Every finding on record at Odin Health and Rehab Center

Based on interview and record review the facility failed to notify the physician for a resident's change in condition for 1 of 3 residents (R1) reviewed for changes in condition in a sample of 13. This failure resulted in R1's hospitalization for sepsis and subsequent death.This failure resulted in an Immediate Jeopardy, which was identified to have begun on 10/5/25 when the facility staff failed to notify the physician that R1 had decreased urine output and oral intake, was refusing to eat, and appeared lethargic. On 10/7/25, R1 was found to have a worsened pressure ulcer and a sharp decline in R1's overall condition and was sent to the ER (Emergency Room). R1 expired on 10/8/25 with a cause of death of Sepsis. The findings include: R1's Face Sheet documented an admission Date of 3/3/22 and listed Diagnoses including Asthma, Peripheral Vascular Disease, Hypothyroidism, Bipolar Disorder, Hypertension, and Diabetes Type 2. R1's Minimum Data Set, dated [DATE] documented that R1 was severely cognitively impaired, had an indwelling catheter, and was totally dependent on staff for eating, showering, toileting, and transfers. An October 2025 Wound Log documented that R1 had a stage 4 pressure wound to the sacrum and a stage 4 pressure area to the right heel. R1's Care Plan dated 9/17/25 documented problem areas, Resident is a full code, and, Resident has impaired skin integrity as evidenced by right heel arterial ulcer, sacrum pressure ulcer related to impaired cognition, incontinent of bowel, poor nutritional intake, with a corresponding intervention, Notify Physician/Nurse Practitioner/Physician's Assistant of signs/symptoms of infection(new or change in type/amount/color of drainage, bleeding, foul odor) . R1's October 2025 Physicians Orders Sheet (POS) documented orders for a daily skin check using the CROPS method (Clear Red Open Pressure Skin Tear), daily foot check, contact Isolation for ESBL (Extended-Spectrum Beta-Lactamase) in the urine, and (trade name) indwelling catheter, (check) output two times a day. This same POS documented treatment orders as follows:Non pressure chronic ulcer of the right heel: Cleanse with normal saline, apply Medihoney, apply bordered gauze, (change) every Tuesday, Thursday, Saturday, and as needed, order date 9/24/25.Pressure ulcer to Sacrum: Cleanse with wound cleanser, apply collagen hydrogel, collagen particles, silver sulfadene, and calcium alginate to base of the wound, change every Tuesday, Thursday, and Saturday and as needed, order date 9/24/25.R1's October 2025 Treatment Administration Record (TAR) documented the above wound treatment orders, with a blank space for day shift 10/4/25, indicating the treatments to the wounds of the sacrum and right heel had not been done. R1's October 2025 Follow Up Questions Report, Fluid Intake, Catheter Output, and Eating and Amount Eaten, (CNA output charting) and October 2025 TAR (Nurse output charting) documented the following total urine outputs:10/1/25: 720cc (cubic centimeters). 10/2/25: 775cc. 10/3/25: 940cc. 10/4/25: 240cc. 10/5/25:1775cc. 10/6/25: 1920cc.R1's October 2025 Follow Up Questions Report, Fluid Intake, Catheter Output, and Eating and Amount eaten documented the following meal and fluid intakes:10/1/25: Breakfast: 0-25% (percent) Lunch: 0-25%. Supper-blank, not documented. Fluids total 720cc.10/2/25: Breakfast: 76-100%. Lunch 76-100%. Supper-blank, not documented. Daily fluid total: Blank, not documented.10/3/25: Breakfast: 76-100%. Lunch: 76-100%. Supper-blank, not documented. Daily fluid total: 940cc.10/4/25: Breakfast: 26-50%. Lunch and supper: Blank, not documented. Daily fluid intake total: 240cc.10/5/25: Breakfast, lunch, and supper refused. Daily fluid intake total: 1300cc.10/6/25: No documentation on any meals. Daily fluid intake total:120cc.R1's Wound Assessment Reports, authored by V4 (Wound Care Nurse Practitioner) documented the following:9/30/25: Stage 4 pressure area, sacrum: Facility acquired: No. Wound status: Improving with delayed wound closure. Length: 9.00 cm (centimeters), Width: 9.00 cm long by width: 81.00 cm, 2 Depth: 6.00 cm. 70% granulation (tissue), 30% slough. Undermining: from 6 o'clock to 9 o'clock, 6.0 cm. Heavy seropurulent drainage. Odor post cleansing: Malodorous. Arterial ulcer right heel: Acquired in facility: Yes. Wound status: Improving with delayed wound closure. Moderate amount of seropurulent drainage. Odor post cleansing: None. % Granulation: 50% granulation % Slough: 30% slough % Eschar: 20% eschar.10/7/23: Stage 4 pressure area, sacrum: Facility acquired: No. Wound status: Worsening. Length: 9.00 cm Width: 12.00 cm long by width: 108.00 cm. 2 Depth: 6.00 cm.0% Granulation, 100% slough. Undermining: from 6 o'clock to 9 o'clock, 6.0 cm. Heavy amount seropurulent drainage. Odor post cleansing: Malodorous. Arterial ulcer right heel. Acquired in facility: Yes. Wound status: Improving with delayed closure. Moderate amount of seropurulent drainage. Odor post cleansing: None. % Granulation: 50% granulation % Slough: 30% slough % Eschar: 20% eschar. R1's Nursing Progress note dated 10/7/25 at 10:42am, authored by V3 (Registered Nurse/RN) documented: Wound rounds completed with (V4). Recommendations received to send (R1) to hospital due to worsening sacral ulcer with possible infection and decreased urine output over the last 24 hours. (V4) contacted family members who were thankful for the update and agreed with the recommendations. MD (Medical Doctor) aware.R1's Provider Skin and Wound Note dated 10/7/25 at 1:18pm, authored by V4 documented, Evaluation for follow-up of wound sacrum stage 4 pressure ulcer, current/prior treatments include (trade name sodium hypochlorite solution) collagen, hydrogel, silver sulfadene cream, and calcium alginate. Right heel arterial ulcer, treatment stalled and changed to Santyl. After assessment of wound today, consult was conducted with staff, (V3), and (review of history and physical) and it was decided that patient would be sent to the hospital due to deteriorating wound over the last 4 days. Wound bed to sacrum is necrotic and malodorous with heavy amounts of purulent drainage. According to staff, resident has also felt warm to touch and had very little urine output since (10/5/25) Sunday per her (indwelling) catheter. Urine present in (catheter) bag was dark and had sediment present. Resident was not eating well and looked more tired than usual. She reports she feels terrible at this time. Family was contacted and agreed that (R1) would be sent to (local hospital) for further work up, diagnostic testing, and IV (Intravenous) antibiotic therapy.R1's ED (Emergency department) Provider Note dated 10/7/25 at 1:07pm documents Chief Complaint: Skin Ulcer, Failure to Thrive, Oliguria. The patient is a [AGE] year-old female that presents the emergency department for the evaluation of progressive weakness, failure to thrive, not wanting to eat or drink, and decreased urine output. The patient resides at (the facility). This has been going on for several days and getting progressively worse. Patient has used a [sic] oriented to self but not very communicative. The staff is concerned that the patient has a sacral ulcer which has been present for some time now but getting progressively worse. The patient is not a very good historian. She denies any pain. She is pretty somnolent and appears fatigued. She does help us assess enroll [sic] her. The Physical Exam documents: Constitutional: Negative for fever. Appearance: She is ill-appearing and toxic-appearing. Comments: The patient is pale. Oriented to self but not very interactive, according to the NH (Nursing Home) this is her baseline. Under Musculoskeletal documents: Large (Sacral) Decubitus to the bone. Foul odor. No active drainage. Pictures in chart. The patient has bilateral heel ulcers. An ED Provider Note dated 10/8/25 at 9:37 AM documents The patient remained fairly somnolent her whole stay here. Her vitals remained normal but she had minimal interaction. She would deny any pain when I asked her. The patient is to be transferred to (local critical access hospital) but we are still waiting for a bed at this time.R1's ED Provider Note dated 10/8/25 at 5:53pm documents The patient was moaning in the room The nurse went in to talk to her and the patient denied any pain. She then went apneic and bradycardic. This is shortly before 7 am today. The patient was immediately started to bag and we called family to see if they wanted her to be in fact a full code which they confirmed. At that point the patient was intubated. She became more bradycardic and we did not feel strong pulses, epi (epinephrine) was given and CPR (Cardio Pulmonary Resuscitation) was initiated. The patient was successfully intubated and not very responsive. Levophed was started, the patient was given 3 more doses of epi and her heart rate was just erratic she would be bradycardic PA 1 (clinical reference not found) rhythm looked like the [sic] tach (tachycardia) and she was shocked. The patient just was not responding to interventions. We have has been waiting for family to come but the patient was not doing well not responding to all aggressive measures and the resuscitative effort was stopped. The patient stopped making any attempt at spontaneous respirations. I cannot palpate any pulses or obtain a blood pressure. She was on full dose of Levophed, had head [sic] rounds of epi, CPR and at that time I decided it was time to stop these resuscitative efforts. I could never recovered [sic] the patient. This started approximately 7:00 a.m. this morning and we pronounced the patient is (dead at) 7:49 (am). Post procedure diagnoses: 1. Dehydration. 2. Hyperglycemia. 3. Failure to Thrive in Adult. 4. Skin ulcer of sacrum with necrosis of bone. 5. Urinary Tract Infection without Hematuria, site unspecified. 6. Sepsis, due to unspecified organism, unspecified whether acute organ disfunction present.R1's Culture Wound +Gram Stain Report for the sacrum from the hospital records dated 10/7/25 from the hospital records documented, Result: Positive: Heavy gram-positive cocci. Positive: Heavy gram-negative bacilli. R1's Blood Culture results from the hospital records collected on 10/7/25 documents culture results on 10/9/25 document growth of Staphylococcus hominis and Gram positive cocci in clusters.R1's Death Certificate documents a date of death of [DATE] with Cause of Death: A. Sepsis.On 10/30/25 at 8:55am, V9, R1's Power of Attorney, stated R1 had resided at the facility about 4 years. V9 stated R1 had been being treated by V4. V9 stated on the morning of 10/7/25, V4 called her and said that (R1) was very sick, not eating or drinking, no urine output, and needed to be sent to the hospital. V4 stated R1 died in the hospital less than 24 hours from being admitted . V4 stated nobody from the facility called in the days prior to inform her that R1's condition had declined. V4 stated she got R1's Death Certificate which lists the cause of death as Sepsis. V4 stated she believes R1 was septic from her wounds and that, Poor care had to have caused the sepsis, which caused her death.On 11/4/25 at 11:05am, V4 stated she started coming to the facility on 7/8/25. V4 stated she performs quarterly skin assessments on all residents, and it is staff's responsibility to notify her of any new skin issues or wound deterioration. V4 stated she assumed care of R1 on 7/8/25, and prior to that other wound care providers employed by V4's company were taking care of R1. V4 stated R1 had a stage 4 pressure ulcer to the sacrum and an arterial wound to the right heel. V4 stated the arterial wound was improving and the sacral wound was also responding well to treatment and was improving. V4 stated R1 had chronic conditions which are barriers to healing such as being in bed most of the time, Diabetes, incontinence of stool, and Peripheral Vascular Disease. V4 stated she last evaluated R1 on 10/7/25. V4 stated at the door of R1's room she was met with a strong necrotic smell, which was not usual for R1. V4 stated as she was entering, an unknown CNA (Certified Nursing Assistant) stated that R1 had had very little urine output, had been warm to the touch, and had little intake of food or fluids since 10/5/25. V4 stated the urine in R1's catheter bag was scant, less than 100cc, very dark, and contained sediment. V4 stated R1 was alert but confused, her baseline, but told V4 she, Felt like (expletive). V4 stated examination of the sacral wound showed it was obviously worse, with heavy, purulent drainage and a very strong necrotic odor, and the heel wound was about the same as it had been the previous week. V4 stated she told staff the resident needed to go to ER due to signs of wound infection, and arrangements were made. V4 stated she called (V9) to say R1 was going to the hospital due to a decline in her health, and V9 stated nobody from the facility had called V9 to report R1 had declined. V4 stated the facility had not notified R1's Physician about her decline and the signs of infection. V4 stated, The sacral wound did not get worse overnight. The wound most likely deteriorated because her body was shutting down. (R1) should have been sent to the hospital sooner, when she had decreased intake and output.On 11/4/25 at 12:58pm, V3, Registered Nurse/Wound Care Coordinator, stated he started in the position on 9/16/25. V3 stated R1's heel and sacral wounds were, Stable, until he and V4 rounded on 10/7/25 and found the sacral wound had deteriorated. V3 stated he works Monday through Friday, and R1 was sent to ER Tuesday 10/7/25. V3 stated he worked Monday 10/6/25 but doesn't recall any staff saying anything about R1 declining over the weekend. V3 stated on that date he did a skin check on R1 and there were no new skin issues noted, including the left heel. V3 stated he could not remember when the dressings on the wounds were