented the following: .SKIN: clean dry and intact with no open areas. Cont (continue) with poc (plan of care). On 8/20/15 (late entry) RN 1 documented the following: . continues to have wound to right lateral foot that is getting routine dressing changes. Has some redness in panas (sic) area that is receiving cream. Buttock continue to have discolored area, but no new open areas at this time. On 9/3/15 a weekly note documented the following: .Wound to right lateral foot treated as ordered. Healing w/o (without) s/s (signs and symptoms) of infection. Redness in panas (sic) continues. Tx. (treatment) as ordered. Rt. (right) Buttock with noted fragile/ healed area. Not open at present. A physician's progress note for recertification dated 9/4/15, stated: .She has a chronic open area on her right lateral foot. Assessment and Plan: .Right lateral foot wound-DFU (dorsal foot ulcer). continue current care. On the 9/12/15 weekly note RN 1 documented the following: .continues to have wound to right lateral foot that is getting routine dressing changes. Has some redness in panas (sic) area that is receiving cream. Buttock continue to have discolored area, but no new open areas at this time. On 9/14/15 a Skin/wound note by RN 4 stated: .check on right buttock. Has abrasion and looks as though pt. (patient) was scratching area. Cleansed and put on [MEDICATION NAME] for future shearing. left buttock has abrasion and [MEDICATION NAME] placed in between crack of buttocks is the (sic) beginning of an open area. Cleansed with dressing in place. On 9/14/15 a weekly note by RN 3 documented the following: .Skin is warm dry and intact less previous excoriation to buttocks, which continues to heal at this time. On 9/17/2015 a weekly note by RN 1 documented the following: . Continues to have open area to right lateral foot, areas on buttocks have closed off except for one area to right inner buttocks. Cream applied to buttocks and wound to foot receives routine dressing changes. On 10/1/15 a weekly note by RN 2 documented the following: .Skin: Resident has wound to right foot, resident also has breakdown to buttocks. Staff instructed to apply barrier cream each time peri care is done. On 10/8/15 a weekly note by RN 1 documented the following: . continues to have an open area to righ tfoot and red area on buttocks. On 10/15/15 a skin/wound note by RN 1 documented the following: Resident has area to upper area in gluteal fold that is open. Dressing applied and surrounding areas is having as it is red (sic). Continues to have open area to right lateral foot. On 10/22/15 a Skin/wound note by RN1 documented the following: Resident has open area in gluteal fold in buttocks and open area to right lateral foot. Is receving cream to buttocks and routine dressing changes to foot. On 10/24/15 a Orders- Administration note stated: cleanse right lateral foot wound, then apply abx ointment and opti-foam PRN (as needed) (use contact precuations ( sic), bio bag for soiled drsg and gloves) for wound as needed for wound care QD ( every day). A review of resident 8's Treatment Administration Record (TAR) for September of 2015 revealed an order with a start date of 2/26/15: BARRIER CREAM TO BUTTOCK as needed for REDNESS/BREAKDOWN BID (twice a day). There were no entries in the TAR to demonstrate that barrier cream had been applied for the month of September 2015. This order was on the TAR for the month of October 2015. It was signed as administered once by RN 2 on 10/12/15 and marked as effective. On 10/28/15 at 11:30 AM, an observation was made of resident 8's buttocks, with resident 8's consent. RN 1 was present during the observation which revealed the following: a) The entire surface of the right buttock was red and non- blanchable. b) Additionally on the right buttock there were 4 areas approximately 2 to 2.5 cm. (centimeters) in diameter on the medial aspect of right buttock, with partial loss of dermis and red wound bed. c) One area on the fissure of the buttocks was open with drainage, approximately 1 1/2 cm in diameter. d) The large medial area of left buttock was red and non- blanchable. e) Additionally on the left buttock there were 5 areas approximately 2 cm. in diameter, with partial loss of dermis with a red wound bed. f) There were no dressings to any of these areas, and there did not appear to be any traces of cream having been applied to the area. g) The wound on the right foot was approximately 3 cm in diameter, the wound bed was red, with significant loss of dermis and copious amounts of sero- sanguineous exudate on dressing. On 10/28/15 at 11:40 AM an interview was conducted with RN 1 and the facility Director of Nursing (DON). RN 1 stated that facility nurses were not allowed to stage wounds, per facility policy. RN 1 stated that if he was allowed to stage wounds at the facility, he would have assessed resident 8 as having multiple stage I pressure sores, and multiple stage II pressure ulcers to the buttocks. RN 1 stated that the wound to resident 8's foot had once almost healed because it had scabbed over. RN 1 stated that the wound care nurse was qualified to stage pressure ulcers. There were no assessments by the wound care nurse for resident 8. RN 1 was not able to provide information on whether resident 8 had been assessed by the wound nurse. The DON confirmed that per facility policy, licensed nurses were not allowed to stage wounds. The DON stated that the wound on resident 8's fissure could have tunneled and be deeper if no full assessment had been completed. The DON further stated that nursing staff should have been measuring wounds and including more descriptive charting. On 10/28/15 at 11:50 AM an interview was conducted with the Business Office Manager (BOM), who is also the facility owner, who confirmed the facility policy regarding licensed staff not being allowed to stage wounds and that the wound nurse was responsible to complete those assessments. The BOM then stated .I can't remember the last time she was here, (in reference to the wound care nurse) it has been months, I better give her a call. The BOM stated she was not aware of resident's 8 skin breakdown to the buttocks. On 10/28/2015 at 1:00 PM The facility's Skin/Wound protocol was reviewed and revealed the following: Purpose: That every NURSE will discover, assess and treat any skin (sic) or wound in a timely manner. That the doctor, and family will be notified and the treatment will be ordered, written and delivered for the best level of healing for that resident (sic). Protocol: 1. The C.N.A will observe each resident's skin as they are being showered. 2. The C.N.A will observe the skin observation (sic) for each resident they shower, at least once a week. 3. If there is a skin problem, the C.N.A will report directly to the nurse to assess the skin condition. 4. The nurse will call the MD, write the T. O, ( telephone order) start the treatment for [REDACTED]. 5. An incident report will be filled out for all new skin problems, ie (sic): as a change of condition. 6. Staff nurses will treat the skin/wound as ordered and chart that this treatment was done as ordered. 7. The nurse will begin alert charting ( 72 hours) in the resident's chart. After 72 hours the nurse will chart on the wound condition in the nurses note for that resident each time she/ he performs a dressing change. The skin nurse will begin wound protocol which is to put a wound tracking sheet in the skin section of the resident chart. 8. The skin nurse will also record all wounds and skin conditions on a weekly skin sheet that will be copied to the house MD, dietary and Nursing staff. 9. The residents with wounds will be followed weekly in the skin and weight meeting until the wound is healed. 10. The skin nurse will place a skin care plan in the residents chart with the appropriate interventions and goals for wound healing. A document labeled General Wound Guidelines was also provided and reviewed at this time. It revealed the following: General rules of wounds . Wound cleanse . Debridement: . Too moist . Too dry . Describing the wound in your charting Describe the size of the wound, the way it looks and if it is dry or draining. Describe the surround (sic) skin, [MEDICAL CONDITION], red, pale Describe odor----present or not Where the wound is located---L, (left) upper buttocks; coccyx; R. (right) lateral distal foot; below the knee mid shin; etc.(etcetera) Do Not Call the wound a Decubitus or pressure wound----just call it a wound. ( Name of staff member) is the wound nurse. Make sure she is notified of all wounds discovered, so our wound protocol can be implemented.

Based on interview and record review, it was determined the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 29 sampled residents. Specifically, one sample resident sustained [REDACTED]. Resident identifier: 68. Findings include: Resident 68 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 68's medical record was reviewed on 8/1/13. Review of the "Nurse's Notes" revealed the following entries: a. 7/27/13 from 6:00 AM to 5:00 PM: "CNA (Certified Nurse Assistant) found her in hallway as she called out for help. C/O (complained of) extreme pain to lt (left) hip and lt hand. Lt lateral finger has slight redness. No swelling noted at either side. Lt forearm skin tear r/t (related to) fall. Covered (with) suresite after cleansed well. Notified (primary care physician) and (resident 68's daughter) of fall. VS (vital signs) (blood pressure) 180/91, P (pulse) 85, RR (respirations) 28, T (temperature) 97.2 and O2 (oxygen saturation) 93%. Rechecked BP 25 min. (minutes) later and it was (down) 162/80. Res. (resident) has bump on top of head. No signs of bleeding. Alert and disoriented to place only. Repositioned her into bed (without) moving hip. Order for x-ray stat was made. Waiting on results. C/O pain. [MEDICATION NAME] given to help (decrease) pain. Pillows used. res. laying in bed. ...HOB (head of bed) (up). res has (decreased) yelling and calling for help. WCTM (Will Continue To Monitor)." (Note: On 7/26/13, resident 68's primary care physician wrote an order to discontinue the [MEDICATION NAME]. The facility licensed nurse administered the [MEDICATION NAME] without an order.) b. 7/27/13, no time documented: "Received a report that x-ray showed fracture of left femoral neck. Pt (patient) family requested advice on how to proceed. Explained options for continued care at (the facility), hospitalization , hospice assessment. Family will discuss. Requested pt. be made comfortable. Pt. continues to complain of extreme pain. Providing oral [MEDICATION NAME] (every hour) PRN (as needed). Pt. is extremely painful when moved recommended foley. (Another facility registered nurse) obtained TO (telephone order) for foley and placed. Procedure tolerated well but (with) pain. Pt. presently resting comfortably. Neuro checks being completed per protocol." c. 7/27/13 from 11:00 PM to 6:00 AM: "Placed foley r/t extreme pain when moving resident in bed. Draining well. Family was notified of foley placement. Family will be meeting at 10:00 AM to make decision on whether or not to take resident to hospital. Held 0200 (2:00 AM) dose of [MEDICATION NAME] r/t respirations at 10. WCTM." d. 7/28/13 at 2:00 PM: "This morning it was discussed (with) family, pain meds (medications), low respirations, teaching done regarding pt. pain, risk of meds (and) pt condition. Family briefly met (with) the hospice staff (and) made the decision to send pt. to (local hospital) ER (emergency room ) for further evaluation. Pt. given 0.50 ml (milliliters) MS ([MEDICATION NAME]) at 12:05 PM when EMS (Emergency Medical Services) arrived. Pt. taken to ER via ambulance. When pt. left (facility) resp (respiration) rate was 18/min (per minute)." Review of the left hip x-ray that was obtained on 7/27/13 at 1:18 PM, revealed that resident 68 had a "...fracture involving the left femoral neck with minimal displacement..." The July 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"10". The licensed nursing staff did not document what time the [MEDICATION NAME] was administered, but did document follow up pain ratings at "10" after the [MEDICATION NAME] was administered. The licensed nursing staff did not document that [MEDICATION NAME] was administered on 7/28/13. On 8/1/13 at 12:07 PM, Licensed Practical Nurse (LPN) 2 was interviewed. LPN 2 stated that resident 68 did not get out of bed on 7/28/13 and was in "quite a bit of pain," but was unable to administer the [MEDICATION NAME] related to resident 68's "respirations were in the toilet with apneic events of 10-20 seconds per minute." LPN 2 stated that at the beginning of her shift, she rated resident 68's pain between an 8 or 9 using a pain scale of 1-10. LPN 2 stated that resident 68's pain would be "beyond a 10" with any readjustment or repositioning. LPN 2 stated that she did not call resident 68's family as another facility licensed nurse was communicating with them. LPN 2 stated that resident 68 was sent to the emergency room for treatment of [REDACTED]. LPN 2 stated that she administered [MEDICATION NAME] to resident 68 at approximately 12:05 PM, before resident 68 was transferred out of bed. (Note: On 8/15/13 at 5:02 PM, the facility provided a written statement from LPN 2 who stated, "Resident appeared uncomfortable (FLACC (The Face, Legs, Activity, Cry, Consolability scale is a measurement tool used to assess pain for nonverbal indicators of pain) of 2-4 (mild to moderate pain) throughout the morning) but was resting (and) sleeping throughout the morning. Residents resp were as low as 10 per minute (and) she was having 1-2 apneic events per minute, each [MEDICATION NAME] 10-20 seconds. Resident had been given her scheduled [MEDICATION NAME] (with) her AM meds, her PRN (as needed) [MEDICATION NAME] was not given due to her low respiration status (and) because she appeared to be uncomfortable but not in severe pain while resting. Resident did appear to experience increased pain while being repositioned (FLACC of 5-6), she returned to her resting state shortly after being repositioned. Resident was not moved unless needed, to aid in comfort by helping her keep her hip in alignment to reduce unnecessary pressure/strain..." LPN 2's written statement was inconsistent with the interview that was conducted on 8/1/13.) On 8/1/13 at approximately 1:30 PM, CNA 1 was interviewed. CNA 1 stated that resident 68 was walking down the hall to go to the dining room when she fell just outside of her room. She stated that resident 68 was "screaming and yelling" out. CNA 1 stated that she attempted to help (Registered Nurse 3) assist resident 68 to a sitting position after her fall, but was unable to do so as the resident was "crying out and screaming." CNA 1 stated that resident 68 was transferred from the hallway to her bed with the use of a sheet. CNA 1 stated that resident 68 continued to yell and scream out in pain. CNA 1 stated that resident 68 was "screaming out" and in "a lot of pain" when she was getting the x-rays. CNA 1 further stated resident 68 appeared to be in "pretty bad shape" at approximately 2:00 PM. On 8/1/13 at 2:00 PM, resident 68's daughter was interviewed. Resident 68's daughter stated that the facility discussed with the family their options for resident 68's treatment after she sustained a [MEDICAL CONDITION] on 7/27/13. Resident 68's daughter stated that the family was "struggling" and was "not really sure" about how to treat resident 68. Resident 68's daughter stated that she was told by the facility ADM and Owner, that it was a "family decision" to make and that (they) were given three choices: (1) Send (resident 68) to the hospital for surgery; (2) Place (resident 68) back on hospice; or (3) Keep (resident 68) at the facility and keep her comfortable. Resident 68's daughter stated that resident 68 was in "severe" and "agonizing" pain when she left the faciity on [DATE] at approximately 8:00 PM. On 8/1/13 at 2:20 PM, the facility Director of Nursing (DON) was interviewed. The DON stated that the facility policy for managing pain included assessing where the pain was located, the severity of the pain, the administration of ordered pain medication and to follow up approximately 30-45 minutes after the pain medication was administered. The DON stated that if the pain was not resolved, the facility licensed nursing staff would be required to notify the primary care physician for additional orders. The DON stated that she did not receive any phone calls from the licensed nursing staff that resident 68's pain was uncontrolled and that the [MEDICATION NAME] could not be administered related to the low respirations. The DON stated that if she had been notified, she would have had resident 68 sent to the hospital for treatment. On 8/1/13 at 2:48 PM, the facility Owner, who also functioned as the Business Office Manager (BOM) was interviewed. The BOM stated that she spoke to resident 68's daughter on 7/27/13 at approximately 2:48 PM. The BOM stated that the family was unsure of "what they (the family) were going to do" regarding the treatment of [REDACTED]. She stated that she reassured the daughter that resident 68 would receive pain medications as ordered by the physician. The BOM stated that she was asked by resident 68's daughter for her "non-expert" opinion and told the daughter that it was "100% up to the family" as to what they wanted to do. The BOM stated that she re-enforced to the daughter that resident 68 could be placed on hospice, have palliative care, or go to the hospital for surgery. The BOM stated that the family had requested to keep resident 68 comfortable through the night and that the family would make a decision about treatment the following morning. The BOM further stated that she instructed the facility staff to turn and reposition the resident every hour and to provide incontinence care as needed. On 7/28/13 at 10:16 AM, the BOM reported that she received a call from the family notifying the facility that they (the family) were going to have resident 68 evaluated at the hospital. The BOM stated that the family reported that resident 68 was "awful and in a lot of pain with treatments." (Note: Review of the hospital records revealed that resident 68 was admitted to the hospital with [REDACTED].)