dated when he saw them on 10/6/25 or 10/7/25. When asked if he was aware the 10/4/25 wound care treatments had not been done, V3 stated he was not aware, and if it had been done it would be documented on the TAR. V3 confirmed that prior to going in to see R1 with V4 on 10/7/25, V8, CNA, stated R1 had declined, I can't recall specific details, but I think it had to do with poor intake of food and fluids. V3 stated he recalls V4 removing the sacral dressing but does not remember the date or who signed it. V3 stated when they looked at the sacrum, the wound looked worse and had purulent drainage. V3 stated he thinks at that point he checked R1's vital signs but could not find them in the chart. When asked if R1 had a fever, V3 stated he did not recall her vitals being out of normal range. V3 stated R1 was then sent to the ER upon the orders of V4. On 11/4/25 at 210pm, V8, CNA, stated meal intakes are not to be left blank on the documentation, and that if a resident refuses a meal, it is to be charted. V8 stated 10/7/25 was the first day she had worked with R1 in a while. V8 stated in report she was told R1 had poor food and fluid intake and had very little urine output. V8 stated R1 looked tired, felt clammy and sweaty, and had a very small amount of brownish urine in her catheter bag. V8 stated she does not recall looking at the dressing on R1's right heel, but the dressing on the sacral wound was falling off, soaked with drainage, and she does not remember what it was dated, But it did have (V3) initials on it. V8 stated she did not get vitals on R1, V8 stated at the facility it is the nurse's responsibility to do vitals. V8 stated R1 refused breakfast and almost all fluids that morning. V8 stated she informed the charge nurse, V16 Licensed Practical Nurse, of R1's status and the condition of the dressing, but by that time, V3 and V4 were going in to see her. On 11/4/25 at 320pm, V11, RN, confirmed she worked 7am to 7pm on 10/4/25. V11 stated it was the only shift she worked alone at the facility as she was prn (as needed/ on call) staff. V11 stated she did not really remember anything about any of the residents. When asked about there being no documentation that R1's wound treatments were done that day, she stated, If I didn't document them, I'd say they weren't done. On 11/5/25at 10:45am, V16 (Licensed Practical Nurse/ LPN) stated she worked 7am to 7pm on both 10/6/245 and 10/7/25. V16 stated on weekends, the floor nurses are responsible for dressing changes, with V3 being responsible through the week. V16 stated on one of those days, an unknown CNA, possibly on night shift, told her the dressing to the sacrum had come off during incontinence care. V16 stated she noted a large amount of yellow slough on the wound which had not been present when she had previously changed the dressing, date unknown. V16 stated additionally, the wound had a foul odor and yellow drainage, and the wound bed was darker. V16 stated she did not recall looking at R1's heel wound. V16 stated she didn't specifically recall R1's urine output but, It was probably inadequate but not unexpectedly so. V16 stated she didn't remember specifically about R1's fluid intake but nobody had reported her refusing food or fluids. V16 stated she did not remember anything about charting on R1, including documenting a dressing change. V16 stated she could not remember hearing anything specific about R1 in report. V16 stated she did recall on Monday, 10/6/25, being aware the sacral wound had deteriorated, but did not feel the need to notify the Physician as she knew V4 was to evaluate R1 the next day. V11 stated she recalled that on the morning of 10/7/25, R1's urine output had decreased, and V4 sent her to the ER. On 11/5/25 at 11:05am, V13, LPN, stated she worked with R1 on the 7am to 7pm shift on both 10/3/25 and 10/5/25. V13 stated on 10/3/25, she recalled R1's fluid intake and urine output were adequate. V13 stated she recalled that R1 had seemed lethargic and was not wanting to eat on 10/5/25 but does not recall what her fluid intake or urine output was like. V13 stated on 10/5/25 R1, was not acting like herself. V13 stated she did not recall checking her vital signs. V13 stated most residents' vital signs are checked once a week on Friday and in between as needed. V13 stated she did not change the sacral dressing as that is V3's responsibility Monday through Friday. V13 stated she does not recall any odor coming from the wound, but R1's urine did smell strong. V13 stated she did recall telling the oncoming night shift nurse on 10/3/25, V14, Registered Nurse, that R1 had been refusing to eat. V13 stated she did not feel any need to contact the physician about R1. On 11/5/25 at 12pm V15, RN, stated she worked with R1 on 10/5/25 from 7pm to 7am. V15 stated she does not recall hearing anything concerning about R1 in report. V15 stated V3 does the wound care treatments through the week and the floor nurses do them only on the weekends unless needed. V15 stated she did not recall changing R1's sacral dressing or looking at the dressing and therefore would not have noticed odor to the wound. V15 stated at the end of the shift an unknown CNA told V15 that R1 hadn't had much urine output. V15 stated she checked R1's catheter and it was draining ok, and the urine was light yellow. V15 stated she does not recall how much output or fluid intake R1 had during that shift. V15 stated she does not recall if vital signs were taken on R1, nor does she recall CNA's reporting the resident felt warm. V15 stated nothing in R1's clinical presentation necessitated calling her Physician. On 11/5/25 at 105pm, V12, Physician/Medical Director, stated R1 had multiple comorbidities including Diabetes, Dementia, Hypothyroidism, Failure to Thrive, and Sleep Apnea. V12 stated several months ago R1 had been treated by an infectious disease specialist due to a history of osteomyelitis in the sacral wound and had been on and off antibiotics several times, as due to her overall condition and comorbidities she had difficulty fighting infection. V12 stated R1 had also recently had ESBL in the urine. V12 stated he was aware R1 had wounds which were being treated by V4. V12 stated in having reviewed R1's care, he noted the facility did not contact him in the days leading up to R1's death, but stated they should have, Called him immediately for any change in condition, especially not eating or drinking or low urine output. V12 stated he would have given orders for R1 to be sent out immediately. V12 stated he had reviewed the ER report, which showed R1's vital signs were pretty stable on admission, her labs in his opinion did not reflect kidney failure but did reflect she was dehydrated. V12 stated R1was stabilized in ER and they were waiting for a bed to transfer her to a critical access hospital when R1 coded. V12 stated R1 could have sustained a Myocardial Infarction or a Pulmonary Embolism. V12 stated he did not fill out the death certificate but was aware it had listed the cause of death as sepsis. When asked if sending R1 out earlier could have prevented her death, V12 stated, It's hard to say. When asked if the dressing not being changed on 10/4/25 could have caused the sepsis, V12 stated it could have. V12 stated with R1's history of wound infections, staff should have been more alert to changes in the wound signaling infection. On 11/6/25 at 9am, V18, LPN, stated she worked the 7pm to 7am shift on 10/6/25 and took care of R1. V18 stated she recalled R1 was having dark urine and decreased output but does not specifically remember the amount. V18 stated nursing staff are informed about urine output by the CNA's and the nurses put it in the chart. V18 stated, I know we were to be keeping an eye on her urine (output). V18 stated she thought she recalled hearing in report that R1 was on hospice. V18 stated she did not recall any other staff saying anything about poor fluid intake. V18 stated she did not think she changed or looked at R1's wound dressings that night but does recall R1 had some odor to the coccyx wound. V18 stated she thought she recalled somebody mentioning in the facility's nursing staff group chat, date unknown, that the wound had odor and probably needed to have the treatment changed. V18 stated all nursing staff including administrative nursing staff are tagged in this chat. Nobody reported to V18 that R1 was feeling warm, and V18 does not think R1's vitals were checked. V18 stated there was nothing in R1's presentation that she felt she needed to call her Physician about. On 11/6/25 at 10:20am V17, CNA, stated the urine outputs are to be reported to the nurse who will chart it, and the CNA then documents, N/A (not applicable) on the output for that shift. V17 stated she worked with R1 from 6pm to 6am on 10/5/25. V17 stated she recalled hearing in report that R1 was not eating much. V17 stated R1 looked, Tired, sick and lethargic and maybe dehydrated. V17 recalled R1's urine looking 'darkish.' V17 stated when a resident such as R1 has a catheter, the CNA's are to report the output to the nurse who then charts it. V17 stated on the night shift there are fewer opportunities to offer fluids as most residents are asleep. V17 stated she thinks she offered R1 fluids but is not sure. V17 stated she recalled seeing a clean dry dressing to the sacral area. V17 stated she does not recall any areas to the heels. V17 stated the sacral wound, Had an odor to it, you couldn't smell it at her door, but you could smell it at the bedside. V17 stated she did not specifically recall informing the nurse about the odor. On 11/6/25 at 11:15am, V1, Administrator, stated that V14, the nurse who worked with R1 from 7pm to 7am on 10/3/25 and 10/4/25, is currently off work with a cardiac condition. On 11/7/25 at 9:10am, V5, LPN/Resident Care Coordinator, when asked about the discrepancy in some adequate urine output observations in the charting, staff were reporting the output was decreased, stated it is possible the charting was incorrect. V5 stated having both CNA and Nursing staff separately chart the output was confusing, so the policy has been changed the CNA's being responsible for it from now on. V5 stated it is also possible that the previous shift did not empty the catheter, making the output on the next shift larger. V5 stated she was not aware there had been a staff group chat about R1's condition, but in any case, it is not an appropriate way to inform staff of a change in resident condition. V5 stated looking back at everything, when R1 refused all 3 meals on 10/5/25, and had a urine output of less than 500cc, staff should have notified V12. V5 acknowledged staff were aware R1's family wanted all needed lifesaving interventions for R1.A Change of Condition Notification Policy dated 10/7/22 documented, It is the responsibility of the charge nurse to notify the physician and the responsible party of the resident's condition. It is the responsibility of all staff members to notify the charge nurse and/or the Director of Nursing of noted changes in a resident's condition. The resident's physician and responsible party will be notified of any changes that occur in the resident's condition by licensed personnel as warranted. These changes are to include but are not limited to; (In part:) Symptoms of an infectious process; New onset or change in pressure ulcers; Change in level of consciousness. The Immediate Jeopardy that began on 10/5/25 was removed on 10/30/25 when the facility took the following actions to remove the immediacy and correct the deficient practice:1. A full house review of all residents with wounds was conducted and was completed by V2, Director of Nurses, on 10/30/25, to verify current wound status and ensure any noted decline was promptly communicated to the physician.2. On 10/30/25, V2 conducted a 72-hour audit of all residents for change in condition. This audit included a review of Nurses Notes, Progress Notes, and Alert Charting for the 72-hour period prior completed by V2 and V5.3. A full-house review of all residents was completed by V3 and V5 on 10/30/25, to verify current wound status and ensure any noted decline was promptly communicated to the physician. Any discrepancies identified were immediately corrected through direct physician notification and documentation updates.4. On 10/30/25, all licensed nursing staff received education by V2 and V5 on the requirements at F580, emphasizing timely physician and responsible party notifications for any change in condition, abnormal labs/vitals, new or worsening wounds, decreased urine output/fluid intake, and functional decline, and appropriate documentation of same. Certified Nursing Assistants (CNAs) were re-educated to immediately report any observed changes in condition to the charge nurse by: V2 (Completed 10-30-25).5. On 10/30/25, V22, Corporate Nurse, and V22, Corporate Chief Operating Officer, reviewed the facility's Physician Notification and Change in Condition Policies, with no changes made.6. V2 will conduct the following ongoing monitoring activities:a. Conduct daily reviews of the Nursing 24 Hour Report for 8 weeks to verify timely and accurate physician/responsible party notifications.b. Review a minimum of three (3) random resident charts weekly for eight (8) weeks to confirm compliance with F580 documentation standards.c. Immediately correct and reeducate any staff involved in identified discrepancies.d. Present audit findings and corrective actions during weekly Quality Assurance /Interdisciplinary Team Meetings.e. Provide ad hoc education and reinforcement as indicated.7. V1, Administrator, will conduct the following ongoing monitoring activities:a. Validate and monitor V2's audit outcomes weekly to ensure continued compliance for 8 weeks.b. Conduct monthly Inservice education for all nursing staff on F580 notification standards and documentation requirements for a period of 3 consecutive months.

Based on observation, interview, and record review the facility failed to recognize and assess the symptoms of a worsened pressure wound and provide and document wound treatments as ordered for 2 of 3 residents (R1, R3) reviewed for pressure ulcers in the sample of 13. This failure resulted in R1's sacral ulcer worsening and R1 being transferred to the hospital, where the wound was found to be infected with gram positive cocci and gram-negative bacilli.The findings include:1. R1's Face Sheet documented an admission Date of 3/3/22 and listed Diagnoses including Asthma, Peripheral Vascular Disease, Hypothyroidism, Bipolar Disorder, Hypertension, and Diabetes Type 2. R1's Minimum Data Set, dated [DATE] documented that R1 was severely cognitively impaired, had an indwelling catheter, and was totally dependent on staff for eating, showering, toileting, and transfers. An October 2025 Wound Log documented that R1 had a stage 4 pressure wound to the sacrum and a stage 4 pressure area to the right heel. R1's Care Plan dated 9/17/25 documented problem areas, Resident is a full code, and, Resident has impaired skin integrity as evidenced by right heel arterial ulcer, sacrum pressure ulcer related to impaired cognition, incontinent of bowel, poor nutritional intake, with a corresponding intervention, Notify Physician/Nurse Practitioner/Physician's Assistant of signs/symptoms of infection(new or change in type/amount/color of drainage, bleeding, foul odor) .R1's October 2025 Physicians Orders Sheet (POS) documented orders for a daily skin check using the CROPS method (Clear Red Open Pressure Skin Tear), daily foot check, contact Isolation for ESBL (Extended-Spectrum Beta-Lactamase) in the urine, and (trade name) indwelling catheter, (check) output two times a day. This same POS documented treatment orders as follows:Non pressure chronic ulcer of the right right heel: Cleanse with normal saline, apply Medihoney, apply bordered gauze, (change) every Tuesday, Thursday, Saturday, and as needed, order date 9/24/25.Pressure ulcer to Sacrum: Cleanse with wound cleanser, apply collagen hydrogel, collagen particles, silver sulfadene, and calcium alginate to base of the wound, change every Tuesday, Thursday, and Saturday and as needed, order date 9/24/25.R1's October 2025 Treatment Administration Record (TAR) documented the above wound treatment orders, with a blank space for day shift 10/4/25, indicating the treatments to the wounds of the sacrum and right heel had not been done. R1's Wound Assessment Reports, authored by V4 (Wound Care Nurse Practitioner) documented the following:9/30/25: Stage 4 pressure area, sacrum: Facility acquired: No. Wound status: Improving with delayed wound closure. Length: 9.00 cm (centimeters), Width: 9.00 cm long by width: 81.00 cm, 2 Depth: 6.00 cm. 70% granulation (tissue), 30% slough. Undermining: from 6 o'clock to 9 o'clock, 6.0 cm. Heavy seropurulent drainage. Odor post cleansing: Malodorous. Arterial ulcer right heel: Acquired in facility: Yes. Wound status: Improving with delayed wound closure. Moderate amount of seropurulent drainage. Odor post cleansing: None. % Granulation: 50% granulation % Slough: 30% slough % Eschar: 20% eschar.10/7/23: Stage 4 pressure area, sacrum: Facility acquired: No. Wound status: Worsening. Length: 9.00 cm Width: 12.00 cm long by width: 108.00 cm. 2 Depth: 6.00 cm.0% Granulation, 100% slough. Undermining: from 6 o'clock to 9 o'clock, 6.0 cm. Heavy amount seropurulent drainage. Odor post cleansing: Malodorous. Arterial ulcer right heel. Acquired in facility: Yes. Wound status: Improving with delayed closure. Moderate amount of seropurulent drainage. Odor post cleansing: None. % Granulation: 50% granulation % Slough: 30% slough % Eschar: 20% eschar.R1's Nursing Progress note dated 10/7/25 at 10:42am, authored by V3 (Registered Nurse/RN) documented: Wound rounds completed with (V4). Recommendations received to send (R1) to hospital due to worsening sacral ulcer with possible infection and decreased urine output over the last 24 hours. (V4) contacted family members who were thankful for the update and agreed with the recommendations. MD (Medical Doctor) aware.R1's Provider Skin and Wound Note dated 10/7/25 at 1:18pm, authored by V4 documented, Evaluation for follow-up of wound sacrum stage 4 pressure ulcer, current/prior treatments include (trade name sodium hypochlorite solution) collagen, hydrogel, silver sulfadene cream, and calcium alginate. Right heel arterial ulcer, treatment stalled and changed to Santyl. After assessment of wound today, consult was conducted with staff, (V3), and (review of history and physical) and it was decided that patient would be sent to the hospital due to deteriorating wound over the last 4 days. Wound bed to sacrum is necrotic and malodorous with heavy amounts of purulent drainage. According to staff, resident has also felt warm to touch and had very little urine output since (10/5/25) Sunday per her (indwelling) catheter. Urine present in (catheter) bag was dark and had sediment present. Resident was not eating well and looked more tired than usual. She reports she feels terrible at this time. Family was contacted and agreed that (R1) would be sent to (local hospital) for further work up, diagnostic testing, and IV (Intravenous) antibiotic therapy.R1's ED (Emergency department) Provider Note dated 10/7/25 at 1:07pm documents Chief Complaint: Skin Ulcer, Failure to Thrive, Oliguria. The patient is a [AGE] year-old female that presents the emergency department for the evaluation of progressive weakness, failure to thrive, not wanting to eat or drink, and decreased urine output. The patient resides at (the facility). This has been going on for several days and getting progressively worse. Patient has used a [sic] oriented to self but not very communicative. The staff is concerned that the patient has a sacral ulcer which has been present for some time now but getting progressively worse. The Physical Exam documents: Musculoskeletal: Large (Sacral) Decubitus to the bone. Foul odor. No active drainage. Pictures in chart. The patient has bilateral heel ulcers. Post procedure diagnoses: 1. Dehydration. 2. Hyperglycemia. 3. Failure to Thrive in Adult. 4. Skin ulcer of sacrum with necrosis of bone. 5. Urinary Tract Infection without Hematuria, site unspecified. 6. Sepsis, due to unspecified organism, unspecified whether acute organ disfunction present.R1's Culture Wound +Gram Stain Report for the sacral wound from the hospital records with a collection date of 10/7/25 documented, Result: Positive: Heavy gram-positive cocci. Positive: Heavy gram-negative bacilli. R1's Blood Culture results from the hospital records collected on 10/7/25 with culture results on 10/9/25 document growth of Staphylococcus hominis and Gram positive cocci in clusters.On 11/4/25 at 11:05am, V4 stated she started coming to the facility on 7/8/25. V4 stated she performs quarterly skin assessments on all residents, and it is staff's responsibility to notify her of any new skin issues or wound deterioration. V4 stated she assumed care of R1 on 7/8/25, and prior to that other wound care providers employed by V4's company were taking care of R1. V4 stated R1 had a stage 4 pressure ulcer to the sacrum and an arterial wound to the right heel, which had initially been identified as a pressure wound, but an arterial doppler showed the area was an arterial wound. V4 stated the arterial wound was improving and the sacral wound was also responding well to treatment and was improving. V4 stated R1 had chronic conditions which are barriers to healing such as being in bed most of the time, Diabetes, incontinence of stool, and Peripheral Vascular Disease. V4 stated she last evaluated R1 on 10/7/25. V4 stated at the door of R1's room she was met with a strong necrotic smell, which was not usual for R1. V4 stated as she was entering, an unknown CNA (Certified Nursing Assistant) stated that R1 had had very little urine output, had been warm to the touch, and had little intake of food or fluids since 10/5/25. V4 stated examination of the sacral wound showed it was obviously worse, with heavy, purulent drainage and a very strong necrotic odor, and the heel wound was about the same as it had been the previous week. V4 stated she told staff the resident needed to go to ER due to signs of wound infection, and arrangements were made. V4 stated the facility had not notified R1's Physician about her decline and the signs of infection. V4 stated, The sacral wound did not get worse overnight. The wound most likely deteriorated because her body was shutting down. (R1) should have been sent to the hospital sooner, when she had decreased intake and output.On 11/4/25 at 12:58pm, V3 stated he started in the position on 9/16/25. V3 stated R1's heel and sacral wounds were, Stable, until he and V4 rounded on 10/7/25 and found the sacral wound had deteriorated. V3 stated he works Monday through Friday, and R1 was sent to ER Tuesday 10/7/25. V3 stated he worked Monday 10/6/25 but doesn't recall any staff saying anything about R1 declining over the weekend. V3 stated on that date he did a skin check on R1 and there were no new skin issues noted, including the left heel. V3 stated he could not remember when the dressings on the wounds were dated when he saw them on 10/6/25 or 10/7/25. When asked if he was aware the 10/4/25 wound care treatments had not been done, V3 stated he was not aware, and if it had been done it would be documented on the TAR. V3 confirmed that prior to going in to see R1 with V4 on 10/7/25, V8, CNA, stated R1 had declined, I can't recall specific details, but I think it had to do with poor intake of food and fluids. V3 stated he recalls V4 removing the sacral dressing but does not remember the date or who signed it. V3 stated when they looked at the sacrum, the wound looked worse and had purulent drainage. V3 stated R1 was then sent to the ER upon the orders of V4.On 11/4/25 at 210pm, V8, CNA, stated on 10/7/25 she does not recall looking at the dressing on R1's right heel, but the dressing on the sacral wound was falling off, soaked with drainage, and she does not remember what it was dated, But it did have (V3) initials on it. V8 stated she informed the charge nurse, V16 Licensed Practical Nurse, of R1's status and the condition of the dressing, but by that time, V3 and V4 were going in to see R1. On 11/4/25 at 320pm, V11, RN, confirmed she worked 7am to 7pm on 10/4/25. V11 stated it was the only shift she worked alone at the facility as she was prn (as needed/ on call) staff. V11 stated she did not really remember anything about any of the residents. When asked about there being no documentation that R1's wound treatments were done that day, she stated, If I didn't document them, I'd say they weren't done. On 11/5/25at 10:45am, V16 (Licensed Practical Nurse/ LPN) stated she worked 7am to 7pm on both 10/6/245 and 10/7/25. V16 stated on weekends, the floor nurses are responsible for dressing changes, with V3 being responsible through the week. V16 stated on one of those days, an unknown CNA, possibly on night shift, told her the dressing to the sacrum had come off during incontinence care. V16 stated she noted a large amount of yellow slough on the wound which had not been present when she had previously changed the dressing, date unknown. V16 stated additionally, the wound had a foul odor and yellow drainage, and the wound bed was darker. V16 stated she did not recall looking at R1's heel wound. V16 stated she did not remember anything about charting on R1, including documenting a dressing change. V16 stated she could not remember hearing anything specific about R1 in report. V16 stated she did recall on Monday, 10/6/25, being aware the sacral wound had deteriorated, but did not feel the need to notify the Physician as she knew V4 was to evaluate R1 the next day.On 11/5/25 at 105pm, V12, Physician/Medical Director, stated R1 had multiple comorbidities including Diabetes, Dementia, Hypothyroidism, Failure to Thrive, and Sleep Apnea. V12 stated several months ago R1 had been treated by an infectious disease specialist due to a history of osteomyelitis in the sacral wound and had been on and off antibiotics several times, as due to her overall condition and comorbidities she had difficulty fighting infection. V12 stated R1 had also recently had ESBL in the urine. V12 stated he was aware R1 had wounds which were being treated by V4. When asked if the sacral dressing not being changed on 10/4/25 could have caused the sepsis, V12 stated it could have. V12 stated with R1's history of wound infections, staff should have been more alert to changes in the wound signaling infection.On 11/6/25 at 9am, V18, LPN, stated she worked the 7pm to 7am shift on 10/6/25 and took care of R1.V18 stated she did not think she changed or looked at R1's wound dressings that night but does recall R1 had some odor to the coccyx wound. V18 stated she thought she recalled somebody mentioning in the facility's nursing staff group chat, date unknown, that the wound had odor and probably needed to have the treatment changed. V18 stated all nursing staff including administrative nursing staff are tagged in this chat. Nobody reported to V18 that R1 was feeling warm, and V18 does not think R1's vitals were checked. V18 stated there was nothing in R1's presentation that she felt she needed to call her Physician about.On 11/6/25 at 10:20am V17, CNA, stated she worked with R1 from 6pm to 6am on 10/5/25. V17 stated R1 looked, Tired, sick and lethargic and maybe dehydrated. V17 stated she recalled seeing a clean dry dressing to the sacral area. V17 stated she does not recall any areas to the heels. V17 stated the sacral wound, Had an odor to it, you couldn't smell it at her door but you could smell it at the bedside. V17 stated she did not specifically recall informing the nurse about the odor.2. R3's Face Sheet documented an admission date of 9/29/25 and listed diagnoses including Chronic Obstructive Pulmonary Disease, Arteriosclerotic Heart Disease, Cervical Spinal Fusion, and Hypertension. R3's Minimum Data Set, dated [DATE] documented that R3 has no deficits in cognition and is dependent on staff for transfers and toileting.The November 2025 Wound Log documented R3 had a deep tissue injury to the left heel with an onset date of 9/9/25.R3's Care Plan dated 10/7/25 documented a problem area, Impaired skin integrity as evidenced by area left heel, with a corresponding intervention, Treatments per physicians orders.R3's Physicians Orders documented a 10/22/25 order, Cleanse Left heel wound with normal saline or wound cleanser, pat dry, apply mix of silver sulfadiazine cream, hydrogel, and collagen powder, secure with dry dressing every day shift.R3's Treatment Administration Record (TAR) for October 2025 showed no documentation that this treatment was done from 10/22/25 to 10/31/25.R3's November 2025 TAR showed no documentation that this treatment was done on 11/1/25 through 11/3/25.On 10/31/25 at 9:35am, V3 was observed providing wound care as ordered to R3's left heel, which was noted to have a non-open deep tissue injury.On 11/13/25 at 11am, V3 stated he does the wound care treatments Monday through Friday, and floor nurses are responsible for doing them on the weekends. V3 stated he generally does all the treatments and goes back and documents them at the end of the day. V3 stated he must have forgotten to document R3's wound care treatments. When asked if the treatment was being done on weekends, V3 stated he is not sure.A Pressure Ulcer Policy dated 8/31/23 documented, Purpose: To provide guidelines that will assist nursing staff in prevention, identification, and appropriate treatment of pressure ulcers. It is the responsibility of the Charge Nurse/Designee to care for pressure areas, and provide treatments as ordered. It is the responsibility of the Charge Nurse/Designee to measure and document the pressure areas weekly. It is the responsibility of the Charge Nurse/Designee to monitor for healing progress, and ensure appropriate treatments are in use. It is recommended that the DON/Designee make frequent pressure ulcer rounds with the Charge Nurse. It is the responsibility of the CNAs to report any skin conditions to the Charge Nurse immediately upon identification. 5. The physician is to be notified when, A. Pressure ulcer develops, B. When there is a noted lack of improvement after a reasonable amount of time, and C. Upon signs of deterioration. 7. Documentation of the pressure ulcer must occur upon identification and at least once a week and as needed until healed. Assessment is to include C. Treatment and response to treatment, and E. Update physician and residents POA of any regression of wound.