Based on interview, observation and medical record review it was determined that the facility failed to properly provide supervision to residents with known special needs, provide interventions for residents who have had falls which have resulted in significant injuries, and to secure physical hazards (razors) from residents who are at risk of using the hazard to harm themselves or others. (Residents 3, 7, 34, 35, and 57) The deficient practice identified for residents 34 and 35 was found to have occurred at an Immediate Jeopardy level, in addition to the unsecured razors found on the facility's Special Needs Unit. The deficient practice identified for residents 7 and 57 was found to have occurred at a harm level and will not be included in the Immediate Jeopardy. The deficient practice identified for resident 3 was found to have occurred at a potential for harm and will also not be included in the Immediate Jeopardy. Review of resident 35's closed and current medical records revealed that resident 35 experienced 11 documented cigarette burns over an 11 month period. The only documented intervention in the medical record was to encourage resident 35 to wear a "smoking apron." No documentation could be found to show facility staff provided additional supervision or interventions to prevent the cigarette burns. No documentation could be found to show facility staff assessed resident 35 for safe smoking or followed the facility's "Safe Smoking Policy" provided to survey staff. On 8/31/11 resident 35 was admitted to a local hospital and received treatment for [REDACTED]. Review of the medical record and incident report log revealed that resident 35 experienced 49 falls over a 12 month period. Resident 35 had 6 significant injuries that occurred during the falls including head lacerations, a skull fracture, a fractured clavicle, and displaced hardware in the clavicle. Facility staff did not implement effective interventions to prevent falls when resident 35 returned to the facility following the surgical repair of her right clavicle. Due to additional falls, the surgically placed hardware in resident 35's right clavicle became dislodged and the resident underwent [REDACTED]. Review of resident 34's closed and current medical records revealed that resident 34 experienced 6 documented cigarette burns over a 9 month period. The only documented intervention in the medical record was to encourage resident 34 to wear a "smoking apron". No documentation could be found to show facility staff provided additional supervision or interventions to prevent the cigarette burns. No documentation could be found to show facility staff assessed resident 34 for safe smoking or followed the facility's "Safe Smoking Policy." Review of the medical record and incident report log revealed that resident 34 experienced 35 falls over a 10 month period. Resident 34 experienced 4 significant injuries as a result of the falls. The injuries included head lacerations, an ankle fracture, a fibular fracture, and a clavicle fracture. No documentation could be found to show facility staff instituted additional interventions to prevent injuries from future falls, other than "increased supervision." Observations on 9/24/11, 9/25/11, 9/26/11, and 10/4/11 revealed unsecured new or used razors left in resident bathrooms on the secured unit. Many of the residents residing on the secured unit have confusion, delusions, impulsiveness, and physical aggression. Multiple staff members when interviewed stated that residents on the secured unit were to be assisted by staff when shaving and that the razors were to be discarded after a single use. The staff members stated that razors were not to be left unattended or unsecured in the secured unit because residents could harm themselves or others. Review of resident 7's current medical record revealed that resident 7 sustained an injury of unknown origin resulting in a fractured humerus. Facility staff assessed resident 7 as requiring full assistance with Activities of Daily Living and that resident 7 was unable to perform any transfers or daily cares without facility staff assistance. Facility staff obtained an x-ray of resident 7's arm and then waited two days to notify the physician of the results of the x-ray resulting in a delay of treatment of [REDACTED]. Review of resident 57's closed and current medical record revealed that resident 57 was identified as being at a risk for falls and sustaining falls. Facility staff implemented no interventions to prevent injuries from future falls. Review of the medical record revealed that resident 57 experienced a fall 5/30/11, facility staff did not report the fall or complete a facility incident report. On 6/2/11 facility staff assessed resident 57 as having difficulty with ambulation and acitivities of daily living and thus ordered an x-ray. The results of the x-ray revealed that resident 57 had sustained an acute Left hip fracture that required surgical intervention. Observations of resident 3 revealed facility staff had implemented side rails for resident 3 with a mattress that did not fit the bed frame. This placed resident 3 at a risk of becoming trapped between the side rails and the bed frame. No documentation could be found to show that facility staff assessed resident 3's bed for safety or resident 3 for safety with the side rails. NOTICE: Notice of immediate jeopardy was given verbally to the Administrator on 9/29/11 at 3:30 PM. The Administrator was asked to develop an immediate plan to ensure resident safety related to accidents and supervision to prevent accidents. PLAN: On 10/5/11 at 4:00 PM, the Administrator provided the surveyors with a written plan of action to remove the immediate jeopardy to residents in the facility. The written plan dated 10/5/11 at 4:00 PM stated the following: "Mountain View Health Services, 5865 South Wasatch Drive, South Ogden, UT Please accept this correspondence as my letter that Mountain View Health Services is alleging that the facility has abated the Immediate Jeopardy to resident health or safety as of October 5, 2011. . . Accident Hazards: Fall prevention: Facility has done a 100% review of all resident falls within the past 90 days. Fall risk assessments were updated for all residents who experienced a fall; care plans were updated with appropriate interventions noted. The facility will continue with 100% reviews of all falls, in periods of 90 days each, going back one full year. Falls policy has been reviewed and revised. A 'Post fall Procedures/Management' portion has been examined, reviewed, and revised. Note specific steps facility will take after a fall, in section B of this section, steps 1 thru 6. Incident reports continue to play an integral role in documenting falls, assessing resident, etc. and review of Incident Log will play a bigger part in care plan review. Another part of the falls policy, include assessment of the physical environment. The maintenance department has done 100% inspection of resident rooms- these are found on "Attachment F" under the falls category. A significant, systemic change in communication of care plan issues, has also been implemented. A 'C.N.A Communication Sheet', is placed inside each resident's bedroom closet. This 'point of care' sheet give information regarding SAFETY and other important issues, as a guide for the C.N.A's to follow. Safe smoking: Continuing under Accident Hazards, the "Safe Smoking" issue has been thoroughly examined. Facility reviewed and re-vamped the smoking policy itself. Based on the smoking policy, a 'Resident Smoking Safety Assessment' has been reviewed and revised. All resident who currently smoke, were re-assessed. Based upon those assessments, the next step was looking a (sic) specific smoking contacts (sic) with the residents. The revised smoking contracts-both for Supervised Smokers, and Unsupervised, were reviewed and discussed with all smoker, by Social Services, and residents signed new contracts. Also based on the Smoking Assessments, 'Tobacco Use Care Plans' were individualized and implemented. Social Services met with each Resident who smokes. She discussed issues regarding smoking safety, and each person sign the new contracts. In-service training was held for direct care staff, regarding smoking safety; smoking oversight; appropriate safety interventions; and other smoking-related issues. Facility implement (sic) 'smoking oversight' monitoring by department head managers, nurses and other non- C.N.A staff, to help in the assessment of safe smoking, and to help implement changes regarding smoking safety. On part of note, is that supervised smokers are now required to wear 'smoking aprons', for improved smoking safety. While nearly all residents have willingly agreed to wear the aprons, there are of course some who refuse to wear them. For those who refuse to wear them, the Care Plan Team will work with them to care plan safety issues, and help educate them on smoking safety. Razors: The issue regarding unattended, single-use razors used on the Special Needs Unit, 'Memory Lane', have been addressed in the following fashion. The first approach was not entirely successful. The approach included staff training and education regarding razor safety; walk-through inspections; discussions about locking cabinets and rooms where razors are kept; and so forth. The team then re-grouped and discussed the issue. It was decided to implement a more controlled-access to razors policy. For people living on Memory Lane, the direct care staff must now ask the Charge Nurse for a razor, and 'sign-out' each individual razor. The razor must then be signed back-in with the charge nurse, and disposed of at the sharps container at the nurse's cart. Daily inspections of Memory Lane will continue for the next 30 days, to help ensure compliance, and to monitor progress. Increased supervision The facility has implemented measures to help in the questions regarding increased supervision. They include: One of the identified residents, received hourly checks by BOTH the C.N.A, and the Charge Nurse. Staff was educated that increased supervision included checking on clients at risk, on a more frequent basis. The concept of increased supervision was also implemented in oversight on the supervised smoking program. The increased supervision in this particular area, has spawned additional training for staff on appropriate interventions to take to help smokers stay as safe as possible while they smoke. For example, even though a resident may be wearing a smoking apron, it may need to be repositioned while the resident is smoking. Prior to leaving the facility on 10/6/11, the surveyors confirmed the components outlined above in the written plan of action had been implemented. During the survey on 10/6/11 the surveyors confirmed removal of the immediate jeopardy situation as of 10/5/11. Deficient practice with actual harm and potential for more than minimal harm remained for the risk of injury. Findings Include: Immediate Jeopardy: A: Resident 35 Resident 35 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/22/11 resident 35's current and closed medical record were reviewed. Review of the Minimum Data Set (MDS) revealed an annual MDS assessment dated [DATE]. Facility staff assessed resident 35 as requiring extensive assistance with a one person physical assist with walking within the resident's room and walking in the corridor. Facility staff assessed resident 35 as requiring limited assistance with a one person physical assist with transfers, locomotion on and off the unit and personal hygiene. Resident 35 was assessed as being not steady and only able to stabilize with human assistance with moving from a seated to standing position, walking, turning around, moving on and off of the toilet, and surface to surface transfer (transfer between bed and chair or wheelchair). Facility staff assessed resident 35 as having 2 or more falls with no injury, two or more falls with an injury (skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall-related injury that causes the resident to complain of pain), and one major injury from a fall during the assessment period. Facility staff indicated on the annual MDS that the Care Area Assessment (CAA) for falls and ADL (Activities of Daily Living) function triggered and would be addressed in a care plan. On 5/18/11 facility staff completed a quarterly MDS for resident 35. Facility staff assessed resident 35 as having burns (2nd or 3rd degree) during the assessment period. Resident 35 was also assessed as having two or more falls with no injuries, and two or more falls with injury but not a major injury. On 8/18/11 facility staff completed a significant change MDS assessment for resident 35. Resident 35 was assessed as requiring extensive assistance with a one person physical assist with walking in the room and corridor, locomotion on and off the unit, dressing, toilet use, and personal hygiene. Facility staff assessed resident 35 as requiring limited assistance with a one person physical assist with transfers. Facility staff assessed resident 35 as being not steady, only able to stabilize with human assistance with moving from a seated to standing position, walking, turning around, moving on and off of the toilet, and surface to surface transfer. Resident 35 was assessed as having two or more falls with no injury, two or more falls with an injury and no major injury during the assessment period. Facility staff also documented that resident 35 had burns of a 2nd or 3rd degree nature. Review of resident 35's medical record revealed a fall risk assessment dated [DATE] with a score of 14, 6/29/10 with a score of 14, 3/4/11 with a score of 25, 5/20/11 with a score of 27 and 8/29/11 with a score of 30. According to the fall risk assessment used by the facility a score of 10 or higher indicated the resident was at a high risk for falls. No fall risk assessment score was completed for the readmission of resident 35 on 9/7/11. As of 9/22/11 the fall risk assessment score had not been completed for resident 35. Review of the care plan revealed a care plan for falls dated 6/24/10 and updated or signed as being updated on 9/17/10, 12/8/10 and 8/9/11. Facility staff documented that resident 35 had a history of [REDACTED]. ambulation ability to be a wheel chair. Staff documented that the goals for the problem area identified (falls) were; "pt. (patient) to remain injury free during facility stay, pt. to have no falls unreported to MD (Medical Doctor) during facility stay, staff and pt. to practice injury prevention measures for pt. during facility stay and to evaluate every monthly summary and every pt. IDT (Interdisciplinary Team Meeting)." The goals, to be accomplished by facility staff were, "maintaining a safe environment, keep room clutter free; clean spills, keep room well lit, call light in reach at all times- respond promptly, assist with all transfers, PT (Physical Therapy) to screen quarterly and prn (as needed), if fall occurs- ensure safety VS (vital signs), neuro checks, ROM (range of motion) assess for injuries, determine cause, report fall to MD and family, assess X 3 days and document after every fall with injuries until stable, encourage resident to wear helmet and to call for assistance, and remind resident to put helmet on." Review of the closed medical record revealed a Fall Risk Care plan dated 8/29/11. Facility staff documented that resident 35 had a history of [REDACTED]. The goal of the care plan was, "Pt. will receive adequate supervision and assistance every day to help prevent falls, evaluate every monthly summary and every IDT and resident refuses at times to wear helmet." Interventions to accomplish the goal were documented as follows: "assess current abilities and risk factors for potential falls, use adaptive/safety equipment as necessary and ordered, assess resident as needed to prevent falls, skilled or restorative therapies as ordered to increase ROM and maintain abilities, monitor and document changes in abilities or conditions which may lead to falls, keep environment clear of obstructions, floors dry, well lit, etc., assess resident to assist physician to determine cause: vital signs, appetite, recent relocation, possible hearing or vision losses, change in LOC ( Level of consciousness), medications, recent labs, call light accessible at all times when in room, Fall Risk Assessment quarterly, increase supervision PRN, and encourage pt. to wear helmet when up - assist with putting helmet on/off." On 9/22/11, when resident 35's current medical record was reviewed, no documentation could be found to show facility staff developed or implemented a care plan for resident 35's history of falls upon her readmission to the facility, on 9/7/11, after sustaining a fractured clavicle from a previous fall at the facility. On 9/22/11 the facility's "Resident Supervised Smoking Policy" was reviewed. According to the facility policy, dated 6/30/10, the purpose of the smoking policy was to "Regulate smoking procedure for comfort and safety of the residents." The facility also provided a copy of the "Independent & Unsupervised Smoking Policy." According to the policy, the facility "attempts to allow eligible individuals the right to smoke in an independent and unsupervised manner, IF they meet specific criteria. The criteria are based upon the Smoking Assessment and Associated Rules. People who do not meet the criteria are NOT eligible to smoke independently and fall under the guidelines of the Supervised Smoking Policy. ... The smoking assessment is completed by the Interdisciplinary Team (IDT), and is subject entirely to their approval. Smoking Assessment and Associated Rules: Resident has no behavior or condition (medical or otherwise) which negatively impacts the ability to safely smoke independently., Resident is taking no medications, or combination of medications, which impairs their ability to smoke safely in an unsupervised setting., Resident may not use oxygen anywhere near smoking area., Resident possesses appropriate manual dexterity to control smoking materials., resident can recite basic limitations of 'Supervised Smoking' criteria., Resident follows appropriate safety precautions regarding smoking., Resident agrees to not give smoking materials to any Resident in the Supervised Smoking program., Resident will smoke ONLY in the designated smoking area., Resident keeps personal smokes in a safe area. ..." At the bottom of the policy was a place for the resident's signature indicating that the resident had read the policy and agreed to the terms of the policy. According to the "Resident Supervised Smoking Policy", "CNA (Certified Nursing Assistant) staff will supervise smoking; and are to remain with residents at all times during the supervised smoke break." At the bottom of the "Resident Supervised Smoking Policy" was a place for the resident's signature indicating that the resident had read the policy and agreed to the terms of the policy. No documentation could be found in resident 35's closed or current medical record to show that resident 35 was assessed for safe smoking by the IDT, signed the "Supervised Smoking Policy", or received a copy of the "Supervised Smoking Policy." On 11/6/10, facility staff documented on an incident report that facility aides were to use a smoking apron for resident 35 while she smoked. No other documentation could be found to show facility staff implemented other interventions regarding the cigarette burns resident 35 sustained. Review of the nurse's notes in the closed and current medical record revealed the following entries. Nurses Notes: a) 9/11/10: "Pt. in ice cream room, stood up and fell on bum. ... No c/o (complaints of) pain. ..." b) 9/18/10: "Burns on fingers seem to be healing well." c) 10/10/10: "Resident slid out of chair in hallway while maneuvering her w/c (wheel chair). No injuries noted. .." d) 10/20/10: "Pt. has what appears to be a cigarette burn on her R (right) middle finger - which has blistered. Her R little finger is swollen. pt. reports that it hurts, but is not sensitive to touch or pressure on her finger." e) 10/23/10: "Pt. fell out of wheel chair in the 200 hall. ... No apparent injuries. ..." f) 11/9/10: "Pt. has burns on L (left) chest and R thigh. Found 11/6/10 on skin checks. Aides reminded to use cigarette apron." g) 11/10/10: "Pt. has a new cigarette burn on R middle finger." h) 12/1/10: "Resident fell in front of CNA. ..." i) 12/3/10: "Lat (sic) entry no problems noted from fall." j) 12/6/10: "CNA reported to me that pt was attempting to sit on bed when she sat 1/2 off 1/2 headboard (sic), causing her to fall to the R hitting her head." k) 12/11/10: "Pt. found on floor." fall l) 12/18/10: "Pt. fell out of bed and against side table in room. She hit L ear and ear is red." m) 1/2/11: "Pt. was in bistro at ice cream machine when she fell back hitting back of head." n) 1/6/11: "Pt. was fof (found on floor) in the bistro fell in the ice cream (sic) no injuries..." o) 1/7/11: "Pt. was fof in Bistro while standing fell on floor. ..." p) 1/25/11: "R thumb cleaned and dressed d/t (due to) previous cigg. (cigarette) burn. ..." q) 2/17/11: "@ 0800 (8:00 AM) aide went into get pt. up, she started brushing her hair when she found that the pt had a laceration on the back of her head. She was bleeding. the wound appeared fresh. it is unknown exactly when she fell or what happened. ... pt. was sent to (local hospital) for eval and suture of laceration. ... pt. returned to facility @ 1130 (11:30 AM). pt. had simple skull fracture and staples placed. ..." r) 3/1/11: "@ 900 this am pt fell out of w/c onto her knees. ..." s) 3/3/11: "At approx (approximately) 1740 (5:40 PM) pt. wheeled self into MDR (Main Dining Room) when it was noticed that she blood (sic) running down face et (and) hands after cleaning blood she had a 1/2 in (inch) lac (laceration) above R eye a pressure drsg (dressing) was applied et passed on to next nurse to apply steri strips. ..." t) 3/26/11: "@ 1345 (1:45 PM) pt. was going to sit in w/c after standing in icecream parlor, when she fell back onto her bum ..." u) 4/5/11: "Pt. was fof lying on L side with w/c tipped on L side did not hit head was wearing helmet. ..." v) 4/16/11: "Pt. fell in ice cream parlor. fell on to knees and bum. Pt. reopened sore on L knee. ..." w) 4/19/11: "pt. was sitting back into w/chair (wheelchair), when the w/c moved and she fell back onto her bum pt. was wearing her helmet. and did not hit her head. ..." x) 5/4/11: "@ 1400 (2:00 PM) pt. fell in room onto bum. Pt. was wearing helmet. ..." y) 5/22/11: "Pt. went to stand up out of wc (wheel chair) falling face forward. Pt. wearing helmet at this time. ..." On 5/22/11 later in the day staff documented that resident 35 refused to wear her helmet. NOTE: This was the first mention in the charting of resident 35 refusing the helmet. z) 6/1/11: "Resident has an unwitnessed burn on her thigh. ..." aa) 6/2/11: "...resident has burned herself X 2 (times 2) with a cigerette (sic). ..." bb) 6/6/11: "... found circular red 1st stage scab on upper abd. (abdomen)." cc) 6/14/11: "Wear apron to avoid cig burns. ..." dd) 6/28/11: "Resident alert, up in Restroom; slipped forward knocked old scab off R elbow; hit her head. She was wearing helmet. ..." ee) 7/11/11: "@ 1100 smoke break, pt. fell on to grass. ..." ff) 7/12/11: "Pt. went to sit in w/c et (and) missed fell to floor was wearing helmet has a lg (large) blister on inner R thigh it has not popped so left it alone." gg) 7/28/11: "Resident was seen standing up out of w/c, went to sit back down and missed the w/c and sat on the floor. ... Reminded resident to get help before standing up out of w/c. ..." hh) 7/31/11: "... pt. stood up and fell forward. pt. wearing helmet @ time of fall. ..." ii) 8/1/11: " Pt. fell while walking in room. No injuries seen. ..." jj) 8/11/11: "R upper lip has small cut. ... cause unknown. ..." kk) 8/11/11: "Pt. has a small area noted on R side hip area - may possibly be a burn? ... pt. also has an area on L middle finger, very red. ... Aids (sic) state areas have been present for several days. ..." ll) 8/12/11: "... Pt. fof during banking. ..." mm) 8/14/11: "Pt. fell @ 1230 (12:30 PM) in ice cream bistro. fell on to L side. was wearing helmet. ..." nn) 8/15/11: "Pt. fell wheeled herself to MDR with blood dripping down forehead. Pressure applied ... left facility at 1315 ( 1:15 PM) to (local hospital). ..." oo) 8/17/11: "Pt. @ approx. 1240 (12:40 PM) was running up the hall when she fell against wall by vending machine et slid down wall. ..." pp) 8/22/11: "Per CNA, CNA heard a loud noise, under investigation. resident was seen on her buttock in bathroom. ..." qq) 8/22/11: "Pt. fell on to bum @ 1300 (1:00 PM) in icecream room. ... and in hallway onto bum @ 1500 (3:00 PM). ..." rr) 8/24/11: "Pt. fell at 1420 (2:20 PM). Fall was unwitnessed heard a loud noise. Nurse/CNA found pt on floor in room. Pt. has deformity of R clavical (sic). pt sent to hospital. ..." NOTE: X-ray results, dated 8/24/11, showed a Right clavicle fracture. ss) 8/27/11: "... @ 1145 (11:45 AM) pt fell while trying to walk to bathroom. Pt. fell back onto bum. pt. wearing helmet. ..." tt) 8/30/11: "Heard a loud bang from the nuses (sic) station. CNA found Resident on floor. ... neuro checks started d/t not knowing if Resident hit head. ..." uu) 8/30/11: "Res. (resident) FOF in bathroom. No apparent injury. Helmet was on. ..." Per documenation on the local hospital's History and Physical, resident 35 was admitted on [DATE] and was treated for [REDACTED]. The following Nurse's Notes entries were documented after resident 35 was readmitted to the facility on [DATE]. (Note: Review of the medical record on 9/22/11 revealed facility staff had not completed a Fall Risk Assessment score, assessed resident 35's risk for falls, nor implemented interventions to prevent falls upon her readmission to the facility.) Nurse's Notes: a) 9/11/11: "@ 1715 (5:15 PM) Pt. fell again tonight. Flung back in w/c and slid out of chair onto floor. Helmet in place. ..." b) 9/12/11: "Pt. found screaming in room this am @ 645 (6:45 AM). Pt. lying on floor part way under bed. ... Pt. placed in w/c several times this am, and pt would continually slide out onto bum. ... Shoulder incision raised, warm. ..." c) 9/13/11: "Resident fell from bed to floor, hitting her bum. ... Resident reminded and shown how to use call light when she needs help. Unable to remember and uncooperative with using call light. ..." d) 9/14/11: "Pt. flinging around in bed yelling unable to understand pt. Found pt. on floor lying on back with legs on bed. ..." e) 9/15/11: "Pt. yelling, thrashing around. Found on floor. New orders for low bed. ..." f) 9/15/11: "Pt. yelling and on the floor multiple times through NOC (night). ..." According to nurse's notes, on 9/16/11, resident 35 was moved to the facility's Special Needs Unit and placed into a carpeted room with mattresses placed on the floor. It was documented by facility staff that resident 35 would receive increased supervision with the placement of resident 35 into the Special Needs Unit. Review of documentation revealed that on 9/22/11 resident 35 underwent surgical removal of the hardware placed in her right clavicle due to the hardware becoming displaced. According to Nurse's Notes documentation resident 35 experienced 35 falls prior to her hospitalization , between 9/11/10 and 8/31/11, and 6 falls after readmission to the facility on [DATE]. Facility staff documented that resident 35 experienced 5 significant injuries either from a fall or unknown cause. Additionally, Nurse's Notes documentation revealed that resident 35 sustained 10 cigarette burns between 9/18/10 and 8/11/11. Review of the facility Incident Report Log revealed the following Incident Reports and documented interventions: a) 9/11/10: "Pt. was in ice cream parlor room when she stood up and fell on her bum." No, "Additional comments and or steps taken to prevent recurrence:" was documented. b) 10/10/10: "Slid out of chair (w/c) while in hallway. Cont. (continue) to monitor. Encourage resident to voice needs." c) 10/23/10: "pt. was wheeling down the hall quickly when she fell out of her wheelchair landing on her side. pt. encouraged to slow down." d) 11/6/10: "Pt. has cigarette burns on L chest and R thigh. Found on Saturday 11/6/10. Make sure resident wears cigarette apron when smoking." e) 11/12/10: " New cigarette burn on R middle finger. Found @ this time. Not sure when occured (sic)." No, "Additional comments and or steps taken to prevent recurrence:" was documented. f) 12/1/10: "Went into her room. Aide saw her stand and then slide down and sat on her bottom - No injury -" No, "Additional comments and or steps taken to prevent recurrence:" was documented. g) 12/7/10: "CNA reported to me that pt. went to sit on bed she missed 1/2 on 1/2 off the head of the bed making her fall hitting her head et. elbow skin is still intact. Remind pt. to get help with transfers." h) 12/12/10: "Pt. was found on floor by CNA ... Encourage resident to stay in chair and ask for help when wanting to walk around out of chair." i) 12/18/10: "Not witnessed pt. said she fell and hit L ear on side table in room while getting out of bed. No deficits noted. L ear is red." No, "Additonal comments and or steps taken to prevent recurrence:" was documented. j) 1/2/11: "Pt. was in Bistro standing up and fell straight back hitting back of head. ... Pt. needs to be reminded to have brakes in place prior to standing up." k) 1/6/11: "Pt. was in Bistro pt. was found on floor slipped in ice cream that was on the floor." A Question Mark was placed in the "Additional comments and or steps taken to prevent recurrence:" section. l) 1/7/11: "Pt. standing getting herself ice cream when she went to sit down sat on floor. ... Reminded pt. to apply brakes prior to standing." m) 1/17/11: "Pt. was in 305 bathroom when she reportedly hit her head and fell . She was found by aide. ... Increase supervision." n) 1/17/11: "Pt. fell while outside in smoking area. The fall was unwitnessed as aide was taking other residents inside. pt. fell on to R side and appears to have fallen on the grass. ... Increase supervision, Encourage her to wait for help in from smoking." o) 1/23/11: "Reported to staff that pt. fell . Went down to room pt. was up getting in w/c. Bystanderd (sic) state she did not hit head. reminded pt. to ask for help when getting out of w/c." p) 2/10/11: "Resident stood up from her chair and lost her balance and hit the L side and tore off scab on L knee. ... Reminded resident to wait for help before standing." q) 2/17/11: " CNA found pt. in room - when doing her hair she found blood and a cut on the back of her head. it is unknown when she fell or how she fell . Increased supervision - Pt. fell in bathroom in early am and went back to bed. Encouraged to use call light and wait for assistance." r) 3/1/11: "While wheeling herself outside for smoke break, pt. fell out of her wheelchair onto

Based on observations, interviews, and record review, the facility did not ensure that a resident received the necessary treatment and services to prevent aspiration pneumonia and/or vomiting. This failure created a situation of immediate jeopardy which had a potential for causing death or injury to a resident in the facility. Resident identifier: 17. NOTICE: Notice of immediate jeopardy was given verbally to the Administrator on 9/29/11 at 3:30 PM. The Administrator was asked to develop an immediate plan to ensure resident safety related to enteral feedings with appropriate assessments and positioning during feedings. PLAN: On 10/5/11 at 4:00 PM, the Administrator provided the surveyors with a written plan of action to remove the immediate jeopardy to residents in the facility. The written plan dated 10/5/11 at 4:00 PM stated the following: "Mountain View Health Services, 5865 South Wasatch Drive, South Ogden, UT Please accept this correspondence as my letter that Mountain View Health Services is alleging that the facility has abated the Immediate Jeopardy to resident health or safety as of October 5, 2011. . . Positioning during tube feedings, and assessment of aspiration The '[MEDICATION NAME]/Enteral Feeding Policy' was reviewed and revised, as was the 'Procedure' regarding such. In-service training was specific for the identified client -- the only client currently receiving enteral feedings. It included placement in a safe chair, wheelchair, recliner -- NOT in his bed. The training emphasized correct positioning. And because the client himself likes to 'scoot down' during feedings, the treatment plan for him is to receive 1:1 care throughout the feeding. Staff was trained to intervene, and help re-position him throughout the feeding. Because he usually receives 3 feedings per day, the facility has assessed and revised the staffing level on the nursing unit where he resides. The Hospice company that follows the identified resident, is also working with the facility in providing additional staffing to help with monitoring during his enteral feedings." Prior to leaving the facility on 10/6/11 the surveyors confirmed the components outlined above in the written plan of action had been implemented. During the survey on 10/6/11, the surveyors confirmed removal of the immediate jeopardy situation as of 10/5/11. Deficient practice with potential for more than minimal harm remained for the risk of injury. Findings include: Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations of resident 17 were made as follows: a) On 9/24/11 from 10:00 AM to approximately 12:00 PM resident 17 was observed in his bed, receiving an enteral feeding via a gastrostomy tube. The enteral feeding was infusing, via pump at 240 milliliters (ml) per hour. Resident 17 was observed to be in a low bed with a pillow placed between the bed mattress and bed frame. This pillow was used to raise the head of the bed. However, resident 17 had slid down in bed and was positioned so that his feet extended over the mattress and his stomach and torso were flat. (NOTE: resident 17 was not positioned at a 30 degree angle per the feeding tube care plan and hospice nurse education to facility staff.) b) On 9/25/11 from 4:00 PM to 5:30 PM resident 17 was observed to be in his recliner, receiving an enteral feeding via a gastrostomy tube. The enteral feeding was infusing, via pump at 250 ml per hour. Resident 17 had slid down in his wheelchair and was positioned so that his stomach and torso were at an angle of less than 30 degrees. c) On 9/26/11 from 2:00 PM to 3:00 PM resident 17 was observed to be in his bed with his enteral feeding infusing. Resident 17 was observed to be in a low bed with a pillow placed between the bed mattress and bed frame. This pillow was used to raise the head of the bed. However, resident 17 had slid down in bed and was positioned so that his feet extended over the mattress and his stomach and torso were flat. (NOTE: resident 17 was not positioned at a 30 degree angle per the feeding tube care plan and hospice nurse education to facility staff.) d) On 9/27/11 from 10:00 AM to 11:00 AM resident 17 was observed to be in his bed with his enteral feeding infusing. Resident 17 was observed to be in a low bed with a pillow placed between the bed mattress and bed frame. This pillow was used to raise the head of the bed. However, resident 17 had slid down in bed and was positioned so that his feet extended over the mattress and his stomach and torso were flat. (NOTE: resident 17 was not positioned at a 30 degree angle per the feeding tube care plan and hospice nurse education to facility staff.) e) On 9/28/11 at 9:30 AM Registered Nurse (RN) 1 was observed to enter resident 17's room. Resident 17 was observed to be in a low bed with a pillow placed between the bed mattress and bed frame. This pillow was used to raise the head of the bed. However, resident 17 had slid down in bed and was positioned so that his feet extended over the mattress and his stomach and torso were flat. RN 1 initiated resident 17's enteral feeding, however, did not reposition the resident prior to initiating the feeding. Resident 17 was then observed to remain with his stomach and torso in a flat position until 11:40 AM. (NOTE: resident 17 was not positioned at a 30 degree angle per the feeding tube care plan and hospice nurse education to facility staff.) Resident 17's medical record was reviewed on 9/26/11. Resident 17's History and Physical from the hospital dated 6/13/11 documented that resident 17 had a history of [REDACTED]. The document further stated that resident 17 "has been a known aspiration risk for many months." Resident 17's History and Physical from the hospice company dated 6/30/11 documented that resident 17 had experienced "recurrrent episodes of aspiration pneumonia. The patient is now completely bed bound . . .in the last 6 months, the patient has had a very significant decline with greater than 5 aspiration pneumonias." Resident 17's admission physician orders [REDACTED].!" Resident 17's Activities of Daily Living Care Plan dated 6/28/11 documented that resident 17 required total dependence on staff for bed mobility and transfers. The care plan also documented that resident 17 needed to be checked for repositioning and safety during rounds and as needed. A "Feeding tube care plan" dated 7/11/11 documented that resident 17 was at "risk for aspiration". The care plan listed that facility staff should elevate the head of resident 17's bed at least 30 degrees during feeding to prevent aspiration. A physician's progress note dated 7/15/11 documented that resident 17's lungs were clear. Resident 17's Enteral Documentation Record signed by resident 17's physician for the month of September 2011 documented that resident 17 needed to have the head of his bed elevated 30 degrees during the administration of the tube feeding. Resident 17's nurses notes from facility staff and hospice documented the following: a) Facility - 7/28/11 - Resident 17 had dark emesis. (NOTE: No evidence could be found to show the facility staff notified the physician or provided interventions to prevent further episodes of emesis.) b) Hospice - 8/9/11 - Resident 17 was lying on the floor with his tube feeding infusing. The hospice nurse educated facility staff and spoke with the Director of Nursing (DON) concerning resident 17 being on the floor without the head of his bed being elevated while the feeding was infusing. The hospice nurse instructed staff to acquire a temperature and monitor resident 17's cough. c) Hospice - 8/16/11 - Resident 17's hospice nurse educated facility staff on keeping the head of resident 17's bed elevated while his tube feeding was infusing. d) Hospice - 8/29/11 - Resident 17 was showing signs and symptoms of aspiration. e) Facility - 9/1/11 - Resident 17 was found to be "making noise" by staff and had vomited. Resident 17 was noted to be coughing. Resident 17 was moved up into bed and placed at a 45 degree angle. Vitals signs were done and resident 17's oxygen saturations were at 54% on room air. Staff applied oxygen, per nasal cannula at 5 liters. The nurse documented that 30 minutes later, staff checked on resident 17 and found 150 ml of fluid "pooring (sic) out" of the resident spontaneously and by coughing. The nurse documented that resident 17 had experienced "possible aspiration" and that they contacted the family of resident 17 the next day to discuss placing resident 17 on antibiotics. No evidence could be found that facility staff provided interventions to prevent further episodes of coughing, emesis, or possible aspiration. f) Hospice - 9/6/11 - Resident 17 was lying in bed with the feeding infusing. g) Hospice - 9/8/11 - Resident 17 "appears to have no adverse effects from aspiration." h) Hospice - 9/12/11 - Resident 17 was lying in bed with the feeding infusing and was receiving antibiotics for signs and symptoms of aspiration. i) Facility - 9/14/11 - Resident 17 had experienced an episode of emesis and had possibly aspirated again. Facility staff subsequently held the tube feedings temporarily. j) Hospice - 9/19/11 - Resident 17 "has 'silent aspiration' likely from fdgs (feedings) being given while pt (patient) is lying down." k) Hospice - 9/27/11 - "aspirates on liquids, lungs have scattered rales". l) Facility - 9/29/11 - Resident 17 had experienced an episode of emesis. m) Facility - 9/30/11 - Resident 17 had experienced two episodes of emesis and had a temperature of 100 degrees Fahrenheit. n) Facility - 10/2/11 - Resident 17 had "coughed up" a dark colored substance and later a small dark chunk of blood. On 9/29/11, a telephone interview was held with resident 17's hospice case manager. The case manager stated that resident 17 had the gastrostomy tube due to past aspiration and that resident 17 continued to aspirate at the facility, and had received antibiotics in September 2011 for the pneumonia. On 9/26/11 at 2:40 PM an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 and the surveyors entered resident 17's room and observed resident 17 together. At that time, resident 17 was in his bed, in a flat position with the enteral feeding infusing. After the observation, CNA 1 was asked about resident 17's position in relation to his tube feeding. CNA 1 stated that resident 17 was in the appropriate position for his tube feeding.