Based on interview and record review, the facility failed to provide narcotic pain medication per physician orders for 2 of 3 (R1 and R3) residents reviewed for pain management in a sample of 3. This failure resulted in R1 and R3 experiencing unrelieved pain and having to be sent to the local hospital for treatment of pain. This past noncompliance occurred from [DATE] to [DATE].The findings include:1. R1's admission Record dated [DATE], documents an admission date of [DATE] with diagnoses in part of displaced comminuted fracture of shaft of humerus to right arm, multiple fractures ribs right side, unspecified fracture of unspecified lumbar vertebra, chronic migraine, and other chronic pain.R1's MDS (Minimum Data Set) dated [DATE], documents in Section C a BIMS (Brief Interview for Mental Status) score of 15 which indicates R1 is cognitively intact.R1's Care Plan with a date initiated of [DATE] has a focus area of R1 (Resident) has potential for pain from trauma/injuries received prior to admission. Interventions listed are administer medication per physician order(s) and monitor for side effects and effectiveness. Notify the physician /NP (Nurse Practitioner)/ PA (Physician Assistant) if current pain medication is ineffective or if the resident is experiencing side effects, determine what the resident's optimal pain level is for the day to day function and quality of life, and encourage the resident to request pain medication before the pain becomes too intense or prior to activities that the resident knows there is potential for increased pain (e.g. therapy).R1's Order Summary report with a print date of [DATE] documents an order for oxycodone HCL (hydrochloride) oral tablet 10mg (Milligrams) give 1 tablet by mouth every 4 hours as needed for pain with an order date of [DATE] and no end date.R1's July MAR (Medication Administration Record) documented on [DATE], R1 received Oxycodone 10mg 1 tablet at 10:17PM with a pain level of 6. No other documentation for oxycodone 10mg on [DATE].R1's progress note dated [DATE] at 1:03PM documents in part Resident c/o (complained of) extreme swelling and increased pain to R (right) arm. Offered p/t (patient) prn (as needed) Tylenol and Excedrin. p/t refused Tylenol yet accepted Excedrin. Called Pharmacy to gain access code to prn narcotics in pixus (Emergency medication storage) how pixus didn't have prn narcotic was told by pharmacy that prn narcotic would be in tonight's delivery. P/T demanded to be sent to ER (Emergency Room). Called (Name of Primary Physician), orders obtained to be sent to (Name of Local Hospital) ER. Gave report to (Name of Local Hospital) ER and (Name of Local Ambulance) (Didn't call 911). Called (R1's) emergency contact to inform. P/t pleased with nurse seeking emergency T/x (treatment).R1's progress note dated [DATE] at 4:12 PM documents, received report from local hospital. R1 was given a lidocaine patch to the right arm, 2 Tylenol, and Oxycodone 10 mg. Caller stated R1 was very happy now. The nurse asked about the swelling to the right arm and shoulder and was told there was no imaging done and that the swelling was part of healing. R1's local hospital records from [DATE] documents todays visit diagnoses as other closed displaced fracture of proximal end of right humerus with routine healing subsequent encounter, closed fracture of lumbar vertebra with routine healing unspecified fracture morphology, and closed fracture of multiple ribs of right side with routine healing.On [DATE] at 1:57PM, R1 stated that they have ran out of his prn pain medication oxycodone 2 times. R1 said the first time was when he was first admitted to the facility, and it took a day for them to get the medication in. R1 said that he was in pain then but was able to tolerate it some then. He said that they ran out of it again on [DATE]. R1 said that he was hurting so bad that day he couldn't tolerate it and he had them send him out to local hospital emergency room to see if they could give him something for the pain since they were out of his oxycodone at the facility. R1 said that the emergency room did give him an oxycodone and put a pain patch on him. R1 said even after the hospital gave him the oxycodone and the pain patch that the pain was still there and didn't help until later.2. R3's admission Record dated [DATE], documents an admission date of [DATE] with diagnoses in part of systemic lupus and chronic pain syndrome.R3's MDS dated [DATE], document in Section C a BIMS score of 15 which indicates R3 is cognitively intact.R3's Care Plan with a revision date of [DATE] documents a focus area of, R3 has chronic pain r/t (related to) lupus, CKD (Chronic Kidney Disease), hernia, chronic pain syndrome, sciatica, osteoarthrosis, neuropathy, IBS (Irritable Bowel Syndrome), Gerd (Gastrointestinal reflux disease), depression Intervention include in part anticipate the resident's need for pain relief and respond immediately to any complaint of pain and monitor/record/report to nurse resident complaints of pain or request for pain treatment. Another focus area Pain/Opioid Therapy: (Moderate) pain experience(s) related to: (Lupus, chronic pain, sciatica). Interventions for this focus area include administer pain medication as indicated/prescribed. R3's Order Summary with a print date of [DATE] documents an order for Oxycodone-Acetaminophen tablet 5-325mg give 1 tablet by mouth every 4 hours as needed for pain do not exceed 3GM (Grams) daily.R3's June MAR documented no oxycodone-acetaminophen 5-325mg was administered on [DATE] or 06/0925. On [DATE] at 10:18PM oxycodone-acetaminophen 5-325mg was administered with a pain level of 8.R3's Progress note dated [DATE] at 1:53PM documents This resident out of oxycodone. Called the facilities on call to ask how they would like for me to handle the situation because the resident is in pain, and I have no access to the pixis. He said I need to call them after hours for the pharmacy and have them do an emergency drop off. The pharmacy said they can't do a drop off because his script has expired, and we would have to get hold of the Dr. (Doctor). DON (Director of Nursing) was notified, and resident was informed of what was going on. Dr was called and voicemail was left to get a new script wrote for oxycodone. Resident did agree to take some [NAME] (Tylenol) in the meantime. R3's Progress note on [DATE] at 3:03PM documents, Dr called back and would like resident sent to (Name of Local Hospital). R3's Progress Note on [DATE] at 8:40PM documents, Resident returned to facility per stretcher by (Name of Local Ambulance) no new orders at this time.R3's local hospital record for [DATE] documents todays visit diagnoses were generalized body aches and chronic pain due to trauma. R3's hospital record documents R3 arrived from the nursing home via stretcher with complaints of needing his oxycodone refilled. R3 upset nursing home staff did not call his primary physician in time to get a refill. R3 complained of generalized pain of 5/10 at the time. R3 stated he was afraid to go into withdrawals. A dose of oxycodone-acetaminophen 5-325 mg was given along with a does of ondansetron tablet 4 mg.R3's Progress note on [DATE] at 6:23AM documents, R1 was complaining about his oxycodone prn pill. I called pharmacy at 1230 checking on possible time of delivery. I then gave R1 a prn acetaminophen for pain. R1 later called 911 and was transported to hospital via ambulance. He later returned with no complaints or further s/s (signs or symptoms) of illness or injury.R3's Progress note on [DATE] at 11:05AM documents, Pharmacy called today to inform the facility that they need a hard script in order to fill R1's pain medication. I informed them that the script was sent over the weekend and that last night, R1 called the ambulance and sent himself out to ER r/t pain. The pharmacy lady stated that she could get anyone access to the pixus if needed including agency nurses. I asked her what good that does when we request the code, and no one provides a code in a timely fashion. She then checked her records for the script and found it. She told me that R1's pain medication would be on the first run.R3's local hospital record for [DATE] documents today's visit diagnosis encounter for medication refill.On [DATE] at 10:58AM, R3 stated that he did have a problem a couple of months ago with the facility running out of his pain medications. R3 said that he went to the hospital emergency room twice in 2 days because he was in such terrible pain, and they didn't have none of his pain medication at the facility. R3 said that on [DATE] and on [DATE] that the local emergency room administered his as needed oxycodone for pain and then sent him back. R3 stated when he ran out of oxycodone that they did give him some Tylenol to see if it would help and he couldn't take the pain anymore, so he requested to go to the hospital.On [DATE] at 11:30AM, V8 (Licensed Practical Nurse/LPN) stated that they did have a problem with getting controlled medication in and that a couple of residents did get sent out to the local hospital emergency room for pain management treatment. V8 couldn't remember what all residents went out to the hospital because they ran out of pain medication and needed pain management. V8 said they did receive training on how to order controlled substance such as pain medication and it has been better, they haven't been running out of pain medication now.On [DATE] at 12:00PM, V5 (Registered Nurse/RN) stated that they were having a problem with not getting controlled medications. V5 said they did have to send several residents out to the emergency room for pain management because the facility ran out of their pain medication. V5 said that R1 and R3 were a couple of those residents that they ran out of their controlled substance pain medication, and they had to send them to the emergency for treatment of the pain. V5 said that they were recently trained on how to reorder pain medications and controlled medications. V5 said since they received training that it has improved, and they haven't been running out of resident controlled pain medications. V5 said that when a resident is getting close to running out of their controlled medications that they send over a note to the doctor and then he will send a script over to the pharmacy and then they will call and follow up to see if the pharmacy got the script and then they will send it. V5 said that they also must click on the EHR (Electronic Health Care) and click that you have received the controlled pain medication.On [DATE] at 2:44PM, V1 (Administrator) stated that she doesn't know why R1 ran out of his pain medication on [DATE] and she doesn't know why R3 ran out of his pain medication as well in June. V1 said they did do an in-service recently with pharmacy to make sure the nurses know how to order controlled substances correctly and that she thinks this has been helping with making sure all residents who take controlled substances have the medications they need.On [DATE] at 8:38AM, V6 (RN) stated that she was working on [DATE] when R1 was sent out to the local emergency room. V6 said that R1 was starting to get low on his pain medication oxycodone and he was going to be out of pain medication on [DATE]. V6 said that they did give R1 a different type of as needed pain medication, but that R1 said he was still in pain. V6 said that R1 was wanting to be sent to the hospital because of his pain. V6 said that they did send R1 to the hospital emergency room. V6 said while R1 was at the hospital they gave him oxycodone, Tylenol and put a lidocaine patch on him. V6 said that when R1 returned to the facility that he was cussing and said that the hospital emergency room didn't help. V6 said that she had sent a reorder for R1's oxycodone over to the doctors' office on [DATE] and they were supposed to send over a script for the medication. V6 said that she tried to get the oxycodone out of the emergency medication storage at the facility, but they didn't have oxycodone in the emergency medication storage, V6 said the pharmacy told her that R1's oxycodone would be at the facility on [DATE], but the medication never showed up. V6 said she called the pharmacy on [DATE] and they said that they didn't have a script for the oxycodone, but after they checked they found the script for the oxycodone. V6 said the pharmacy didn't even check to see if they had the script for oxycodone for R1 until she called. V6 said that it still took a day for them to get R1's oxycodone after they found the script. V6 also stated that she knows that R3 was sent out to the hospital in last month because he ran out of his oxycodone, and he went back and forth to the hospital several times. V6 said that she thinks that they have a better understanding now on how to order the controlled substances. V6 said that they did have recent in-services and reeducation on how to order controlled substances. V6 said that when you need a controlled substance such as oxycodone that you must get a new script and have the doctor send it to the pharmacy. V6 said that you need to order the controlled substance about a week before you run out. V6 said that some of the other nurses thought that the residents had refills left and would just send over a reorder without getting a new script and then the medication wouldn't come in and the resident would be out of the medication. V6 said that since V3 (DON) has done training that getting the controlled substances such as the pain medication has improved, and they have the residents pain medications now. On [DATE] at 10:28AM, V7 (LPN) stated that they did have a problem with getting controlled substance such as pain medications. V7 said that he was working when R3 called 911 himself because he was out of his pain medication oxycodone for a day and half. V7 said that R3 called 911 because he was in pain and didn't have his oxycodone. V7 said the reason that they kept running out of the pain medication was because of a pharmacy thing. V7 said that since they were in-serviced and reeducated that receiving the residents controlled substance pain medications has gotten better. V7 said that some of the problem was that they would only have a script for 6 pills and the resident would go through those quickly and then they would have to get a new script and then wait for the medication to come in again.On [DATE] at 11:00AM, V3 (Director of Nursing/DON) stated that she is aware they had a problem with getting controlled substance such as pain medications for the residents. V3 said that she thinks this was a combination of nursing and pharmacy. V3 said that she did a recent in-service and reeducation with nursing and that pharmacy service also came out and talked to nursing staff about how to reorder controlled substance. V3 said that she feels it has gotten better since the in-service/reeducation which was done on [DATE]. V3 said that she does a daily audit on medication that aren't administered and not available during morning meeting. V3 said that she also does a controlled substance audit usually on Wednesday to check to see if residents are close to needing a refill if so then they will contact the doctor and get a new script and send it to the pharmacy so they can get the medication in before the weekend. V3 said that she will have nursing call and follow up with the pharmacy to make sure they got the new script. V3 said that the admission team is also working with the hospitals to make sure the hospitals send the script for controlled substance with the resident when they get to the hospital so they can order the medication right away.On [DATE] at 12:20PM, V4 (Medical Doctor) stated that he knows that R1 and R3 were sent out to the local emergency room because they were out of their controlled substance pain medication and was sent to the local emergency room for pain management. V4 said that he doesn't know why R1 and R3 ran out of their prescribed pain medication. V4 said that when they would call him, he would send over a script to the pharmacy. V4 said that he thought the reason the facility kept running out of the controlled substance pain medication was because of a pharmacy thing. V4 said that when the resident ran out of the controlled substance pain medication the facility should have been able to get the medication out of the emergency medication storage. V4 said that the facility didn't have the medication in their emergency medication storage, and it was taking almost a day or two for the facility to get the medication from the pharmacy. V4 said they would have to end up sending the resident out to the hospital to get treated for pain and that costs a lot of money to send a resident to the local emergency room for pain management when they could have been treated at the facility. V4 said that he does know that the facility is currently working on fixing this problem, so no resident runs out of their controlled substance pain medication or any medications. V4 said that he knows that they are also working with the hospital to make sure they send scripts with the resident when they return to the facility so they can order the medications right away and have the script so they can send it especially for any controlled substances.The facility policy titled Administering Pain Medications with a revision date of [DATE] documented under general guidelines 1. The pain management program is based on a facility-wide commitment to resident comfort. 2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Procedure step 6 documents Administer pain medications as ordered.Prior to the survey date, the facility took the following actions to correct the non-compliance: 1. A Quality Assurance and Performance Improvement meeting was held on [DATE]. In attendance - V1, V3, V4, V9 (Certified Nursing Supervisor), V11 (Activities Director), V12 (Social Service Director), V13 (Housekeeping/Laundry Supervisor), V14 (Dietary Manager), and V15 (Director of Therapy). 2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents experiencing pain have the potential to be affected. 3. Measures put into place/systematic changes to ensure the deficient practice does not recur: On [DATE] the facility staff were in-serviced by V3 and pharmacy on pharmacy processes including re-ordering of medications and controlled substance prescription processes. On [DATE] licensed staff were in-serviced on pain management. 4. Plan to monitor performance to ensure solutions are sustained: V3 or designee will audit medications not available daily during morning clinical meeting weekly x 8 weeks to ensure all medications are available. For any medications not available, facility staff will contact pharmacy to get resolution. Any discrepancies will be discussed at QA (Quality Assurance) committee meeting with recommendations made accordingly.

Based on interview and record review the facility failed to obtain a new prescription for a controlled substance in a timely manner for 2 of 3 residents (R1 and R3) reviewed for pharmacy services in the sample of 3. This past noncompliance occurred from [DATE] to [DATE].The findings include:1. R1's admission Record dated [DATE], documents an admission date of [DATE] with diagnoses in part of displaced comminuted fracture of shaft of humerus to right arm, multiple fractures ribs right side, unspecified fracture of unspecified lumbar vertebra, chronic migraine, and other chronic pain.R1's MDS (Minimum Data Set) dated [DATE], documents in Section C a BIMS (Brief Interview for Mental Status) score of 15 which indicates R1 is cognitively intact.R1's Care Plan with a date initiated of [DATE] has a focus area of R1 (Resident) has potential for pain from trauma/injuries received prior to admission. Interventions listed are administer medication per physician order(s) and monitor for side effects and effectiveness. Notify the physician /NP (Nurse Practitioner)/ PA (Physician Assistant) if current pain medication is ineffective or if the resident is experiencing side effects, determine what the resident's optimal pain level is for the day to day function and quality of life, and encourage the resident to request pain medication before the pain becomes too intense or prior to activities that the resident knows there is potential for increased pain (e.g. therapy).R1's Order Summary report with a print date of [DATE] documents an order for oxycodone HCI (hydrochloride) oral tablet 10mg (Milligrams) give 1 tablet by mouth every 4 hours as needed for pain with an order date of [DATE] and no end date.R1's July MAR (Medication Administration Record) documented on [DATE], R1 received Oxycodone 10mg 1 tablet at 10:17PM with a pain level of 6. No other documentation for oxycodone 10mg on [DATE].R1's progress note dated [DATE] at 1:03PM documents in part Resident c/o (complained of) extreme swelling and increased pain to R (right) arm. Offered p/t (patient) prn (as needed) Tylenol and Excedrin. p/t refused Tylenol yet accepted Excedrin. Called Pharmacy to gain access code to prn narcotics in pixus (Emergency medication storage) how pixus didn't have prn narcotic was told by pharmacy that prn narcotic would be in tonight's delivery. P/T demanded to be sent to ER (Emergency Room). Called (Name of Primary Physician), orders obtained to be sent to (Name of Local Hospital) ER. Gave report to (Name of Local Hospital) ER and (Name of Local Ambulance) (Didn't call 911). Called (R1's) emergency contact to inform. P/t pleased with nurse seeking emergency T/x (treatment).On [DATE] at 1:57PM, R1 stated that they have ran out of his prn pain medication oxycodone 2 times. R1 said the first time was when he was first admitted to the facility, and it took a day for them to get the medication in. R1 said that he was in pain then but was able to tolerate it some then. He said that they ran out of it again on [DATE]. R1 said that he was hurting so bad that day he couldn't tolerate it and he had them send him out to local hospital emergency room to see if they could give him something for the pain since they were out of his oxycodone at the facility. R1 said that the emergency room did give him an oxycodone and put a pain patch on him. R1 said even after the hospital gave him the oxycodone and the pain patch that the pain was still there and didn't help until later.2. R3's admission Record dated [DATE], documents an admission date of [DATE] with diagnoses in part of systemic lupus and chronic pain syndrome.R3's MDS dated [DATE], document in Section C a BIMS score of 15 which indicates R3 is cognitively intact.R3's Care Plan with a revision date of [DATE] documents a focus area of, R3 has chronic pain r/t (related to) lupus, CKD (Chronic Kidney Disease), hernia, chronic pain syndrome, sciatica, osteoarthrosis, neuropathy, IBS (Irritable Bowel Syndrome), Gerd (Gastrointestinal reflux disease), depression Intervention include in part anticipate the resident's need for pain relief and respond immediately to any complaint of pain and monitor/record/report to nurse resident complaints of pain or request for pain treatment. Another focus area Pain/Opioid Therapy: (Moderate) pain experience(s) related to: (Lupus, chronic pain, sciatica). Interventions for this focus area include administer pain medication as indicated/prescribed. R3's Order Summary with a print date of [DATE] documents an order for Oxycodone-Acetaminophen tablet 5-325mg give 1 tablet by mouth every 4 hours as needed for pain do not exceed 3GM (Grams) daily.R3's June MAR documented no oxycodone-acetaminophen 5-325mg was administered on [DATE] or 06/0925. On [DATE] at 10:18PM oxycodone-acetaminophen 5-325mg was administered with a pain level of 8.R3's Progress note dated [DATE] at 1:53PM documents This resident out of oxycodone. Called the facilities on call to ask how they would like for me to handle the situation because the resident is in pain, and I have no access to the pixis. He said I need to call them after hours for the pharmacy and have them do an emergency drop off. The pharmacy said they can't do a drop off because his script has expired, and we would have to get hold of the Dr. (Doctor). DON (Director of Nursing) was notified, and resident was informed of what was going on. Dr was called and voicemail was left to get a new script wrote for oxycodone. Resident did agree to take some [NAME] (Tylenol) in the meantime. R3's Progress note on [DATE] at 3:03PM documents, Dr called back and would like resident sent to (Name of Local Hospital). R3's Progress note on [DATE] at 6:23AM documents, R1 was complaining about his oxycodone prn pill. I called pharmacy at 1230 checking on possible time of delivery. I then gave R1 a prn acetaminophen for pain. R1 later called 911 and was transported to hospital via ambulance. He later returned with no complaints or further s/s (signs or symptoms) of illness or injury.R3's Progress note on [DATE] at 11:05AM documents, Pharmacy called today to inform the facility that they need a hard script in order to fill R1's pain medication. I informed them that the script was sent over the weekend and that last night, R1 called the ambulance and sent himself out to ER r/t pain. The pharmacy lady stated that she could get anyone access to the pixus if needed including agency nurses. I asked her what good that does when we request the code, and no one provides a code in a timely fashion. She then checked her records for the script and found it. She told me that R1's pain medication would be on the first run.On [DATE] at 10:58AM, R3 stated that he did have a problem a couple of months ago with the facility running out of his pain medications. R3 said that he went to the hospital emergency room twice in 2 days because he was in such terrible pain, and they didn't have none of his pain medication at the facility. R3 said that on [DATE] and on [DATE] that the local emergency room administered his as needed oxycodone for pain and then sent him back. R3 stated when he ran out of oxycodone that they did give him some Tylenol to see if it would help and he couldn't take the pain anymore, so he requested to go to the hospital.On [DATE] at 11:30AM, V8 (Licensed Practical Nurse/LPN) stated that they did have a problem with getting controlled medication in and that a couple of residents did get sent out to the local hospital emergency room for pain management treatment. V8 couldn't remember what all residents went out to the hospital because they ran out of pain medication and needed pain management. V8 said they did receive training on how to order controlled substance such as pain medication and it has been better, they haven't been running out of pain medication now.On [DATE] at 12:00PM, V5 (Registered Nurse/RN) stated that they were having a problem with not getting controlled medications. V5 said they did have to send several residents out to the emergency room for pain management because the facility ran out of their pain medication. V5 said that R1 and R3 were a couple of those residents that they ran out of their controlled substance pain medication, and they had to send them to the emergency for treatment of the pain. V5 said that they were recently trained on how to reorder pain medications and controlled medications. V5 said since they received training that it has improved, and they haven't been running out of resident controlled pain medications. V5 said that when a resident is getting close to running out of their controlled medications that they send over a note to the doctor and then he will send a script over to the pharmacy and then they will call and follow up to see if the pharmacy got the script and then they will send it. V5 said that they also must click on the EHR (Electronic Health Care) and click that you have received the controlled pain medication.On [DATE] at 2:44PM, V1 (Administrator) stated that she doesn't know why R1 ran out of his pain medication on [DATE] and she doesn't know why R3 ran out of his pain medication as well in June. V1 said they did do an in-service recently with pharmacy to make sure the nurses know how to order controlled substances correctly and that she thinks this has been helping with making sure all residents who take controlled substance have the medications they need.On [DATE] at 8:38AM, V6 (RN) stated that she was working on [DATE] when R1 was sent out to the local emergency room. V6 said that R1 was starting to get low on his pain medication oxycodone and he was going to be out of pain medication on [DATE]. V6 said that they did give R1 a different type of as needed pain medication, but that R1 said he was still in pain. V6 said that R1 was wanting to be sent to the hospital because of his pain. V6 said that they did send R1 to the hospital emergency room. V6 said while R1 was at the hospital they gave him oxycodone, Tylenol and put a lidocaine patch on him. V6 said that when R1 returned to the facility that he was cussing and said that the hospital emergency room didn't help. V6 said that she had send a reorder for R1's oxycodone over to the doctors' office on [DATE] and they were supposed to send over a script for the medication. V6 said that she tried to get the oxycodone out of the emergency medication storage at the facility, but they didn't have oxycodone in the emergency medication storage, V6 said the pharmacy told her that R1's oxycodone would be at the facility on [DATE], but the medication never showed up. V6 said she called the pharmacy on [DATE] and they said that they didn't have a script for the oxycodone, but after they checked they found the script for the oxycodone. V6 said the pharmacy didn't even check to see if they had the script for oxycodone for R1 until she called. V6 said that it still took a day for them to get R1's oxycodone after they found the script. V6 also stated that she knows that R3 was sent out to the hospital in last month because he ran out of his oxycodone, and he went back and forth to the hospital several times. V6 said that she thinks that they have a better understanding now on how to order the controlled substances. V6 said that they did have recent in-services and reeducation on how to order controlled substances. V6 said that when a controlled substance such as oxycodone that you must get a new script and have the doctor send it to the pharmacy. V6 said that you need to order the controlled substance about a week before you run out. V6 said that some of the other nurses thought that the residents had refills left and would just send over a reorder without getting a new script and then the medication wouldn't come in and the resident would be out of the