Based on interview and record review it was determined that the facility failed to ensure that a resident had the right to manage his or her financial affairs. Specifically, one resident was denied full access to his funds to use, which caused psychosocial harm to the resident. Resident identifier 40. Findings include: Resident 40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An interview with resident 40 was completed at 11:00 am on 10/4/11. When asked about his personal funds account with the facility, resident 40 stated, "The Administrator is out to get me". Resident 40 further stated that the Administrator had a "grudge" against him and would not allow him to have any of his money. Resident 40 stated he had $500 in his account and the Administrator refused to allow him to have access. Resident 40 also stated that the Administrator had threatened the Activities Director (AD), about giving him money to spend, but that the AD sometimes went against the Administrator and provided him with a small amount of spending money. Resident 40 then stated "If it weren't for the (the AD) I would be . . out of luck." On 10/4/11 at 11:10 AM, resident 40 was observed in the hallway speaking to the AD. Resident 40 stated "he's (the facility Administrator) out to get me". Resident 40 was asked about his comment to the AD. Resident 40 stated that he had a prearranged shopping trip scheduled with the AD that day, but that the Administrator had told the AD that "now was not a good time". Resident 40 stated that he was out of cereal, milk and salami that he kept for snacks in his room. Resident 40 stated that he had deposited $500.00 into his personal funds account and that the Administrator would only allow him to have $4.75 at a time, and only on the scheduled banking days which were Monday, Wednesday and Friday. Resident 40 further stated that he had "supervised " banking and had to spend his $4.75 in the facility vending machine. Resident 40 stated again that the Administrator was "out to get him" and that the money issue had him "tied in knots". On 10/4/11 at 11:15 AM, the facility AD was interviewed. The AD confirmed she had arranged a shopping trip with resident 40 last week as she was unable to take him shopping the previous week. She stated that the facility Administrator had stated that "now was not a good time" to take resident 40 shopping. The AD further stated that resident 40 was only allowed to access $4.75 on banking days and that she was required to supervise resident 40 spending the $4.75 in the facility vending machine. An interview was conducted with the AD at 1:00 pm on 10/4/11. The AD stated that resident 40 had approximately $500 in his personal funds account. The AD then stated that resident 40 had previously gone to the gas station to buy beer and was found passed out in the field by the police; the Administrator took away resident 40's spending privilege because of this incident. The AD stated that the administrator had "Power of Attorney" over resident 40's funds. The AD stated she would give resident 40 small amounts of money, usually $2 to-$4 so he could buy soda and food from the vending machine. The AD stated that she did not like to withhold money from the residents and once in a while she would take resident 40 to the store and pay for the items to be purchased. She would then have the resident sign a slip of paper that stated how much money was spent. The money was then deducted from resident 40's account. The facility business office manager was interviewed on 10/4/11 at 1:45 PM. She stated that she did not know of any resident that had a restricted spending plan and that no resident had been denied access to his/her personal funds account. An interview was conducted with the facility Administrator on 10/4/11 at 3:00 PM. The Administrator stated that resident 40 has had multiple admissions to the facility and had been followed by a county agency for management of his personal funds. The Administrator stated that when resident 40 was admitted to the facility, the resident had requested the facility to be his representative payee. The facility was aware of resident 40's prior behaviors and had requested the resident sign a spending plan arrangement, which resident 40 had refused to sign. The spending plan agreement for resident 40, dated 8/3/11, was reviewed and included the following items: 1. Facility will apply for payee. 2. Resident 40 will make written requests for purchases. 3. Resident 40 may make the purchases himself; at supervised facility provided shopping trips; however staff will write the checks for the purchases. 4. Withdrawals from the Resident Bank will be limited to $2.00 or less, with staff oversight of vending machine purchases. The Social Services Worker (SSW) and SSW consultant were interviewed at 11:20 AM on 10/5/11. They were asked if it was appropriate for a resident to be on a restricted spending plan or be denied access to his/her funds. They both replied that they would have "big concerns" if this were to occur. The SSW further stated that everyone should have access to his/her personal funds. The SSW then stated that she had no knowledge that resident 40 was on a restricted supervised spending plan, and that this should not have occurred. The SSW then stated that resident 40 should have had the right to access his money when he wanted and to spend it on what he would like. An additional interview was conducted with the Administrator on 10/5/11 at 11:40 AM. The Administrator stated that resident 40 would smoke, drink, and panhandle and was therefore a danger to himself with his spending. The Administrator admitted that resident 40 was currently on a spending plan. The Administrator described the plan as follows: Resident 40 was to make a list of what he wanted and have the list approved by the facility; the resident would go to the store accompanied by someone from the facility or have a facility employee pick up the items for him; and resident 40 could only have small amounts of money for supervised spending for the vending machine. The Administrator stated that resident 40 had requested to go shopping on 10/4/11, but was not allowed due to the Administrator not wanting the AD to leave the facility during the State Survey. The Administrator was asked if the resident wanted, for example, $20.00 to go to the movies on a Friday night would he be able to get the money? The Administrator stated the resident could, as long as he was supervised and the money went to the movies; otherwise he would not be given the money. The business office manager was interviewed again on 10/5/11 at 11:50 AM. The business office manager admitted that the facility currently monitored and supervised the spending of resident 40, as a condition of admission to the facility. The business office manager further stated that since resident 40 refused to sign the spending plan, the facility should not have admitted him.

Based on observation and interview it was determined that the facility did not protect 2 sample residents from abuse. Specifically, facility staff used physical force to give medications to one resident who was trying to refuse her medications. Additionally, facility staff left a visually impaired resident in the dining room alone; the resident subsequently became upset. Resident identifiers: 27 and 35. Findings include: The facility "Policy and Procedure for Prohibiting Abuse" identified abuse as, "the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physicial harm, pain, or mental anguish. This also includes the deprivation by an individual including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being." It defined mental abuse as "including but not limited to humiliation, harassment, threats of punishment or deprivation. . ." The "Policy and Procedure for Prohibiting Abuse" further revealed "...Investigation and reporting procedures: 1) Any person, who suspects that abuse, neglect or misappropriation of property may have occurred, will immediately report the alleged violation to his facility administration and/or advocacy agencies. . . " 1. Resident 35 was readmitted to the facility on [DATE] with a right fractured clavicle, [MEDICAL CONDITIONS]'s chorea and dementia with depressive features. On 9/28/11 from 7:30 AM to 11:35 AM, resident 35 was continuously observed. On 9/28/11 at 11:17 AM, Registered Nurse (RN) 1 was observed to enter resident 35's room to administer medications. RN 1 was observed to place a spoonful of medication in front of resident 35's mouth. Resident 35 was observed to move her head repeatedly back and forth, avoiding the spoon placed in front of her mouth. In addition, resident 35 was observed to push RN 1 away with her left arm. RN 1 then left resident 35's room. On 9/28/11 at 11:19 AM, RN 1 was observed to return to resident 35's room with Certified Nursing Assistant (CNA) 2. CNA 2 was observed to hold resident 35's head to prevent resident 35 from moving her head from side to side. RN 1 was then observed to forcefully place a spoonful of the medication in resident 35's mouth. As CNA 2 held resident 35's head still, resident 35 was observed to flail her left arm in what appeared to be an attempt to push RN 1 and CNA 2 away. CNA 2 was then observed to lower the head of the bed so that resident 35 was lying flat in her bed. CNA 2 was then observed to sit on the floor with her right side to resident 35. CNA 2 then leaned over and around resident 35's head, and held her head and shoulders to prevent her from moving side to side. As CNA 2 did this, resident 35 began to kick her legs, by lifting her legs 2 to 2 1/2 feet off of the mattress, and then dropping her legs on to the mattress. Resident 35 was observed to perform this action multiple times. RN 1 was observed to be kneeling on the right side of resident 35's bed with her left side to resident 35. RN 1 was observed to lean over resident 35's torso, and put her left arm and upper body across resident 35 to hold resident 35's arms down. As RN 1 held resident 35 down, she held the medications in her left hand. RN 1 then put the spoon with the medications in her right hand and pushed the medications into resident 35's mouth. RN 1 continued this process until the medications were gone. Throughout this observation, resident 35 continued to kick her legs and slam them on the bed. In addition, resident 35 began to loudly hit her right arm on the wall multiple times. On 9/28/11 at 11:40 AM, observations of resident 35 revealed RN 1 kneeling by resident 35's head and watching while CNA 2 attempted to shove a spoon full of pudding in resident 35's mouth when resident 35 experienced involutary movements and opened her mouth. Resident 35 was observed to shake her head back and forth to dislodge the spoon and attempt to pull away from CNA 2. Resident 35 was observed to have her eyes opened very wide and look from side to side rapidly. CNA 2 was observed to keep attempting to force resident 35 to eat the pudding off the spoon while resident 35 repeatedly shook her head and attempted to pull away from CNA 2. On 9/28/11 at 11:42 AM RN 1 left resident 35's room. RN 1 stated "This is normal for her" (resident 35). On 9/28/11 an interview was conducted with CNA 2 regarding the witnessed incident with resident 35 earlier that day . CNA 2 stated that resident 35 was "sleepy from her medicine" and that "I was holding her (resident 35) up from behind so she could take her medicine. . . She was taking the medicine willingly but (RN 1) needed me to help keep her head steady so she didn't choke on the medications. I was leaning over her to try and give her some water . . . She wasn't intentionally trying to resist. She has a disease that causes jerking. . . She was thrashing around because she was in pain . . . She is capable of pushing us away. . . She taps us on the chest to tell us she is pushing away. Today she wasn't pushing me away. She was grabbing my arm to tell me hi. She wasn't forced in any way. It always takes two of us to give her her meds." On 9/28/11 at 4:19 PM an interview was conducted with RN 1 regarding the witnessed incident with resident 35 earlier that day. RN 1 stated that resident 35 "doesn't mean to, but she flails . . and is in constant movement. She can't control her movements at all. . . She will tell us no, but she wasn't telling us no today. She was saying 'ow'. . . Her eyes get wild if she's afraid and she gets panicky and she moves her head . . . She gets a fearful look on her face." RN 1 further stated that CNA 2 was "steadying her head and her shoulder so I could give her (resident 35) [MEDICATION NAME]." CNA 2 "had her hands on both shoulders to prevent lurching, but she was holding her softly because she was trying to help" resident 35. RN 1 stated that CNA 2 was holding resident 35 softly enough that she did not leave any bruises on resident 35. "When (resident 35) is resisting she is so strong. She will kick you with both feet." RN 1 then stated that "I always do that" referring to giving resident 35 her medicaions. RN further stated, "It looks bad but it's not." On 9/26/11 Licensed Practical Nurse (LPN) 1 was observed to give resident 35 her medications. No observations were made of resident 35 flailing, kicking or lurching while receiving medications from LPN 1. No observations were made of resident 35 widely opening her eyes and moving them back and forth rapidly. 2. Resident 27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/27/11 at 9:43 AM an interview was conducted with resident 27. Resident 27 stated that a CNA left her in the dining room alone and that she started to cry and was upset because she was blind and could not find her way back to her room. Resident 27 stated that she heard a facility CNA laugh at her from across the room. Resident 27 further stated that the CNA said to another staff member, "do you hear that, do you see that"? Resident 27 then stated that the facility CNA told resident 27 to calm down and that "you were never left alone, I was here all along and you were never lost". Resident 27 then stated that she could not find her way back to her room and had accidentally entered other residents' rooms which upset the other residents. On 10/4/11 at 2:45 PM an interview was conducted with the facility Social Services Worker (SSW). The SSW confirmed that she had been informed of the incident regarding resident 27, and that she had held an inservice regarding what it was like to be blind. The SSW stated that she did not do an inservice regarding abuse. The SSW stated that she did not report the incident to the administrator. On 10/4/11 resident 27's medical record was reviewed. No documentation could be found to show that the SSW documented the incident regarding resident 27.