medication. V6 said that since V3 (DON) has done training that getting the controlled substances such as the pain medication has improved, and they have the residents pain medications now. On [DATE] at 10:28AM, V7 (LPN) stated that they did have a problem with getting controlled substance such as pain medications. V7 said that he was working when R3 called 911 himself because he was out of his pain medication oxycodone for a day and half. V7 said that R3 called 911 because he was in pain and didn't have his oxycodone. V7 said the reason that they kept running out of the pain medication was because of a pharmacy thing. V7 said that since they were in-serviced and reeducated that receiving the resident controlled substance pain medications has gotten better. V7 said that some of the problem was that they would only have a script for 6 pills and the resident would go through those quickly and then they would have to get a new script and then wait for the medication to come in again.On [DATE] at 11:00AM, V3 (Director of Nursing/DON) stated that she is aware they had a problem with getting controlled substance such as pain medications for the residents. V3 said that she thinks this was a combination of nursing and pharmacy. V3 said that she did a recent in-service and reeducation with nursing and that pharmacy service also came out and talked to nursing staff about how to reorder controlled substance. V3 said that she feels it has gotten better since the in-service/reeducation which was done on [DATE]. V3 said that she does a daily audit on medication that aren't administered and not available during morning meeting. V3 said that she also does a controlled substance audit usually on Wednesday to check to see if residents are close to needing a refill if so then they will contact the doctor and get a new script and send it to the pharmacy so they can get the medication in before the weekend. V3 said that she will have nursing call and follow up with the pharmacy to make sure they got the new script. V3 said that the admission team is also working with the hospitals to make sure the hospitals send the script for controlled substance with the resident when they get to the hospital so they can order the medication right away.On [DATE] at 12:20PM, V4 (Medical Doctor) stated that he knows that R1 and R3 were sent out to the local emergency room because they were out of their controlled substance pain medication and was sent to the local emergency room for pain management. V4 said that he doesn't know why R1 and R3 ran out of their prescribed pain medication. V4 said that when they would call him, he would send over a script to the pharmacy. V4 said that he thought the reason the facility kept running out of the controlled substance pain medication was because of a pharmacy thing. V4 said that when the resident ran out of the controlled substance pain medication the facility should have been able to get the medication out of the emergency medication storage. V4 said that the facility didn't have the medication in their emergency medication storage, and it was taking almost a day or two for the facility to get the medication from the pharmacy. V4 said they would have to end up sending the resident out to the hospital to get treated for pain and that cost a lot of money to send a resident to the local emergency room for pain management when they could have been treated at the facility. V4 said that he does know that the facility is currently working on fixing this problem, so no resident runs out of their controlled substance pain medication or any medications. V4 said that he knows that they are also working with the hospital to make sure they send scripts with the resident when they return to the facility so they can order the medications right away and have the script so they can send it especially for any controlled substances.The facility's pharmacy policy titled Controlled Substance Prescriptions with a revision date of 08/2020 documented under section titled policy state before a controlled substance can be dispensed, the pharmacy must be in receipt of a clear, complete, and signed written prescription from a person lawfully authorized to prescribe controlled substances. Section VII. Titled Refill Requests for CIII-CV and Partial Fill Requests for CII documents If one or more refills or a partial fill quantity remains, the facility must request the medication from the pharmacy.Prior to the survey date, the facility took the following actions to correct the non-compliance: 1. A Quality Assurance and Performance Improvement meeting was held on [DATE]. In attendance - V1, V3, V4, V9 (Certified Nursing Supervisor), V11 (Activities Director), V12 (Social Service Director), V13 (Housekeeping/Laundry Supervisor), V14 (Dietary Manager), and V15 (Director of Therapy). 2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents experiencing pain have the potential to be affected. 3. Measures put into place/systematic changes to ensure the deficient practice does not recur: On [DATE] the facility staff were in-serviced by V3 and pharmacy on pharmacy processes including re-ordering of medications and controlled substance prescription processes. On [DATE] licensed staff were in-serviced on pain management. Narcotic medications be audited mid-week to ensure active script is on file and refills obtained prior to weekend. V3 was made agent of medical director to assist with refills as applicable as an agent of medical director. 4. Plan to monitor performance to ensure solutions are sustained: V3 or designee will audit medications not available daily during morning clinical meeting weekly x 8 weeks to ensure all medications are available. For any medications not available, facility staff will contact pharmacy to get resolution. Any discrepancies will be discussed at QA (Quality Assurance) committee meeting with recommendations made accordingly.

Based on interview and record review, the facility failed to ensure resident received the correct medications in accordance with their physician's orders for 1 (R4) of 3 residents reviewed for medications in the sample of 5. This failure resulted in R4 having increased behaviors and being hospitalized for behaviors. R4's admission Record documents that R4 was admitted to the facility on [DATE]. Diagnoses listed are vascular dementia, type 2 diabetes mellitus, brief psychotic disorder, unspecified mood disorder, auditory hallucinations, schizophrenia, anxiety and unspecified psychosis.R4's MDS (Minimum Data Set) dated 03/26/2025, documents R4 has a BIMS (Brief Interview for Mental Status) score of 15, indicating R4 is cognitively intact.R4's Care Plan with a revision date of 5/7/24 documents a Focus area of This resident is on an antipsychotic. Documented interventions include: Administer medication as directed by physician. R4's Order Listing Report dated 07/10/2025 documented an order for Haloperidol Decanoate Intramuscular Solution (Haldol) 100 milligram (mg)/milliliter (mL) Inject 1.5 mL intramuscularly every 28 days for agitation related to bipolar disorder with a start date of 06/27/2025 and an order status of active. R4's Order Listing Report documented the same order dated 09/05/2023 with a revision date of 06/27/2025 and an order status of discontinued.'R4's May 2025 Medication Administration Record (MAR) on 05/14/2025 documented MN for the Haloperidol injection. R4's June 2025 MAR on 06/11/2025 documented MN for the Haloperidol injection. The chart code on the MAR documented that MN meant medication not available.R4's Progress Note dated 06/01/2025 at 7:27 P.M. documents that R4 became belligerent. R4 threw two books and a remote control at a resident. R4 continued yelling and threatening. R4 shoved her wheelchair at a resident and staff member missing them. R4's wheelchair hit the medication cart. R4 turned to run back to her room slipping and falling. R4 continued to be belligerent laying on floor. Notified physician of behaviors and received order to send to the hospital. R4 continued making threats to staff including I want to shoot you in the head.R4's Progress Note dated 06/02/2025 with a time of 9:10 A.M. documents R4 verbally aggressive towards staff and attempted to hit another resident. While R4 was in her room she placed wheelchair in front of door was screaming and yelling at staff that she would hurt herself and others. R4 sent to the local hospital for evaluation.R4's Progress Note dated 06/02/2025 with a time of 3:48 P.M. documents R4 has been verbally aggressive on multiple occasions, observed swinging her fists at staff and other residents. R4 was kicking the medication cart when nurse tried to go past R4. Attempted to calm multiple times with no change in behavior. While in room, R4 can be heard throwing items and slamming doors.R4's Progress Note dated 06/03/2025 with a time of 9:25 A.M. documents R4 was admitted to behavioral health with diagnosis of aggressive behavior. R4's Progress Note dated 06/18/2025 with a time of 1:50 P.M. documents R4 was threatening suicide with plans to staff, call placed to physician, R4 sent to the local hospital for evaluation and treatment. R4's Progress Note dated 07/02/2025 with a time of 12:36 A.M. documents R4 sitting on side of bed stating she hears voices in her head. R4 pushed her walker against the wall and wheelchair to the other side of the room.R4's Progress Note dated 07/07/2025 with a time of 11:48 P.M. documents attempted to notify physician of missed injections. Message left to return call.The Emergency Department Note from the local hospital dated 06/02/2025 documented R4 is a [AGE] year-old female who presents to the emergency department this evening from local facility due to concern for behavioral health issues. Patient does have a known history of dementia and schizophrenia and per report, has been very aggressive toward staff and residents at facility. R4 was seen at our facility a few days ago after sustaining a fall while getting in an altercation with some of the staff and residents they are where she was throwing books at them and trying to hit them with her wheelchair. R4 admits that she has been very verbally aggressive with them as she got really agitated at them. R4 admits that she is hearing voices and says that she has been taking her psych meds regularly. Denies any active suicidal or homicidal plans. R4 was evaluated by our central intake team recommending inpatient voluntary psychiatric admission for unspecified mood disorder.The Behavioral Health Note from the local hospital dated 06/06/25025 documented R4 was admitted voluntarily from local emergency department who presents with worsening depression and with psychosis, inability to keep themselves safe, and inability to keep others safe reports passive homicidal ideation. R4 was monitored in emergency department until medically cleared and transferred to the unit for observation and was placed on suicidal precautions. R4 was provided inpatient psychiatric treatment with Face to Face Interaction, Medication Review & Management, safe and supportive environment, group therapy, individual counseling, behavior management, psychiatric medication, medication adjustment, adverse effect monitor, medical evaluation, medical treatment, social service assessment, resource assessment, and psychoeducation and coordination of care with discharge planning. The Emergency Department Note from the local hospital dated 06/19/2025 documented R4 presents with signs and symptoms of depression, anxiety, psychosis, bipolar disorder, schizophrenia, and neurocognitive disorder which include psychosis and inability to keep themselves safe in the context of psychosocial stressors. R4 meets criteria for inpatient hospitalization with capacity to make medical decisions and is observed a danger to self and/or unable to care for self-requiring inpatient psychiatric hospitalization for stabilization and coordination of care. Expected length of stay 5-7 days. On 07/09/2025 at 1:15 P.M. V1 (Administrator) stated she has no idea why R4 did not get the Haldol that was ordered in May 2025 and June 2025. V1 stated that would be a question for V2 (Director of Nursing). V1 stated that it is her expectation that residents in the facility receive the medication that the doctor orders when it is due. On 07/09/2025 at 1:37 P.M. V2 (Director of Nursing) stated he is not sure why R4 was not given her Haldol when it was ordered. V2 stated that he was not aware until today that it was a problem. V2 stated that he reviewed the medication cart and there are vials of Haldol with R4's name on it. V2 stated that it is his expectation that the nurses give the medication that the doctor orders. V2 stated that the Medication Administration Record documents that the medication was not given, and the nurse should have notified the physician and followed up on it. On 07/08/2025 at 9:33 A.M. V4 (Certified Nurse Assistant) stated that she was told by other staff that R4 was off her medication and that is why she had been having an increase in behaviors. V4 stated she is not sure if the doctor had discontinued a medication or if she had run out and they were waiting on the pharmacy to deliver it. V4 stated that R4 has been better since she came back from the hospital the last time. V4 stated she is not sure if there was a medication change or if she was back on what she was supposed to be on.On 07/08/2025 at 9:37 A.M. V5 (Registered Nurse) stated she does not remember R4 ever running out of her medications. V5 stated that if a resident is out of medications, she will attempt to get it out of the backup pharmacy.On 07/08/2025 at 3:52 P.M. V6 (Family Member) stated that she can tell when R4 is not receiving her medications correctly. V6 stated that R4 has not been stable in a couple of months. V6 stated that R4 had a break down and was sent to a local hospital for treatment last month due to her behaviors. V6 stated she has tried to ask the facility and the pharmacy about R4's medication but she feels she is getting the run around and no real answers. V6 stated that she thinks that R4 has not received her Haldol injections because the medication was not on the bills she has received. V6 stated that when R4 is off her medications, she gets hateful, and rude. V6 stated that if R4 was receiving her Haldol she would not be having the hallucinations. V6 stated that R4 has been on Haldol for the last 15 years. V6 stated the only time that R4 hears voices is because she is not receiving her medications. V6 stated that R4's admission to the hospital in May she feels is related to her not receiving her medications as she is supposed to. V6 stated that a certified nurse assistant from the facility told V6 that she does not think R4 is getting her medication like she is supposed to.On 07/08/2025 at 9:23 A.M. R4 stated that there has been trouble getting the medications that she is supposed to take. R4 stated she does not remember the last time she received her Haldol injection.The facility policy titled Medication Administration Policy / Procedure with a revision date of 09/27/2022 documented Medications will be administered safely to residents within the facility by licensed nurses at the specified time / timeframe, following the recommended administration method and will be documented as required.