Based on observation and medical record review it was determined, for one sample resident, that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, facility staff placed a resident with known uncontrollable involuntary movements on mattresses on the floor, resulting in the resident receiving "rug burns" on portions of her body. In addition, facility staff waited four days to treat the "rug burns" the resident received while "flailing" on the floor. Resident identifier: 35. Findings include: Resident 35 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/22/11 resident 35's current and closed medical record were reviewed. Review of the nurse's notes revealed the following entries made by facility nurses: a) "9/12/11 pt. (patient) found screaming in room this am @ (at) 645 (6:45 AM), pt. lying on floor part way under bed. ... pt. has increase in [MEDICAL CONDITION] movements, making it very difficult to transfer." b) "9/13/11 0300 (3:00 AM) Resident fell from bed to floor... took 3 people to help transfer resident back into bed d/t (due to) large movements d/t Hunningtons (sic) disease. Resident reminded and shown how to use call light when she needs help. Unable to remember and uncooperative with using call light. ..." c) "9/14/11 @ 2330 (11:30 PM) pt. flinging around in bed. Yelling unable to understand pt. found pt. on floor lying on back with legs on bed. ... Flinging around grabing (sic) at staff. ..." d) "9/15/11 @ 0027 (12:27 AM) pt. yelling, thrashing around. Found on floor. New orders for low bed. ..." e) "9/15/11 1550 (3:50 PM) ... Sweating and flailing.... Has floor mat and rolled from bed to mat...." f) "9/16/11 0100 (1:00 AM) Resident tries to get up from bed unattended. Involuntarily flails arms et (and) body. ... Unaware of own safety..." g) "9/16/11 2130 (9:30 PM) Pt. threw herself off bed, was sitting on floor. Took bedframe out of room - placed two mattresses side by side on floor, pt. placed diagonally on beds, ..." h) "9/17/11 0600-1600 (6:00 AM - 4:00 PM) Resident mattress on floor res. was on the floor next to the mattress this morning. Res found with uncontrollable movements of arms and legs. Flailing of arms and legs d/t [MEDICAL CONDITION]. res has some "rug burn" on her back, shoulders, hips, elbows and ankles. In addition res has several bruises on legs and arms d/t uncontrollable movements, hitting into walls and the floor. RN (Registered Nurse) cleaned res and bandaged ankles and elbows. Res repositioned comfortable on bed...." Review of wound progress notes revealed that the "rug burns" resident 35 sustained on 9/17/11 were not evaluated or treated until 9/22/11 after the survey team had entered the building and expressed their concerns for resident 35. On 9/22/11 at 2145 (9:45 PM), the following entry was made in the nurse's notes by the facility's Director of Nursing: "... Res has multiple abrasions from prior times when restless... the following wound measurements performed- R (right) lateral lower leg ankle 2.8 X 5.0 X 0 (centimeters?); R lower buttock 0.4 X 3.2 X 0.1; L (left) lower buttock 0.3 X 3.0 X 0.1; L knee medial 6.5 X 3.4 X 0; L mid knee 1.5 X 1.0 X 0 scab; L distal knee 1.3 X 1 X 0 scab; L lat (lateral) ankle 1.2 X 2.0 X 0 abrasion; R interior elbow 3.0 X 3.2 X 0.1; R elbow 2.0 X 4.0 X 0.1; R lateral forearm 4.0 X 7.5 X 0.1; R wrist 1.6 X 2.4 X 0.1; L arm wrist 3.0 X 5.2 X 0.1; L elbow 7.8 X 0.1. ..." No documentation could be found in resident 35's medical record to show that facility staff implemented interventions to keep resident 35 from sustaining injuries due to the "uncontrollable involuntary movements" or "flailing". Review of documentation revealed that facility staff waited 5 days before evaluating and treating the "rug burns" resident 35 sustained on 9/17/11. On 9/24/11 resident 35 was observed to be wedged between the two mattresses facility staff had placed on the floor. Resident 35 was observed to be lying on the carpet of the floor. No observations were made of a bed alarm or any other device to alert facility staff if resident 35 moved off of the mattresses. On 9/26/11 resident 35 was observed to be wedged between the two mattresses facility staff had placed on the floor. Resident 35 was observed to be lying on the carpet of the floor.

Based on interview, observation, and medical record review it was determined, for 3 sample residents, that the facility did not ensure that a resident who entered the facility without a pressure sore, did not develop a pressure sore unless the individual's clinical condition demonstrated that they were unavoidable. Specifically, three residents developed pressure sores within the facility with little or no intervention prior to the development of the pressure sore. Resident identifiers: 17, 57, and 74. Findings include: 1. Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/28/11 resident 17 was continuously observed from 8:00 AM through 11:40 AM. Resident 17 was observed to be lying in bed on his back. At no time during the observation did staff check resident 17's incontinence brief or attempt to reposition resident 17. In addition, resident 17 did not reposition himself. Resident 17's medical record was reviewed on 9/26/11. Resident 17's initial nursing assessment dated [DATE] documented that resident 17 did not have any red areas or pressure ulcers on his back, buttocks, or heels. Resident 17's Minimum Data Set ((MDS) dated [DATE] documented that resident 17 did not have any pressure ulcers on his body. Resident 17's Activities of Daily Living Care Plan dated 6/28/11 documented that resident 17 required total dependence on staff for bed mobility and transfers. The care plan also documented that resident 17 needed to be checked for repositioning and safety during rounds and as needed. Resident 17's Pressure Ulcer Risk Care Plan dated 7/11/11 documented that resident 17 was at risk for impaired skin integrity due to mechanical factors such as pressure and shearing, moisture, medications, and imbalanced nutritional state. The goal was for resident 17 not to have any avoidable alteration in skin integrity. Interventions included changing incontinence pads or briefs frequently, reposition as needed, encourage continued mobility as able, provide optimum nutrition as ordered, and assess patient's ability to change positions independently. Resident 17's Pressure Sore Risk assessment dated [DATE] documented that resident 17 was at high risk for developing pressure sores due to his slightly limited sensory perception, skin that was often moist, bedfast status, slightly limited mobility, probably inadequate nutrition, and moderate to maximum assistance in moving. Resident 17's Bowel and Bladder assessment dated [DATE] documented that resident 17 was "frequently incontinent" and was a "total assist" with cares. Resident 17's History and Physical dated 6/13/11 documented that resident 17 was at "high risk for skin breakdown". A physician's progress note dated 7/15/11 documented that resident 17 "has multiple areas of skin breakdown." Resident 17's Skin Condition Sheets documented the following: a) On 7/7/11 resident 17 had a large blister measuring 6 x 5 cm (centimeter) on his right heel. b) On 7/18/11 resident 17 continued with a blister on his right heel. c) On 7/20/11 resident 17's right heel blister was healing, and measured 5.3 x 4 cm. d) On 7/25/11 resident 17's right heel blister was healing. e) On 8/1/11 resident 17's "wound" on heel "looks healed but fragile". f) On 8/22/11 resident 17 had an open area on his right upper buttock. g) On 9/15/11 resident 17's "bottom wounds are healed". Resident 17's Wound Progress Notes documented the following: a) On 9/7/11 "Resident (17) has a pressure wound on his R (right) buttocks the wound measures 0.3 x 0.3 x 0.1 cm. The area is . . .crater-like in appearance (with) a small amount of serous drainage. . . Buttocks wound is improving (and) nearly healed." b) On 9/15/11 Resident 17's right "buttock is closed". Resident 17's facility and hospice nurses' notes documented the following: a) 7/21/11 (hospice) "Pt (patient) has a suspected deep tissue injury" on right heel. b) 8/19/11 (facility) "Wound to fold of buttock (approximately) 2 cm diameter" c) 8/19/11 (hospice) "noc (night) shift reported to RN that patient has breakdown on buttocks." d) 8/22/11 (hospice) "coccyx - R (right) buttocks stage II." e) 8/22/11 (facility) "RN (Registered Nurse) examined wound on res (resident) (right) buttock. Wound measures 0.5 cm x 0.8 cm x 0.2 (cm). . . . Position res off the area." f) 8/26/11 (hospice) pt has a stage II pressure ulcer on coccyx . . . enc (encouraged) (and) educated staff to turn pt q (every) 2 (hours) off of coccyx". g) 8/29/11 (hospice) "Stage II pressure ulcer to coccyx". h) 8/31/11 (hospice) "pt cont (continue) to have stage II pressure ulcer on coccyx." i) 9/12/11 (hospice) "healing slowly stage II to coccyx". j) 9/14/11 (hospice) "healing stage II on coccyx". The facility's Weekly Weight and Wound Report documented that on 8/23/11 resident 17 had developed a wound on buttocks that was 0.5 x 0.5 x 0.8 by 0.2 cm. The wound report documented that the wound was caused by "pressure". On 10/4/11 an interview was conducted with the facility Director of Nursing (DON) regarding resident 17. The DON acknowledged that on 8/23/11 she had documented that resident 17 had a pressure sore on his buttocks per the weekly weight and wound report. The DON further stated that resident 17's wound was from shearing or incontinence and was not a pressure sore because the wound was "on the fleshy part of his buttocks . . almost in the crease." On 9/28/11 an interview was conducted with Certified Nursing Assistant (CNA) 2. During the interview CNA 2 stated that she was supposed to check on resident 17 every 2 hours because resident 17 required total assistance with cares. When asked why resident 17 had not been assisted with cares during the observation, CNA 2 stated that she was "running behind today." CNA 2 stated that resident 17 was able to throw his legs off of the bed but that he could not reposition himself. CNA 2 also stated that resident 17 needed to be repositioned every 2 hours. CNA 2 stated that resident 17 had a "sore on his bottom" that was a pressure sore but that the facility staff "caught it and healed it up." On 10/4/11 at 7:30 AM an interview was conducted with CNA 9 regarding resident 17. CNA 9 stated that when resident 17 was asleep he was "out" and that facility staff were supposed to reposition him every 2 hours. 2. Resident 74 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 9/26/11 resident 74 was continually observed from 6:52 AM to 9:45 AM. Resident 74 was in her wheelchair with a lap buddy in place. Resident 74 did not attempt to get out of the wheelchair during the continual observation. In addition, staff did not attempt to reposition resident 74 during the nearly 3 hour observation. On 10/3/11 resident was continually observed from 9:02 AM until 11:10 AM. Resident 74 was in her wheelchair with a lap buddy in place. At 11:10 AM resident 74's family took her for a walk in her wheelchair with the lap buddy still in place. Resident 74 did not attempt to get out of her wheelchair during the observation. In addition, staff did not attempt to reposition resident 74 during this observation. On 10/4/11 several observations were made between 8:53 AM and 1:00 PM of resident 74 in her wheelchair with lap buddy applied backwards. At 1:00 PM resident 74 remained in her wheelchair with the lap buddy applied backwards. Resident 74's medical record was reviewed on 9/26/11. Resident 74's admit skin assessment on 9/1/11 revealed that the resident had a "2 (inch) scab on R (right) wrist from skin tear, small scab on hand. Buise (sic) on R arm. Bruise L (left) shin, blister on L ball of foot. Scar on stomach." No pressure ulcers were noted upon admit. Resident 74's nurses' notes documented the following: a) 9/10/11 "quarter-sized DQ (Decubitus Ulcers/pressure ulcer) R buttocks stage III - needs barrier cream. L calf sore - bloody bandage noted with patient asleep. Did not change." b) 9/11/11 "stage II sore noted on R buttock. cream applied small amount of bleeding noted." c) 9/25/11 "right buttock healed with right and left knee scab intact and bilateral leg skin tears. Dress with hyrdofoam. The sores are improving." d) 9/30/11 "skin tears to right and left shin were dressed. No other skin issues were noted at that time." An assessment dated [DATE] entitled "[MEDICAL CONDITION] Dehydration-Pressure Sore Risk Assessment" indicated resident 74 was at high nutrition and skin risk. A Braden score on 9/5/11 indicated resident was at high risk for developing pressure sores. An MDS dated [DATE] revealed that resident 74 was assessed as being at risk for developing pressure ulcers. Facility staff also indicated resident 74 did not have one or more unhealed pressure ulcers at stage 1 or higher. A care plan entitled "Pressure Ulcer Risk Care Plan" was dated 9/14/11. The care plan goals for resident 74 included no alterations in skin integrity, unless unavoidable, through next review. Resident 74 would be evaluated with a monthly summary and at every interdisciplinary team meeting. The interventions to prevent pressure ulcers included assess resident's current ability to change positions independently, weekly skin check, assess blood supply, use pads to turn and position with pillows, reposition as ordered and as needed, provide pressure reducing devices as ordered, encourage continued mobility, activity, and range of motion as able, keep linen wrinkle free, medications as ordered, treatment as ordered, labs as ordered, provide optimum nutrition as ordered, and provide adequate hydration. No order was found in the medical record regarding the frequency of repositioning by facility staff. No assessment was found in the medical record regarding resident 74's ability to change positions independently. On 9/23/11 wound progress notes revealed "RN checked buttocks today and there was no wound on buttocks - a small 0.5 mm (millimeter?) pink area appears to be where a wound was noted on the weekly nurses skin checks but none was present today and was apparent that resident does not seem to clean herself well after a BM (bowel movement) and staff was alerted." An interview was conducted on 9/27/11 at 9:50 AM with RN 1. RN 1 stated the skin issue was a stage 1 pressure ulcer. RN 1 further stated that a CNA reported resident 74 had a stage 3 pressure ulcer, but that resident 74 was asleep when the nurse received report of the wound. RN 1 stated she looked at the suspected pressure ulcer a few days later, and the wound was "barely a stage 1." RN 1 stated that she reported the wound to the medical director (MD). RN 1 stated the wound appeared closed with a light tan covering similar to a scab. RN 1 stated that she treated resident 74's wound with barrier cream. RN 1 then stated that no dressing was applied and the wound was healed within 3-4 days. An interview was conducted on 9/26/11 at 2:32 PM with RN 3. RN 3 stated resident 74 had excoriation to her buttocks, and that there was never a pressure sore. RN 3 stated the wound was clarified as "shearing" in the chart. RN 3 stated "some nurses wrote down she (resident 74) had a pressure sore, but it was not." An interview was conducted on 9/26/11 at 2:55 PM with the DON. The DON stated resident 74 had shearing on her buttocks. The DON also stated that nurses did skin checks on shower days and skin sheets were filled out and put into the residents' medical records. The DON stated that CNAs were educated about reporting skin issues. The DON stated that she performed weekly skin checks, and that any skin issues found upon admit were reported to her (DON). The DON also stated that there was a communication sheet which nurses used to communicate to the Interdisciplinary Team (IDT), and that skin problems were reviewed in the weekly skin meeting. An interview was conducted on 9/27/11 at 11:00 AM with RN 5. RN 5 stated another nurse reported resident 74's pressure ulcer, and that RN 5 had documented what was told to her. RN 5 stated the wound appeared to be a stage 1 when she looked at it a few days after it was reported. RN 5 further stated that the skin appeared to have some scratches with a red area but the skin was not open. RN 5 stated "For example, it looked like when someone scoots on the ground and there was rubbing. . it looked similar to a rug burn." An interview was conducted with CNA 3 on 10/3/11 at 10:40 AM. CNA 3 stated that residents were supposed to be repositioned every 20 minutes, if they are totally dependent. CNA 3 stated residents were checked on every time their room was passed by a CNA. An interview was conducted on 10/3/11 at 1:55 PM with CNA 4. CNA 4 stated staff repositioned residents every 2 hours or more often as needed. CNA 4 stated when a resident was in their wheelchair they were supposed to be repositioned at least every 2 hours. CNA 4 stated that there were special instructions for resident 74, which included watching her closely because she liked to get out of the wheelchair. CNA 4 stated resident 74 tried to get out of her chair, which was the reason resident 74 had the lap buddy in place. 3. Resident 57 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/27/11 resident 57's medical record was reviewed. Review of the Significant Change MDS assessment completed on 7/8/11 for resident 57 revealed that facility staff assessed resident 57 as requiring extensive assistance with a two person physical assist with bed mobility, and an extensive assist with a one person physical assist with transfers, walking in the room and the corridor, and locomotion on and off the unit. Facility staff also assessed resident 57 as having limitations in his range of motion in his lower extremities on both sides of his body. Resident 57 was assessed as being at risk of developing pressure ulcers but did not have any unhealed pressure ulcers of a stage 1 or higher. Review of the Admission MDS assessment dated [DATE] revealed that resident 57 had no skin breakdown upon admission to the facility. Review of the Braden Scale for Predicting Pressure Sore Risk completed by facility staff on 6/6/11 revealed that resident 57 scored 13. According to the facility form a score of 13 indicated that resident 57 was at a moderate risk for developing a pressure ulcer. Review of the facility Skin Condition Sheets revealed that on 6/15/11 (10 days after admission to the facility) facility staff documented that resident 57 had a 4 cm X 7.5 cm fluid filled blister found on his left heel. Review of resident 57's care plan revealed that facility staff did not initiate a care plan for pressure ulcer risk for resident 57 until 7/18/11, 33 days after resident 57 developed the pressure ulcer on his left heel. Review of physician orders [REDACTED]. On 10/4/11 CNA 3 was interviewed. CNA 3 stated that when resident 57 returned from the hospital he was dependent upon staff for turning and repositioning. CNA 3 stated that she was unsure how resident 57 developed the pressure ulcer on his heel but that the facility did institute heel protectors for resident 57 after the development of the pressure ulcer.

Based on observation, record review, and interview, the facility did not ensure that 2 residents maintained acceptable parameters of nutritional status, specifically body weight. Resident identifiers: 17 and 57. Findings include: 1. Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 17's medical record was reviewed on [DATE]. Resident 17's History and Physical from the hospice company dated [DATE] documented that resident 17 had experienced "recurrrent episodes of aspiration pneumonia. The patient is now completely bed bound . . .in the last 6 months, the patient has had a very significant decline with greater than 5 aspiration pneumonias." The multiple episodes of aspiration led to placement of a percutaneous endoscopic gastrostomy (PEG) tube. Resident 17's admission physician orders dated [DATE] documented that resident 17 was to receive 360 milliliters (ml) of Boost three times a day and ,[DATE] scoop of Myoplex protein powder three times a day via feeding tube. A document entitled "Nutritional Assessment" for resident 17 dated [DATE] was reviewed. The Registered Dietitian (RD) documented that the Myoplex protein powder gave 170 calories and 20 grams of protein per scoop. The assessment written by the RD also documented that the tube feeding for resident 17 "appears adequate to meet current needs. . . Tube feeds provide 1875 (calories) (and) 93 g (grams) protein." Based on a weight of 151 pounds, the RD calculated resident 17's energy needs as 2100 calories and 68 grams of protein a day. On [DATE], [DATE], [DATE], [DATE], and [DATE] resident 17 was observed to be receiving Boost and [MEDICATION NAME] in his PEG tube. (Note: [MEDICATION NAME] has 25 calories and 6 grams of protein per scoop. The Boost and [MEDICATION NAME] provided 1117 calories and 54 grams of protein each day, below resident 17's calculated energy needs.) Resident 17's weight history was reviewed. The following entries were listed: a) Admit 151# b) [DATE] 150# c) [DATE] 138.6# On [DATE] an interview was conducted with the facility Director of Nursing (DON). The DON confirmed that resident 17 had been receiving [MEDICATION NAME] in his PEG tube instead of the Myoplex supplement as ordered by the physician. On [DATE] an interview was conducted with the facility RD. The RD stated that resident 17 was supposed to be receiving Boost Plus instead of Boost, Myoplex protein instead of [MEDICATION NAME] powder, and juice. The RD stated that he did "not realize that (resident 17) wasn't receiving Boost Plus or Myoplex" as ordered. The RD further stated that [MEDICATION NAME] was inferior to Myoplex in this case. When asked about resident 17's weight loss, the RD stated that he had attributed the weight loss to a large bowel movement. Dietary Progress Notes dated [DATE] documented that resident 17 had experienced weight loss "related to getting Boost instead of Boost Plus. Per RN Hospice changed protein powder to [MEDICATION NAME]. Due to weight loss changed TF (tube feeding) to Resource 2.0 360 ml (milliliters) (with) 1 scoop [MEDICATION NAME] BID providing 2200 calories and 100 grams protein. TF at this rate should prevent wt loss. Will follow for tolerance and wt trends as able." 2. Resident 57 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] resident 57's medical record was reviewed. Review of resident 57's medical record revealed no Physician Orders for Life-Sustaining Treatment (POLST). No documentation could be found to show if resident 57 wanted a tube feeding or if resident 57 wanted to have Cardiopulmonary Resuscitation (CPR) performed if he was found without a pulse. Review of the "[MEDICAL CONDITION]/Dehydration-Pressure Sore Risk Assessment" revealed that facility staff assessed resident 57 on [DATE] at a score of 17. According to the facility "[MEDICAL CONDITION]/Dehydration-Pressure Sore Risk Assessment" a score of 10 or higher indicated the resident was at an "Additional High Nutrition Risk". Review of resident 57's care plan revealed a nutritional care plan dated [DATE] and [DATE]. Facility staff assessed resident 57 as being at Nutritional Risk as evidenced by (AEB) significant weight change and impaired physical/mental functioning. The documented goal on the care plan was for resident 57 to gain ,[DATE] pounds by 90 days, tolerate diet, and skin would remain intact by 90 days. Documentation showed that facility staff would accomplish the goals by monitoring weights monthly/weekly, encouraging intake greater than 100%, supplement as ordered 500 calories four times daily, multivitamin with minerals, and med/treatment (medication) as ordered. No other interventions were listed on the care plan. Review of the Dietary Notes revealed that upon admit on [DATE] resident 57 weighed 144 pounds (lbs). The facility RD assessed resident 57 as having a Body Mass Index (BMI) of 21, Ideal Body Weight Range (IBWR) ,[DATE], resident 57 to receive house supplement 400 (calories?) three times daily (TID) and snacks TID. Review of the Quarterly Nutritional Note completed by the facility RD revealed that in [DATE] resident 57 weighed 132 lbs, 14 lbs less than the IBWR calculated by the facility RD. Documentation showed that resident 57 lost 8.3% body weight in 3 months. The facility RD documented in the Comments section of the quarterly note, "Resident continues to lose weight, encourage intake, increased supplements as high as he will take, and Need TF? (tube feeding)." No orders could be found for the increased supplement. No documentation could be found to show the RD discussed the tube feeding option with resident 57. Review of the medical record revealed no documentation addressing the tube feeding option or whether staff discussed the tube feeding option with the resident or his family. On [DATE] the facility Dietary Manager (DM) stated that if the RD was questioning whether a tube feeding should be started or not, he would discuss the option with the resident. The DM stated that nursing and social work would also get involved and discuss tube feedings with the resident and the family. The DM stated that the documenation of those discussions would be in the nurses notes or SSW (Social Services Worker) notes. Review of the nursing and SSW notes revealed no documentation regarding the discussion of the tube feeding with resident 57 or his family. On [DATE] at 9:14 AM, the SSW was interviewed. The SSW stated that she did not discuss tube feedings with residents or family, as that was a nursing issue. The SSW stated that she did not know enough about tube feedings to discuss the concern with families or residents. The SSW stated that resident 57 did not have a POLST because she could not get in touch with resident 57's sister to have her fill out the POLST. The SSW further stated that resident 57 was not capable of filling out the POLST due to his mental capacity. On [DATE] the DON was interviewed. The DON stated that she did not know why the tube feeding option had not been discussed with resident 57 or his family. The DON stated that she had not been told that the facility RD was questioning whether to start resident 57 on a tube feeding. The DON further stated that she would need to look through the medical record to determine why resident 57 had experienced the weight loss and why facility staff had not spoken with resident 57 or his family about the tube feeding option. (Note: The facility DON was unable to provide additional information regarding resident 57's weight loss or the discussion of the tube feeding with resident 57 or his family).

Based on observation, interview and medical record review, it was determined the facility did not ensure that one resident received proper treatment and care for a [MEDICAL CONDITION]. Resident identifier: 45. Findings include: Resident 45 was admitted to the facility on [DATE] and readmitted on [DATE] after a failed surgical attempt to reconnect [MEDICAL CONDITION], ischemic bowel, [MEDICAL CONDITION], depression and [MEDICAL CONDITION]. Resident 45's medical record was reviewed on 9/22/11. On 6/4/11, facility staff completed a significant change Minimum Data Set (MDS) assessment for resident 45. Facility staff assessed resident 45 as requiring extensive assistance (resident involved in activity, staff provided weight-bearing support) with the physical assistance of two people with dressing (defined as how resident puts on, fastens and takes off all items of clothing, including donning/removing a prosthesis or compression stockings. Dressing includes putting on and changes pajamas and house dresses), toilet use (defined as how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter and adjusts clothes. Do not include emptying of bedpan, urinal, beside commode, catheter bags or ostomy bag), and bathing. The MDS indicated that resident 45 had a ostomy in place and required surgical wound care, application of nonsurgical dressings with or without topical medications. The Care Area Assessment (CAA) for activities of daily living and use of an indwelling catheter triggered on the MDS and facility staff indicated on the CAA that activities of daily living and indwelling catheter use would be addressed in the plan of care. On 9/4/11, facility staff completed a quarterly MDS for resident 45. Facility staff assessed resident 45 as requiring extensive assistance of one person with dressing and toilet use with a two person assistance for bathing. Resident 45's medical record contained a care plan for activities of daily living (ADLs) dated 5/23/11. Facility staff assessed resident 45 as requiring partial assistance with dressing, toileting and bathing due to generalized weakness and decreased mental functions. The goals listed on the care plan were: "pt. (patient) to be neat and clean in appearance every day, ADLs to be met by pt./staff on a daily basis without complaints of pt. or family, evaluate q (every) monthly summary and q pt. IDT (Interdisciplinary Team) with individual pt. goals which included: wear underwear, let staff know if he needs help changing clothes, change clothes when toileted from [MEDICAL CONDITION], be compliant with showers." Facility staff listed the following interventions to achieve the goals: "Bathe 3 times a week, dentures, meals in "encourage to eat in dining room", assist to assure adequacy of food and fluid intake, hair care - comb every day and as needed, dress in clean clothes every day and change clothing prn (as needed) soiled or dirty, check every 2 hours for change briefs if wet or soiled, help him to (change), set up for ADLs, explain procedures, encourage participation; praise attempts at self care, allow ample time for completion, report changes in ADL ability to DON (Direct of Nursing) for evaluation for possible rehab need, wash face and hands before and after each meal, keep nails clean and trimmed, responds promptly to calls for assistance and pleasant, respectful interaction during care." A skin integrity care plan related to the abdominal midline incision or the excoriated area around the [MEDICAL CONDITION] site was not completed until 9/30/11, 130 days after resident 45 was readmitted to the facility. Review of resident 45's medical record revealed the following physician orders/consultant notes: a) 6/20/11 - "[MEDICATION NAME] 1% ointment cream apply topically (with) dressing (changes)". b) 6/20/11 - "EMLA cream to abd (abdomen) before dressing changes and wafer (changes). Wait 30 min. (minutes before applying wafer." c) 6/25/11 - A "Wound/Ostomy Consult Note" revealed: "A wound and ostomy consult was requested for (resident 45). Assessment of the R (right) quadrant of the abdomen and mid abdomen revealed a stoma measuring 3/4 cm (centimeter) in diameter. The [MEDICATION NAME] skin was denuded and excoriated and was weeping serous drainage. The area was tender and painful for the Resident. The stool coming from the stoma was yellow liquid and the nurses and staff reported to me that the patient often rips his wafer and ostomy pouch off as well as his wound dressing. The wound is a slow healing post surgical wound, midline and adjacent to the [MEDICAL CONDITION] site. ...All the denuded skin on the R quadrant of the Residents abdomen was crusted. There was a precut wafer opening which was too large for the [MEDICAL CONDITION] stoma. The stoma was turned slightly downward. The wafer was a flat wafer and the stoma would be better fitted with a convex type wafer connecting to a belt which would hold the stoma in a better position for draining into the pouch. After crusting the skin, the wafer was placed but the stool had immediately dripped under the wafer and down the R side of his abdomen. Better fitting supplies will be obtained and applied as soon as can be obtained. If those size wafer/pouch set up works for the patient, more will be ordered for him. In the interim, the skin needs to be protected from the acidic stool; there, [MEDICATION NAME] was applied liberally and the stoma was covered with an adult brief cut into 1/3rds. It was secured with netting material around his abdomen. Nurses were instructed to change the brief and reapply [MEDICATION NAME] PRN to protect skin and remove waste from the stoma..." d) 6/27/11 - "Wound/Ostomy Consultant Report", "Follow up consultant visit to (resident 45) today at (facility). (Resident 45's) general R quadrant abdominal area was much improved today. Redness of the [MEDICATION NAME] abdominal area had diminished and less tender to touch per patient report. The area directly 3 cm around the [MEDICAL CONDITION] stoma was still bright red and sore. Today I brought a Durahesive [MEDICATION NAME] Convex wafer with flange and belt. The stoma is 3/4 cm round with an opening that turns slightly under at the bottom of the stoma and is level with the skin surface. treatment of [REDACTED]. The convex wafer was then placed over the stoma and it did push the stoma out enough to begin to drainage into the ostomy pouch. The belt was then fitted and placed around his upper body and connected to the flange of the ostomy pouch on both sides. The wafer appeared to be adhering to the skin and the stoma was draining slightly formed yellow stool into the pouch. The remaining skin was treated with [MEDICATION NAME] cream. ...An order book of ostomy supplies was left with the care center as a guide to the type of supplies available and for comparison to the care center's vendors for ostomy supplies. The staff nurses were trained on application of the convex wafer and how it will better fit this patient's [MEDICAL CONDITION] as compared to the previous ostomy wafer." e) 7/4/11 - "D/C (discontinue) [MEDICATION NAME] - was part of previous drsg (change) orders". f) 7/8/11 - "Clarification [MEDICATION NAME] 1 mg PO (by mouth) q 6 hrs routinely". (Note: Risperal change was due to resident removing [MEDICAL CONDITION] supplies.) g) 7/12/11 - surgical follow up: "...1. Use [MEDICATION NAME] powder around stoma with skin prep before applying wafer; 2. Please use barrier cream (such as [MEDICATION NAME] ointment) on skin rash to prevent irritation/inflammation. Can mix ointment with [MEDICATION NAME] gel 5% and apply 2-3x/day (2-3 times a day); and 3. Please use an abdominal binder to hold the appliance in place and reduce leakage". h) 7/13/11 - "...Use stoma adhesive around stoma w(with) skin prep. Use Barrier Cream to prevent irritation. Continue to use binder." i) 8/18/11 - "Apply Bordeaux's Butt Paste to effected (sic) area q 2 hours & PRN until healed (with) q brief (change)." j) 8/19/11 - "Apply ostomy durahesive [MEDICATION NAME] convex wafer and pouch per protocol to R [MEDICAL CONDITION] stoma on Tues and Fridays Q week." k) 8/19/11 - "D/C Butt Paste to affected area. If ostomy wafers & pouch are removed by resident apply [MEDICATION NAME] to excoriated skin & cover with ABD pad - 1/2 brief and stretch net until next wafer application." l) 8/26/11 - "Reduce [MEDICATION NAME][MEDICATION NAME] mg IM (intramuscularly) Q 2 weeks. Begin PO [MEDICATION NAME] 2 mg BID (twice a day). D/C PRN [MEDICATION NAME]". m) 8/30/11 - "clarification order (change) EMLA TX (treatment) order to PRN. D/C TX orders from 5/24/11 standard ostomy care. 7/13/11 use stoma adhesive. (Change)[MEDICATION NAME] tx (treatment) order to PRN (with) bag and wafer change." n) 9/8/11 - "Applesauce 1/2 cup QID (four times a day) for loose stool". o) 9/24/11 - "continue ostomy appliance changes on Tue/Fri (with) Durahesive [MEDICATION NAME] convex wafer (and) pouch per protocol to R [MEDICAL CONDITION] stoma. Check wafer & pouch daily. (Change) appliance PRN if lossen (sic) or leak". (Note: this order was implemented after the facility was made aware of the surveyors' identified concern regarding ostomy care with resident 45.) p) 9/24/11 - 'if resident removes stoma appliance multiple times then apply dressings as ordered on [DATE] to protect skin PR. continue to apply wafer & pouch as skin can tolerate it". (Note: this order was implemented after the facility was made aware of the surveyors' identified concern regarding ostomy care with resident 45.) Facility staff documented in the "Nurse's Notes" the following: a) 5/23/11 (no time documented) - "Resident admitted per facility mini van... skin appears C/D/I (clean, dry and intact) (with) exception of surgical wound et (and) colonoscopy (sic). New colonoscopy (sic) bag to down drain". b) 5/23/11 (5 PM to 9 PM) - "...