Based on interview and record review, the facility failed to provide narcotic pain medications per physician's orders for 1 (R1) of 3 residents reviewed for pain management in the sample of 5. This failure resulted in R1 experiencing unrelieved pain and having to be sent to the local hospital for treatment of pain. R1's admission Record documents that R1 is a [AGE] year-old that was admitted to the facility on [DATE]. Diagnoses included are unspecified fracture of right femur, cirrhosis of liver, pain due to internal orthopedic prosthetic device, pain in right hip, weakness, chronic kidney disease, anemia, and osteoarthritis of right knee. R1's MDS (Minimum Data Set) dated 06/16/2025, documented that R1 has a BIMS (Brief Interview for Mental Status) score of 15 indicating R1 is cognitively intact. R1's Care Plan with a revision date of 09/30/2024 has a focus are of The resident has chronic pain. Interventions listed are administer analgesia as per orders, anticipate the resident's need for pain relief and respond to any complaint of pain, monitor/record/report to nurse any signs and symptoms of nonverbal pain, monitor / document for probable cause of each pain episode, notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past, and monitor / record/ report to Nurse resident complaints of pain or requests for pain treatment. R1's Order Summary with a print date of 07/02/2025 document an order for hydrocodone -acetaminophen 7.5 mg - 325 mg by mouth every 4 hours as needed for moderate pain with an order date 06/10/2025 and an order for hydrocodone - acetaminophen 5-325 mg by mouth every 6 hours as needed for pain with an order date of 06/19/2025. Both orders were documented as being active.R1's June 2025 Medication Administration Record (MAR) documented that R1 received hydrocodone - acetaminophen 7.5 - 325 mg on 06/24/2025 at 12:28 P.M. with a pain level of 7. R1 did not receive another dose until 06/26/2025 at 5:11 P.M. with a documented pain level of 10. There is no charted effectiveness for either date. R1's Progress Notes dated 06/25/2025 at 11:20 P.M. document R1 woke up crying in pain stating her pain level was a 12, currently no pain medication on unit, awaiting refill at pharmacy signed by physician. Requesting to go to local hospital for pain management.R1's Progress Notes dated 06/26/2025 at 4:15 A.M. document Resident back on unit via ambulance company. Paper prescription received for Norco (hydrocodone - acetaminophen) 7.5 mg -325 mg, 8 tablets. Resident in bed stating she was in no pain.The local hospital ED Provider Note dated 06/26/2025 1:25 A.M. documented that R1 is at a nursing facility and apparently was controlled with Norco. However, she says that the nursing home ran out this am, and her last dose was 06/25/2025 at 11:00 A.M. She states she feels the pain is due to not being able to take any medications. I guess patient has pain medication but ran out now has pain, so I guess that is what I am treating, so gave some IM (Intramuscular) fentanyl. So, plan to discharge back. Nursing home is asking us to write a prescription for the Norco, I don't have a problem with writing it, but in theory the prescription for narcotics has to be done electronically, and patient has to pick it up. Who picks up the prescription (paper electronic or otherwise) so not sure how the prescription will be honored. I guess it also begs the question, if I can just write a paper prescription for the Norco then why didn't they just call the primary care physician and have her do it? So, I am writing the prescription as a way to help out but its not how the pharmacies usually want a narcotic prescription.R1's June 2025 MAR documented that R1 received hydrocodone - acetaminophen 5-325 mg on 06/29/2025 at 11:41 A.M. with pain level rated at a 10. There is no documentation of R1 receiving another dose until 6/30/25 at 10:00 A.M. with a pain level rated at a 7. R1's Progress Notes dated 06/29/2025 at 2:02 P.M. document Resident is crying due to pain in her right hip and leg. Surgical incisions have no apparent signs / symptoms of infection. Resident is requesting to go to the hospital to get evaluated. Call was placed to physician to make aware and ok'd sending her out for evaluation and treatment as indicated.R1's Progress Notes dated 06/29/2025 at 2:15 P.M. document Resident left the facility per ambulance to go to local hospital. This nurse placed another call to physician regarding having the pharmacy call her for a pain medication refill. Spoke to pharmacy, medication would arrive tonight with the delivery. And a code (to utilize back up supply) be obtained if needed. At 2:26 P.M. this nurse spoke to the local emergency department charge nurse regarding a local prescription that the facility could obtain until the delivery arrives. Pain medications were picked up from local pharmacy by staff.The local hospital ED Provider Note dated 06/29/2025 documented that R1 presents to the emergency department for pain management. R1 has been out of Norco for a few days. On 07/02/2025 at 2:51 P.M., R1was alert and orientated to person, place and time, stated she has gone to the hospital twice recently because the facility did not have her pain medication. R1 stated she is not sure why the facility was running out of her medications. R1 stated the ride in the ambulance to the hospital was horrific. R1 stated that she had hip surgery in June. R1 stated that she needs her pain medication because she can't stand the pain. On 07/09/2025 at 1:15 P.M., V1 (Administrator) stated that she was not notified about R1 having to be sent to the hospital for pain control until after it had occurred. V1 stated there should not be a time that the facility does not have medications for a resident. V1 stated the only way to ensure that the resident received pain medications was to have the emergency department send the prescription to a local pharmacy and have a staff member pick it up. V1 stated that the nurses are to check narcotics in the middle of the week to see if they have any that need refills or a new prescription to prevent residents from running out.On 07/08/2025 at 9:43 A.M., V2 (Director of Nursing) stated when a resident has a script that runs out, the nurse should call the doctor and get a new prescription for the medication. If it is after hours or a weekend, V2 stated the pharmacy can call the doctor on call and obtain the prescription. V2 stated that if the resident has an active prescription for a medication, they can get it out of the backup medication kit. V2 stated that R1 was without her medication and the nurse sent her out twice. V2 stated the resident did have the last prescription filled from a local pharmacy to ensure that she did not have to go back to the emergency department. V2 stated that the prescription was not asked in enough time that R1 would not run out of medications. V2 stated he would expect for the nurses to make sure that a resident does not run out of pain medications. V2 stated now they are looking at the narcotic cards on Wednesday or Thursday of each week to see if anyone needs a refill or a new prescription before the weekend to prevent them from running out of medications. V2 stated on Fridays the nurses are to check to make sure what was ordered came in. On 07/02/2025 at 2:40 P.M., V3 (Registered Nurse) stated the first time that R1 went to the hospital she was sent back with a script for 8 pills. V3 stated that when residents come back from the hospital with scripts, the facility will fax it to the pharmacy. V3 stated she does not know why the pharmacy does not fill the medications when they receive a script. V3 stated the day she sent R1 to the hospital, she was out of medication, and she did not know when the pharmacy would deliver it. V3 stated that she told the hospital that they would get the medication filled at a local pharmacy to ensure that R1 had medication.On 07/09/2025 at 3:13 P.M., V10 (Physician's Nurse) stated that V9 (Physician) wrote a new prescription for R1's hydrocodone on 07/01/2025. V10 stated she has no documentation of the facility trying to get a prescription before that date. The facility policy titled Administering Pain Medications with a revision date of October 2010 documented under general guidelines 1. The pain management program is based on a facility-wide commitment to resident comfort. 2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Procedure step 6 documents Administer pain medications as ordered.

Based on interview and record review, the facility failed to ensure residents were free from physical abuse for 1 (R4) of 3 residents reviewed for abuse in the sample of 5. R4's admission Record documents that R4 was admitted to the facility on [DATE]. Diagnoses listed are vascular dementia, type 2 diabetes mellitus, brief psychotic disorder, unspecified mood disorder, auditory hallucinations, schizophrenia, anxiety and unspecified psychosis. R4's MDS (Minimum Data Set) dated 03/26/2025, documents R4 has a BIMS (Brief Interview for Mental Status) score of 15, indicating R4 is cognitively intact. R4's Care Plan with a revision date of 07/08/2025 has a focus are of, (R4) is at risk for decline in psychosocial well being related to: Allegation of abuse related to a resident-to-resident altercation. The interventions listed are: provide 1:1 visit, and staff educated to keep residents separated. R5's admission Record documents that R5 was admitted to the facility on [DATE]. Diagnoses listed are acute respiratory failure, chronic obstructive pulmonary disease, chronic combines systolic and diastolic heart failure, anxiety, essential hypertension, and Alzheimer's Dementia. R5's MDS dated [DATE], documents under section C0100. Should the Brief Interview for Mental Status be conducted? 0. No resident is rarely / never understood. R5's Care Plan with a revision date of 04/02/2024 has a focus area of, (R5) is/has potential to be physically aggressive related to dementia. The interventions listed for this area are administer medications as ordered. Document / monitor for side effects and effectiveness. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior, assess and anticipate residents needs: food, thirst, toileting, comfort level and pain, when the resident becomes agitated intervene before it escalates, guide away from distress, engage in calm conversation.A Verification of Incident Investigation / Administrative Summary documented on 05/27/2025 at 8:30 P.M. R4 and R5 were both out in the common area sitting in their wheelchairs when R5 reached over and made contact with R4 in the neck area. Staff immediately separated residents moving them to different areas allowing time to calm down. Nurse assessed with no injuries noted. Administrator reinterviewed both residents, neither remembered the incident. Other residents were interviewed with no negative findings. Staff were interviewed with no negative findings. Neither resident show any negative psychosocial affects related to incident and continue their normal daily routine. There was no documentation in the Nurse's Notes of R4 or R5's medical records to describe the resident-to-resident altercation. On 07/09/2025 at 1:15 P.M. V1 (Administrator) stated she was not working at the facility when the resident-to-resident altercation occurred. V1 stated that what she can tell from the investigation, R4 and R5 was in the common area and R5 struck R4. V1 stated there were no injuries documented. On 07/09/2025 at 1:37 P.M. V2 (Director of Nursing) stated he is not aware of the resident-to-resident altercation that occurred in May 2025 between R4 and R5. V2 stated the previous administrator would not share any information about those situations with him. V2 stated he is not aware of any new interventions that were put into place to prevent a new altercation.On 07/08/2025 at 3:52 P.M. V6 (Family Member) stated R4 and R5 had a resident-to-resident altercation in May 2025, and she cannot remember the exact date. V6 stated that she was not made aware of the outcome of the resident to resident altercation and believes the facility should provide 1:1 monitoring of R5 to prevent any further altercations from occurring. The facility policy titled Abuse Policy with a revision date of 01/09/2024 documented under section titled purpose To provide guidance and Procedures to the facility and staff to assure the residents remain to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or management. Under section titled Abuse Policy The purpose of this policy is to assure that the facility is doing all hat is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents.