(Changed) [MEDICAL CONDITION] and wound vac. Skin red under [MEDICAL CONDITION] down to upper thigh area". c) 5/28/11 (6 AM to 6 PM) - "...Skin CDI with abdominal wound vac and [MEDICAL CONDITION] both of which are patent and dry". d) 5/30/11 (6 PM to 6 AM) - "...stoma changed." e) 6/2/11 at 4:00 PM - "...Pt. had picked (at) wafer et it caused stool to leak under wound vac drsg (dressing). Wound vac drsg (changed) by (facility employee). Wafer et bag (changed). Skin is excoriated." f) 6/2/11 (no time documented) - "...stoma et wound bag intact." g) 6/4/11 - "...Wound vac et stoma bag intact". h) 6/5/11 at 12:30 AM - "Pt. apparently awoke confused and ripped off wound vac, along with 1/2 the dressing and his ostomy bag & wafer". "...A new ostomy wafer and bag were applied". i) 6/5/11 (no time documented) - "[MEDICAL CONDITION] bag (changed)". j) 6/6/11 at 1:00 AM - "...Pt. awake and [MEDICAL CONDITION] bag off". k) 6/11/11 from 6 PM to 6 AM - "...Redress ostomy bag - doing much better". l) 6/16/11 (no time documented) - "...Skin surrounding ostomy red. Powder applied". m) 6/18/11 (no time documented) - "...Ostomy site very red and raw". n) 6/25/11 at 3:00 PM - "...Report to oncoming RN (Registered Nurse) and CNA (Certified Nursing Assistant) about freq (frequency) of drsg to ostomy site." o) 7/8/11 from 6 PM to 6 AM - "...Wafer and bag changed but wafer not sticking well to skin due to excoriation; excoriation increasing over last few days d/t (due to) cont. (continued) ostomy leakage. EMLA cream in use. Passed to AM nurse. On call NP (Nurse Practitioner) notified of (increased) excoriation. WCTM (Will Continue to Monitor)." p) 7/11/11 - "(Changed) wafer et stoma bag et dsg (dressing) to abd (abdomen). Stool was on all et clothing." q) 7/14/11 - "(Changed) stoma bag/wafer et dsg - stool saturated et clothing covered (with) stool." r) 7/15/11 - "Pt. notified nurse that pts [MEDICAL CONDITION] wafer and bag were in toilet. Found pt. sleeping in bed (with) nothing covering ostomy and abd dressing soiled (with) BM (bowel movement). Pt. was cleaned. New wafer and bag placed. Dressing (changed)..." s) 7/27/11 - "Pt. alert with some confusion noted. Pt. found lying in bed (with) ostomy waffer (sic) (and) bag half off. Pt. was covered in stool. Pt. woke up. Pt. showered. Pt. red and raw around ostomy (and) down leg (and) c/o (complained of) pain. No ostomy bag available at this time. Pt. covered (with) siladine (sic) cream. ABD pad & attends X 2 (twice). Pt. (changed) q (every) 2 hours during NOC (night) to keep area clean (and) dry. WCTM." t) 7/28/11 - "Pt. pulled off drsg X 3 today despite educating the pt. Cont (continues) to be confused. Site excoriated to (right) groin area. Unable to place bag d/t breakdown. Cleansed (with) warm H2O (water) and barrier cream to area. Freq (frequent) monitoring d/t leaking. ABD pads intact. WCTM." u) 7/30/11 - "...diaper used for ostomy." v) 8/12/11 - "Weekly wound check...Res. was found on his bed covered in feces - liquid/yellow stool. He was hurting r/t burning from the stool on raw skin on his R side. Resident was stripped down R side skin (and) [MEDICAL CONDITION] site cleansed then skin covered in silvadine and barrier cream..." w) 8/17/11 - "(Changed) & cleansed dressing to skin around stoma and (right) side & groin area X 5 this shift - have tried diligently to keep it clean (and) keep ointment/cream on the red area. Bright red, painful, (and) bleeding - Notified DON". x) 8/19/11 - "...Ostomy (changed). Cleansed (with) warm H20 and pat dry. Wound cleanser used. Applied powder, spray adhesive (no sting) and another layer of powder and adhesive. Wafer (with)[MEDICATION NAME] molded and applied (with) waist belt. NO (new order) not to use butt paste to area. When off (wafer) in between scheduled drsg (change) use [MEDICATION NAME] to area." y) 8/20/11 - "...Ostomy bag was changed yesterday. Still intact. Some redness and tenderness noted around stoma. Barrier cream applied. WCTM'. z) 8/24/11 - "Resident had an appointment scheduled for today @ (at) 8:30 A.M. that was canceled due to resident being non-compliant (with) [MEDICAL CONDITION] dressing... Another appointment for Friday (8/26/) was made. Will continue to monitor resident's condition and ability to attend next appointment." aa) 8/25/11 (Late entry for 8/23/11) - "weekly wound/skin check report - Res continues to take of (sic) his ostomy wafer & pouch. Skin on R side is denuded and red, weeping serous material - In [MEDICAL CONDITION] meeting it was recommended to (increase) residents Respiradol (sic) to calm him (and) hopefully keep him from touching his wounds (and) ostomy pouch and give his skin a chance to heal. He was unable to go due to ripping off his ostomy dressing (and) having feces all over him - the appointment was rescheduled for Friday but we called and explained that the same problem may occur. We requested that (name of counselor) come to see resident @ facility..." bb) 8/27/11 - "...Colonoscopy (sic) bag et wafer placed - skin around stoma red et excoriated...". cc) 8/30/11 IDT note - "...(insert facility name) follows his psych meds (and) resident recently saw them for a med change to help with his anxiousness in hopes he will leave his ostomy wafer (and) bag alone. He continues to take if off and be drenched in feces - skin is tx PRN (and) a dressing placed to catch the feces..." dd) 9/3/11 - "Pt. alert X 3. Cooperative w/skin (with skin) check. Area around surgical wound and stoma looking less red, healing..." ee) 9/4/11 - "...stoma is excoriated and flaming red. Cleansed (with) [MEDICATION NAME] placed on site. ABD and small cut brief applied." ff) 9/8/11 - "New diet orders: apple sauce 1/2 cup QID (four times a day) for loose stools." gg) 9/10/11 - "...has ostomy which site is excoriated and /including (right) groin... Pt. continues to pull off wafer w/in (within) hrs (hours) of application making it difficult to manage." hh) 9/14/11 - "Resident is being evaluated & followed in S&W (skin and weight) meeting originally for severe excoriation to his R abdomen where resident has a [MEDICAL CONDITION]. He pulls his wafer and pouch off r/t (decreased) mental capacity to understand the full purpose of the ostomy care & supplies - His skin is excoriated & we are trying a behavior plan & tx his skin. Resident often needs a dressing over his stoma (and) is often covered in liquid feces..." ii) 9/17/11 from 6 AM to 6 PM - "...Stoma normal beefy red appearance. Skin around stoma is red and painful to the touch. Barrier cream applied. WCTM". Within resident 40's medical record was the following: "Protocol for (resident 45's) ostomy: 1. Ostomy supplies will be given to the nurse in a plastic bag for the week. (Resident 45) will receive enough supplies to place his [MEDICAL CONDITION] wafer and pouch on Tuesday (and) Friday. Procedure: 1. Clean and dry skin on R side around stoma; 2. [MEDICATION NAME] to the sticky side of the wafer after the [MEDICATION NAME] opening has been peeled back to size; 3. prepare ostomy site by spraying on skin barrier (no sting) then apply light film of stoma powder; 4. spray on another coat of no sting barrier and let dry; 6. apply the wafer to the stoma site making sure the opening of the stoma is pushed upward as you press barrier on; 7. Make sure the belt is attached to the ostomy pouch where the two tabs are, one on each side; 8. Apply stretch net to abdominal area; 9. apply [MEDICATION NAME] to any excoriated skin that is not covered by the ostomy wafer and pouch. If Resident pulls off his wafer and pouch between scheduled changes, follow the back up procedure: 1. clean the R abdominal area; 2. cover all skin with [MEDICATION NAME]; 3. cover stoma with an ABD pad, followed by a 1/2 diaper over the pad; 4. stretch net over abdominal area to hold dressing in place; 5. THE KEY TO THIS WORKING IS: the C.N.A.'s (sic) have to check him every 2 hours to make sure it is on and change it if soiled. We are working with (another facility name) also to increase his psych (psychiatric) meds so he will be calmer until the skin heals and he gets used to the routine." The following nurses notes were documented in the medical record for resident 45 after surveyors identified the concern regarding [MEDICAL CONDITION] care: a) 9/22/11 at 4:30 PM - "Residents ABD pads (changed) at 9:45 AM, 1:00 PM, and 3:00 PM. Redness around stoma appears as if it is a lighter pink in color. Resident drsg (changed) on wound per treatment book and cleansed. Resident c/o pain so pain meds given PRN @ 7:30 AM and 11:30 AM. Resident has been compliant with leaving ABD pads on today with constant reminders... Will continue to check and (change) ABD pads [MEDICAL CONDITION] q 2 h (hours) and PRN..." b) 9/22/11 at 9:30 PM - "Resident's drsg was changed and cleaned q 2 (hours) as directed. Pain (and) anxiety meds given as prescribed and at request. Resident has been compliant (with) leaving drsg on for this period of time - (4 PM - 9:30 PM). will pass on report to oncoming nurse and give instruction concerning drsg changes." c) 9/23/11 - the DON documented: "taken from weekly wound note - late entry to chart for 9/7/11" - "resident has an ostomy stoma in the R upper quadrant of his abdomen. He frequently pulls off his wafer and pouch which then allows liquid stool to drain on to his skin (and) clothes. Presently the R lat (lateral) abdomen down to his groin area is bright red (and) excoriated the area around the stoma 4 cm (centimeters) circumferential is bright red (with) serous drainage which makes skin very raw (and) makes ostomy wafer difficult to stick. Area treated (with) [MEDICATION NAME] to denuded skin then ABD pads, 1/2 brief and stretch knit over dressing.." d) 9/23/11 - the DON documented: "taken from weekly wound note - late entry to chart for 9/15/11" - "R lateral abdominal ostomy site continues to be red for 3 cm around the stoma, the lower abdominal area has much improved. [MEDICATION NAME] is used to denuded skin then ostomy pouch (and) wafer are placed on Tues/Fri (Tuesday and Friday). If resident pulls it off then [MEDICATION NAME] to denuded skin, ABD pad (and) 1/2 brief with stretch knit to stoma to help prevent skin break(down) until next scheduled ostomy wafer/ouch can be placed. This is an effort to protect skin, allowing healing so wafer will stick to skin..." e) 9/24/11 - The facility DON documented "Resident has left ostomy wafer (and) pouch on since it was placed on late afternoon of 9/22/11. The edges of the flange were starting to lift today (and) the midline dressing was loose (and) nearly off the wound. RN changed ostomy to perform cares. The wafer itself was still adhered to skin (and) was gently removed. There was approx (approximately) 100 cc (cubic centimeters) liquid stool in pouch. The skin under the wafer and under the stoma was pink and not weeping. The area was healed. RN reinforced with resident verbally that the skin was healed. Resident agreed that the skin did not hurt. We discussed and praised him for leaving the wafer (and) belt on. The procedure for ostomy care was to cleanse area - spray skin (with) No Sting barrier and skin protectant, apply a piece of eakins seal to a wrinkle of skin between wound (and) stoma and a piece from stoma laterally where the same wrinkle in the skin appears. This is to allow the wafer to fit level over the stoma (and) help prevent leaking from the wrinkle area. The wafer is molded to be a little larger than the stoma then placed over stoma (and) secured - the pouch is then snapped into placed. After the wound is dressed, the belt is secured to the wafer..." f) 9/23/11 at 8:00 AM - "RN (and) staff RN applied residents ostomy wafer and ostomy pouch before breakfast today. The skin around the stoma is improved from last week. Area of [DIAGNOSES REDACTED] is approx. (approximately) 3 cm wide circumferentially around stoma. Area cleansed (and) no sting spray applied - eakins seal placed at skin folds near midline wound (and) lateral side. Belt placed to hold ostomy wafer on (and) help stoma rise above skin line..." g) 9/23/11 at 9:20 AM - "RN checked ostomy (and) it was still intact." h) 9/24/11 - "RN checked ostomy (and) it was still intact but wound dressing was nearly off (and) edge of ostomy wafer was loosening. Wound (and) ostomy care performed..." i) 9/25/11 at 2:00 PM - "Pt. alert. Ostomy checked still intact. Bag emptied 50 mls (milliliters) out. Pt. has been emptying bag on own this shift as well. WCTM." j) 9/28/11 at 5:45 AM - "...Ostomy checked and intact. Bag emptied by CNA. Resident tried to empty bag on his own but CNA helped". k) 9/28/11 - "Changed bag (and) wafer, dressed wound. Ostomy looks good. Skin slightly red on (right) inner thigh (and) groin. [MEDICATION NAME] cream applied..." l) 9/29/11 at 7:00 AM - "Ostomy bag checked. CDI. 9:00 AM [MEDICAL CONDITION] checked (checked). Has air and liquid stool. Edges are intact, drsg remains intact (with) no fecal matter to drsg. Wound site to the (left) abd wound is also intact. CNA et RN to assist et teach pt. to empty bag. Pt. has gloves on and RN et CNA supervising the emptying of the bag. Pt. required cont'd (continued) supervision during the emptying of his bag. No redness noted around both drsg. Pt. is getting on toilet to empty rather than standing up to empty. this works well for him. Pt. needs to continue (with) this education and will check q 2 hrs to ensure that he will develop a routine habit... 11:00 AM - Colos ([MEDICAL CONDITION]) bag checked. Intact... 1:30 PM Pt. sitting on toilet. CNA (and) RN assist with [MEDICAL CONDITION] emptying. Req. (requiring) cueing, assist... 4:00 PM Pt. emptied [MEDICAL CONDITION] bag w/ supervision from CNA (and) RN." m) 10/1/11 at 7:00 PM - "At start of shift pt. checked. Asleep in bed. Easily arouseable. Asked if he was in pain. Stated no. Wafer et drsg checked to abd and (left) side of abd. CDI. No fecal leakage of [MEDICAL CONDITION] or no rolling of edges to colos. drsg. Bag has been burped and sm (small) amt (amount) of feces in bag. Wear pull ups and strap in place that helps keep colos. bag in place. Will watch CNA empty and assist pt. (with) removing feces in bag (with) stool precautions. 9:00 PM Drsg cont. to be intact. Pt. sleeping". n) 10/3/11 at 10:00 PM - "Resident pulled off wafer and was refusing to put one back on b/c (because) of pain. Pain medication was given. Resident was cleaned up and the (sic) was cooperative with letting nurse apply waffer (sic) and new drsg. Wafer and drsg apply per treatment book. Resident skin is red and raw in groin area bag balm applied to groin area. WCTM". Reference: Removing And Applying The [MEDICAL CONDITION] Appliance: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 10th Edition, Suzanne C. Smeltzer and Brenda Bare, Chapter 38, Pg. 1062-1063: "...Care of the [MEDICATION NAME] skin is an ongoing concern because excoriation or ulceration can develop quickly. The presence of such irritation makes adhering the ostomy appliance difficult, and adhering the ostomy appliance to irritated skin can worsen the skin condition. The effluent discharge and the degree to which it is irritating vary with the type of ostomy. With a [MEDICATION NAME], the stool is soft and mushy and irritating to the skin. With a descending or sigmoid [MEDICAL CONDITION], the stool is fairly solid and less irritating to the skin. Other skin problems include yeast infections and allergic [MEDICAL CONDITION]. If the patient wants to bathe or shower before putting on a clean appliance, [MEDICATION NAME] tape applied to the sides of the pouch will keep it secure during bathing. Then remove the appliance, the patient assumes a comfortable sitting or standing position and gently pushes the skin down from the faceplate while pulling the pouch up and away from the stoma. Gentle pressure prevents the skin from being traumatized and any liquid fecal contents from spilling out. The nurse advises the patient to protect the [MEDICATION NAME] skin by then washing the area gently with a moist, soft cloth and a mild soap. Soap acts as a mild abrasive agent to remove enzyme residue from fecal spillage. The patient should remove any excess skin barrier. While the skin is being cleansed, a gauze dressing can cover the stoma, or a vaginal tampon can be inserted gently to absorb excess drainage. After cleansing, the patient pats the skin completely dry with a gauze pad, taking care not to rub the area. The patient can lightly dust [MEDICATION NAME] ([MEDICATION NAME]) powder on the [MEDICATION NAME] skin if irritation or yeast growth is present. Smoothly applying the drainage appliance for a secure fit requires practice and a well-fitting appliance. Patients can choose from a wide variety of appliances, depending on their individual needs. The stoma is measured to determine the correct size for the pouch; the pouch opening should be about 0.3 cm (1/8 in (inch)) larger than the stoma. After the skin is cleansed according to the previously described procedure, the patient applies the [MEDICATION NAME] skin barrier (ie, wafer, paste, or powder). Mild skin irritation may require dusting the skin with [MEDICATION NAME] or [MEDICATION NAME] powder before attaching the pouch. The patient removes the backing from the adherent surface of the appliances, and places the bag down over the stoma for 30 seconds. The patient empties or changes the drainage appliance when it is one-third to one-fourth full so that the weight of its contents does not cause the appliance to separate from the adhesive disk and spill the contents. Most appliances are disposable . . .; commercially prepared deodorizers are available..." On 9/22/11 at 7:45 AM, resident 45 was observed to be laying on his right side in bed. Resident 45 was observed to have several soaked bandages over the [MEDICAL CONDITION] site with yellowish stool running down the residents lower abdominal area onto the bed linens. The skin surrounding the [MEDICAL CONDITION] appeared to be beefy red. Resident 45 stated that the skin on his abdomen was tender. On 9/22/11 at 10:30 AM, resident 45 was observed to be laying in bed. He appeared to have a clean, thick bandage over the abdominal area with paper tape over the entire surface. On 9/22/11 at 7:57 AM, CNA 8 was interviewed. CNA 8 stated that resident 45 pulled off the [MEDICAL CONDITION] bag and wafer. She stated that she was instructed to put a brief on him after he pulls off the [MEDICAL CONDITION] supplies and then notify the nurse. On 9/22/11 at 8:04 AM, RN 2 was interviewed. RN 2 stated that resident 45 ripped off the [MEDICAL CONDITION] supplies and that he was "going through the bags". She stated that it was hard to keep a bag on him. On 9/22/11 at 8:10 AM, RN 4 was interviewed. RN 4 stated that she tried to put a wafer and [MEDICAL CONDITION] bag on resident 45 but that resident 45 pulled the supplies off. She stated that when the resident pulled off the [MEDICAL CONDITION] supplies she applied a barrier cream and an ABD Pad. She stated that the ABD pad was to be changed every 1-2 hours and that his skin was "very raw". On 9/22/11 at 10:45 AM, RN 4 was re-interviewed. RN 4 stated that she had applied "Bag Balm" to the excoriated area on resident 45's abdominal area instead of the ordered [MEDICATION NAME] as they were "the same". RN 4 stated that resident 45 was on a behavior modification program because he "rips the bags off". She stated that the facility DON provided the nursing staff with enough [MEDICAL CONDITION] supplies to last for a week. RN 4 stated that the facility was currently out of the "netting". On 9/22/11 at 11:00 AM, the facility DON was interviewed. The DON stated that resident 45 was on a "behavior modification program" related to the [MEDICAL CONDITION] bags and that the resident pulled off the wafers. She stated that the resident was "allowed 2 changes a week - maybe 3" if she thought that it was appropriate. She stated that if she did not monitor the wafers and the bags, that the resident would run out of supplies. The DON stated that the current order was to apply [MEDICATION NAME] to the excoriated area on the abdomen as it had "healing properties", and apply an ABD pad with a brief over the ABD pad when resident 45 removed the [MEDICAL CONDITION] supplies. The DON stated that the [MEDICAL CONDITION] supplies were stored in her office and that she provided the nursing staff with enough supplies to last a week. The DON stated that her office was locked when she was not at the facility and that the nursing staff did not have access to her office when she was gone. On 9/22/11 at 1:43 PM, the facility Administrator was interviewed. The Administrator stated that the "DON misspoke" when she reported to the State that resident 45 was on a "behavior modification schedule". He stated that resident 45 was on a "medical management" program, not "behavior modification". On 9/22/11 at 2:20 PM, the facility DON was re-interviewed. The DON stated that resident 45 was on "medical management" program due to not leaving the [MEDICAL CONDITION] supplies in place. She stated that the [MEDICAL CONDITION] supplies were "very expensive." The DON stated that she was not aware that the facility nurses were using bag balm to treat the excoriated area instead of the ordered [MEDICATION NAME]. On 9/28/11 at 9:48 AM, CNA 2 was interviewed. CNA 2 stated that resident 45 was "not fully there" and was unable to determine right from wrong. She stated that she was told by facility administration that the facility was "unable to buy the bags and wafers". She stated that she was instructed by the DON to put a brief over the resident's [MEDICAL CONDITION] site when he pulled the [MEDICAL CONDITION] supplies off. She stated that she felt that resident 45 was "being punished" and that she "doesn't feel it's right to punish someone that way". A confidential staff interview was conducted after the recertification survey was initiated on 9/26/11. The staff member

Based on interview, observation, and medical record review it was determined for 3 sample residents, that the facility did not provide or obtain from an outside resource routine dental services to meet the needs of each resident. Specifically, residents with visible dental issues were not afforded the opprotunity for dental care due to their payor source being Medicaid. Resident identifiers: 40, 43, and 66. Findings Include: 1. Resident 66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/3/11 resident 66's medical record was reviewed. On 6/3/11 facility staff completed an admission Minimum Data Set (MDS) assessment for resident 66. Facility staff assessed resident 66 as receiving a mechanically altered diet. Resident 66 was assessed as having obvious or likely cavity or broken natural teeth. The Care Area Assessment (CAA) for Dental Care was triggered on the MDS and facility staff indicated on the CAA that Dental Care would be addressed in the care plan. Review of the medical record revealed a quarterly MDS dated [DATE]. Facility staff assessed resident 66 as not having a 5% weight loss in the last month, or a 10% weight loss in the last 6 months. Resident 66 was assessed as receiving a mechanically altered diet and a therapeutic diet. Facility staff assessed resident 66 as having mouth or facial pain, discomfort or difficulty with chewing. Review of the admission assessment revealed that facility staff assessed resident 66 as having "poor-broken and worn down teeth" upon admission to the facility. Review of resident 66's care plan revealed a care plan dated 6/6/11 for "At nutritional risk r/t (related to) pt. (patient) has stage II pressure ulcer." The goal for the care plan was resident 66 would receive adequate amounts of nutrition to maintain resident's needs through next review. Facility staff listed the following interventions to accomplish the indicated goal: "meds (medications) as ordered, assess causative factors, provide interventions as ordered to address causative factors, offer additonal snacks/fluids as ordered, staff will assist resident as needed to eat meals/snacks, assess resident's acceptance of foods offered, monitor labs and weights as ordered, notify MD (Medical Doctor) for any abnormal findings or inability of resident to maintain adequate nutritional intake/balance, review in weekly NAR (Nutritional At Risk), diet as ordered, honor food preferences within therapeutic needs, oral care q (every) shift." Resident 66's medical record also contained a care plan for dental care dated 6/6/11. Facility staff care planned resident 66 as having poor dentition related to dietary habits, ineffective oral hygiene manifested by worn down or abraded teeth, tooth fractures, and missing teeth. The goals listed on the care plan were "pt. will have no further tooth loss unless unavoidable through next review, pt. will receive adequate nutritional and fluid intake (manifested by weight) through next review and evaluate every monthly summary and every IDT (Interdisciplinary Team) meeting." Facility staff listed the following interventions to achieve the stated goal: "assist with or provide oral care as indicated, administer [MEDICATION NAME] antibiotic therapy prior to dental procedures, weight as ordered, diet as ordered and tolerated, refer to appropriate care providers as ordered." Review of nurse's notes revealed an entry dated 8/30/11. A facility nurse documented, ..."Res. (resident) has had a slow weight loss and her teeth are bothering her. Res has a mech (mechanical) soft diet and says her teeth are partly why she doesn't eat well...." On 9/14/11 a facility nurse documented, "... on assessment pt has broken and missing teeth, she states that they bother her at times. ..." No documentation could be found to show facility staff notified the MD regarding any abnormal findings or inability of resident 66 to maintain adequate nutritional intake. Review of social service notes revealed no documentation regarding resident 66's dental status or appointments made for resident 66 to see a dentist. Review of resident 66's weight history revelaed an admission weight of 126 pounds (lbs). Review of the facility weight documentation revealed that in July of 2011 facility staff documented resident 66 weighed 126 lbs. In September of 2011 facility staff documented that resident 66 weighed 118 lbs. On 10/3/11 resident 66 was observed to be weighed by the Director of Nursing. Resident 66 was observed to weigh 114 lbs. Calculations revealed that resident 66 had lost 9.5% body weight in a 3 month time period. On 10/3/11 at 9:30 AM, resident 66 was interviewed regarding her dentition. Resident 66 stated that she was told by a dentist at one time that she needed dentures. Resident 66 stated that she had not seen a dentist since being at the facility. Resident 66 further stated that her teeth hurt when she was given hard things to eat, but if the foods were soft she could chew them "okay". Resident 66 stated that she had not had any dental work done due to the cost. Resident 66 further stated that if the facility paid for it she would have dental work done or her teeth pulled. On 10/5/11 at 10:35 AM, the SSW (Social Services Worker) was interviewed. The SSW stated that there were resources that the Transport worker knew about to get dental assistance for residents without funding. The SSW further stated that she did not get involved with dental concerns. On 10/3/11 at 9:45 AM, Registered Nurse (RN) 3 was interviewed. RN 3 stated that if she assessed a resident as having problems with their teeth she would let the medical director know and the medical director would then make a referral for the resident to see a dentist. RN 3 further stated that if the resident had medicaid as a payor source then the referrals were not made because medicaid would not cover dental expenses. RN 3 stated that because resident 66 had medicaid she did not inform the medical director of resident 66's poor dentition. RN 3 stated that resident 66 did not have the money to pay for the dental care and her payor source was medicaid. RN 3 further stated that "it would not have done any good to inform the medical director" of the bad dentition due to resident 66's payor source. RN 3 stated that she wished the facility would "hurry and get an in-house dentist to see patients and provide dental services." 2. Resident 43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 43 was interviewed on 9/27/11. It was observed during the interview that the resident had several areas of decay on his lower teeth near the gum line. Resident 43's gums were observed to be inflamed, with food and a build up of tartar present on his teeth. Resident 43's medical record was reviewed on 10/3/11. The Comprehensive MDS dated [DATE] revealed in section L that the resident had broken teeth, cavities, and inflamed gums. The CAA summary indicated the area of dental care triggered and the issue would be addressed in a plan of care. Further review of resident 43's medical record revealed no evidence of a dental plan of care. Nursing could not provide evidence that a dental care plan existed for resident 43. Nursing notes dated 9/22/11 and 9/29/11 documented that resident 43 required total assistance with activities of daily living (ADL), including oral hygiene. CNA 3 and CNA 8 were interviewed on 10/4/11 at 3:00 PM. CNA 3 and CNA 8 both stated that resident 43 required 2 staff members to assist resident 43 with his ADL's related to his behaviors. When asked what assistance resident 43 required, CNA 3 and CNA 8 stated they would assist him to brush his teeth each day by placing toothpaste on his toothbrush and monitor him while he was brushing his teeth to ensure he cleaned them. Both CNAs stated that they had not noticed that resident 43 had inflamed gums. On 10/4/11 at 10:15 AM an interview was conducted with RN 2. RN 2 stated that if a resident had dental problems staff would inform the medical records director (MRD) or the Social Services Worker (SSW). RN 2 further stated that the MRD or SSW would make an appointment with a dentist or with the free clinic that provided low/no cost care to persons in need. RN 2 then stated that she did not know if resident 43 had seen a dentist. On 10/5/11 at 2:00 PM an interview was conducted with the SSW. The SSW stated she was not aware of any dental issues with resident 43. The SSW then stated, "No one should have to deal with rotting teeth even if they don't complain of pain." 3. Resident 40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/27/11 at 8:08 AM, resident 40 was interviewed. Resident 40 stated that he had problems with chewing food due to a "top tooth abscess that "needed to be taken care of." Resident 40 further stated that he was missing most of his back molars. On 10/3/11 resident 40's medical record was reviewed. On 8/16/11 facility staff completed an admission MDS assessment for resident 40. Facility staff assessed resident 40 was assessed as having obvious or likely cavity or broken natural teeth. The CAA for Dental Care was triggered on the MDS and facility staff indicated on the CAA that Dental Care would be addressed in the care plan. Resident 40's medical record contained a care plan for dental care dated 8/16/11. Facility staff care planned resident 40 as having impaired dentition related to chronic use of tobacco, coffee tea or red wine, ineffective oral hygiene and barriers to self care manifested by worn down or abraded teeth, tooth fractures, and missing teeth. The goals listed on the care plan were: "pt. will receive adequate nutritional and fluid intake (manifested by weight) through next review and evaluate every monthly summary and every IDT (Interdisciplinary Team) meeting." Facility staff listed the following interventions to achieve the stated goal: "assist with or provide oral care, as indicated, administer [MEDICATION NAME] antibiotic therapy prior to dental procedures, weight as ordered, diet as ordered and tolerated, refer to appropriate care providers as ordered." On 10/5/11 at 10:35 AM, the facility SSW was interviewed. The SSW stated that she did not get involved with residents that required dental assistance as the MRD did all of that. The SSW further stated that there were resources that the MRD knew regarding funding to assist residents without dental funding. On 10/5/11 at 10:40 AM, the MRD was interviewed. The MRD stated that she had not been notified by the nursing staff that resident 40 had complained of tooth pain and had requested to see a dentist. Review of the medical record revealed no documentation that the facility referred resident 40 to a dentist or that resident 40 was seen by the medical director for his teeth. No documentation could be found to show facility staff implemented the care plan and referred resident 40 to appropriate care providers for his teeth.