Based on interview and record review the facility failed to obtain a new prescription for a controlled substance in a timely manner for 1 of 3 residents (R1) reviewed for pharmacy services in the sample of 5.R1's admission Record documents that R1 is a [AGE] year-old that was admitted to the facility on [DATE]. Diagnoses included are unspecified fracture of right femur, cirrhosis of liver, pain die to internal orthopedic prosthetic device, pain in right hip, weakness, chronic kidney disease, anemia, and osteoarthritis of right knee. R1's MDS (Minimum Data Set) dated 06/16/2025, documented that R1 has a BIMS (Brief Interview for Mental Status) score of 15 indicating R1 is cognitively intact. R1's Care Plan with a revision date of 09/30/2024 has a focus are of The resident has chronic pain. Interventions listed are administer analgesia as per orders, anticipate the resident's need for pain relief and respond to any complaint of pain, monitor/record/report to nurse any signs and symptoms of non - verbal pain, monitor / document for probable cause of each pain episode, notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past, and monitor / record/ report to Nurse resident complaints of pain or requests for pain treatment. R1's Order Summary with a print date of 07/02/2025 document an order for hydrocodone -acetaminophen 7.5 mg - 325 mg by mouth every 4 hours as needed for moderate pain with an order date 06/10/2025 and an order for hydrocodone - acetaminophen 5-325 mg by mouth every 6 hours as needed for pain with an order date of 06/19/2025. Both orders were documented as being active.R1's Progress Note dated 06/25/2025, with a time of 11:20 P.M. documented that R1 woke up crying in pain stating her pain level was a 12, currently no pain medication on unit. Requesting to go to local hospital for pain management. R1's Progress Note dated 06/29/2025, with a time of 2:02 P.M. documented that R1 was crying due to pain in her right hip and leg. R1 is requesting to go to the hospital for treatment.R1's Progress Note dated 06/29/2025, with a time of 2:15P.M. documented that V3 (Registered Nurse) placed call to V9 (Physician) to obtain a refill on R1's pain medication. R1's Progress Note dated 06/29/2025, with a time of 2:26 P.M. documented that V3 spoke with the local hospital and asked if the hospital could send a prescription to a local pharmacy because R1's medication would not be at the facility from the pharmacy until later that night. Pain medication was picked up by facility staff from local pharmacy.On 07/02/2025 at 2:51 P.M. R1 stated she has gone to the hospital twice recently because the facility did not have her pain medication. R1 stated she is not sure why the facility was running out of her medications. R1 stated the ride in the ambulance to the hospital was horrific. R1 stated that she had hip surgery in June. R1 stated that she needs her pain medication because she can't stand the pain. On 07/09/2025 at 1:15 P.M. V1 (Administrator) stated that she was not notified about R1 having to be sent to the hospital for pain control until after it had occurred. V1 stated there should not be a time that the facility does not have medications for a resident. V1 stated the only way to ensure that the resident received pain medications was to have the emergency department send the prescription to a local pharmacy and have a staff member pick it up. V1 stated that the nurses are to check narcotics in the middle of the week to see if they have any that need refills or a new prescription to prevent residents from running out.On 07/08/2025 at 9:43 A.M. V2 (Director of Nursing) stated when a resident has a script that runs out, the nurse should call the doctor and get a new prescription for the medication. If it is after hours or a weekend, V2 stated the pharmacy can call the doctor on call and obtain the prescription. V2 stated that if the resident has an active prescription for a medication, they can get it out of the backup medication kit. V2 stated that R1 was without her medication and the nurse sent her out twice. V2 stated the resident did have the last prescription filled from a local pharmacy to ensure that she did not have to go back to the emergency department. V2 stated that the prescription was not asked in enough time that R1 would not run out of medications. V2 stated he would expect for the nurses to make sure that a resident does not run out of pain medications. V2 stated now they are looking at the narcotic cards on Wednesday or Thursday of each week to see if anyone needs a refill or a new prescription before the weekend to prevent them from running out of medications. V2 stated on Fridays the nurses are to check to make sure what was ordered came in. On 07/02/2025 at 2:40 P.M. V3 (Registered Nurse) stated the first time that R1 went to the hospital she was sent back with a script for 8 pills. V3 stated that when residents come back from the hospital with scripts, the facility will fax it to the pharmacy. V3 stated she does not know why the pharmacy does not fill the medications when they receive a script. V3 stated the day she sent R1 to the hospital, she was out of medication, and she did not know when the pharmacy would deliver it. V3 stated that she told the hospital that they would get the medication filled at a local pharmacy to ensure that R1 had medication.On 07/09/2025 at 3:13 P.M. V10 (Physicians Nurse) stated that V9 (Physician) wrote a new prescription for R1's hydrocodone on 07/01/2025. V10 stated she has no documentation of the facility trying to get a prescription before that date. The facility's pharmacy policy titled Controlled Substance Prescriptions with a revision date of 08/2020 documented under section titled policy state before a controlled substance can be dispensed, the pharmacy must be in receipt of a clear, complete, and signed written prescription from a person lawfully authorized to prescribe controlled substances. Section VII. Titled Refill Requests for CIII-CV and Partial Fill Requests for CII documents If one or more refills or a partial fill quantity remains, the facility must request the medication from the pharmacy.

Based on interview and record review, the facility failed to notify a resident's representative of a hospital admission for 1 (R1) of 3 residents reviewed for notification of changes in the sample of 8. Findings include: R1's admission Record documents an admission date of 03/06/25 and includes diagnoses of encounter for orthopedic aftercare following surgical amputation, type 2 diabetes mellitus with diabetic neuropathy, unspecified; unspecified severe protein-calorie malnutrition; osteomyelitis, unspecified; local infection of the skin and subcutaneous tissue. R1's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 6, indicating that R1 has severe cognitive impairment. On 06/03/25 at 10:24am, V2 (Director of Nursing/DON) stated R1 had an appointment with Podiatry on 05/29/25 and they scheduled him for a debridement the next morning. V2 stated they were waiting on the preauthorization for R1's procedure. V2 stated on 05/30/25 when they took R1 to the hospital for the procedure they did not have the authorization for the procedure and they sent him to the ER (Emergency Room). V2 stated R1 was a direct admit from the ER and he had the procedure inpatient. V2 stated she was not sure what R1's BIMS score was, but confirmed he was listed as financial responsible party and his wife was listed as his first emergency contact, not POA (Power of Attorney). V2 stated if someone was cognitively intact and did not have a POA or responsible party it would be up to the resident if they contacted family or not, if they were not cognitively intact, family should be contacted. On 06/03/25 at 12:08pm, V3 (Family Member) stated she was not aware that R1 was hospitalized until a Social Worker from the hospital called and left a message about where to send her husband to. V3 stated she called them back and was all but arguing with the hospital because she had no knowledge of R1 being hospitalized . V3 stated she had received a picture of R1's foot the night before and it looked good, she stated she could hardly believe that he needed surgery on it. V3 stated she was not even informed R1 was scheduled for the outpatient debridement on 05/30/25. V3 stated that R1 on his best days has a BIMS of maybe a 4. V3 stated that she is R1's POA and designated R1's son as his emergency contact #1. V3 stated she filled out the POA paperwork at the facility. V3 stated she has yet to hear anything from the facility about R1. On 06/03/25 at 12:39pm, V2 (DON) stated that residents who have a BIMS score of 6 or 7 should have a Power of Attorney (POA) in place. V2 stated in a perfect world R1's family should have been notified as soon as they found out he was going to be admitted to the hospital. On 06/03/25 at 12:40pm, V4 (Corporate Nurse) stated a resident should have a BIMS of 12 or above to be able to be their own representative. On 06/03/25 at 12:42pm, V5 (Social Service Director/SSD) stated she knew that R1's wife had filled out POA paperwork and she would locate it. On 06/23/25 at 1:26pm, V5 (SSD) stated she had not filed R1's POA paperwork was because his wife had requested that one of his sons also be POA because of her health problems. V5 stated R1's son had not returned their calls. On 06/03/25 at 2:25pm, V6 (Transportation/Certified Nurse Aide/CNA) stated it was her understanding on Thursday 5/29/25 that R1 was having a procedure the next morning at the procedure center. V6 stated that when she left work that evening, she was instructed to call before they left the next morning to ensure the doctor had secured approval from insurance. V6 stated she called around 6:30am and was informed that they did not have the authorization yet, to call back in 30-45 minutes. She stated she called back, and they still had not received it, to stand by and they were calling the doctor. V6 stated shortly after someone at the facility told her to take R1 to the emergency room per the procedure center. V6 stated they loaded R1 up and the other transportation aide drove him in the van, and she followed in her personal vehicle so she could sit with him, and the van could be utilized for other already scheduled appointments. V6 stated she heard the ER staff talking about R1 being a direct admit amongst themselves, but no one had notified her of this. V6 stated finally she questioned them about it and they said, we are admitting R1 to the hospital. V6 stated she went back to the facility and went right into the morning meeting and let everyone know what was happening with R1. V6 stated she knows R1's family personally and would have let them know had she not had such a busy day and all the confusion. V6 stated it is technically not a part of her job responsibilities to notify family, someone who is a nurse should be notifying them, in case there are questions. On 06/03/25 at 2:42pm, V7 (Transport CNA) stated it is not their responsibility to notify family in these situations. V7 stated R1 is still hospitalized , and they have not been able to get a clear picture of what is going on with him. On 06/03/25 at 2:51pm, V2 (DON) confirmed it is not the responsibility of the transportation aide to inform the family that a resident is admitted to the hospital. A facility document titled Power of Attorney for Health Care signed by R1 on 03/07/25 and witnessed by V5 (SSD) on 03/07/25 documents R1's wishes that V3 (Family Member) be his healthcare agent. R1's admission Record documents that R1 is the financial responsible party and V3 is listed as emergency contact #1. There is no Power of Attorney, or any other responsible party listed on this document. A facility document titled Notice of Transfer or Discharge signed on 06/03/25 found in R1's electronic medical record, documents that R1 was discharged on 05/30/25 per physician's orders. The facility was unable to provide any reproducible evidence that V3 was contacted regarding R1's procedure or hospitalization on 05/30/25. The facility policy titled Discharge/Transfer Policy with a revision date of 08/15/22 documents under the section procedure: when the facility transfers or discharges a resident under any circumstances .appropriate documentation shall be make in the resident's clinical record.

Based on observation, interview, and record review the facility failed to provide sanitary food service by not performing hand hygiene. This failure has the potential to affect all 64 residents residing at the facility. Findings include: 1. On 05/05/25 at 12:35 PM, V17 (Certified Nurse Aide/CNA) transferred glasses onto several residents' lunch trays by the rim area where the resident would drink from after touching the wheelchair handles of two wheelchairs and her scrub top with no hand hygiene in between. On 05/06/25 at 12:03 PM, throughout lunch service V4 (CNA) transferred glasses onto several residents' lunch trays by the rim area where the resident would drink from after touching the wheelchair handles of two wheelchairs and her scrub top with no hand hygiene in between. On 05/06/25 at 12:07 PM, throughout lunch service V5 (Housekeeping Supervisor) transferred glasses onto several residents' lunch trays by the rim area where the resident would drink from after touching the dietary cart door, the handles of a wheelchair, and her sweater with no hand hygiene in between. On 05/06/25 at 12:16 PM, throughout lunch service V6 (CNA) transferred glasses onto residents lunch trays by the rim area where the resident would drink from after touching the back of three dining room chairs and her top with no hand hygiene in between. On 05/07/25 at 11:40 AM, throughout lunch service V7 (CNA) transferred glasses onto residents' lunch trays by the rim area where the resident would drink from after touching the back of dining room chairs and her pants with no hand hygiene in between and then transferred the glasses by the rim area onto the table for the residents. On 05/07/25 at 12:09 PM throughout lunch service V8 (CNA) transferred glasses onto residents lunch trays by the rim area where the resident would drink from after touching the handles of five wheelchairs with no hand hygiene in between and then transferred the glasses by the rim area onto the table for the residents. On 05/07/25 at 12:12 PM, while assisting four residents with condiments on their burgers, V4 (CNA) touched the top buns after touching the wheelchair handles of two wheelchairs and her scrub top with no hand hygiene in between. On 05/08/25 at 1:54 PM V15 (Food Service Director) stated, staff should not touch the top of the glasses where the residents drink from after touching anything that is not a clean sanitized item and they should not be touching resident's food items if their hands are not clean or if they don't have clean gloves on. 48356 R22's Admission Record dated 05/08/25 documents an admitted [DATE] and included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominate side, aphasia following other cerebrovascular disease and type 2 diabetes mellitus. R22's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 04, which indicates severely impaired cognition. R22's MDS also documented R22 requires supervision or touching assistance with eating. R22's Care Plan documents a focus area of: Altered Nutrition and hydration (Risk) r/t (related to) GI (gastrointestinal) disturbance. Another focus area documents: Self-Care deficit as evidenced by needs assistance with ADL'S (Activities of Daily Living). Interventions include in part: Eating -supervision to one person physical assist required. On 05/06/25 at 12:25PM, V12 (CNA) served R22 her tray. V12 grabbed the top of R22's drinking glasses by the rims around the mouthpiece to place R22's glasses on the table. V12 then gave several bites of food to R22, then got up to go punch in the code to the smoking door to assist other residents in from smoking. V12 then went back to assisting R22 to eat without performing hand hygiene after touching other residents, the keypad and the door. On 05/06/25 at 12:35PM, V12 grabbed a spoon from another resident who had her hand on the end of the spoon and used it to stir R22's sugar into her tea. On 05/06/25 at 12:36PM, V12 got up again from assisting R22 with eating to go open the smoking door for severals resident that were outside smoking. V12 was punching in the code to the door and assisting residents in. V12 then went back to assisting R22 to eat without performing hand hygiene. On 05/06/25 at 12:45PM, V12 got up once more to go punch the code in for the smoking door and assisting residents in from outside, then went back to assisting R22 to eat without performing hand hygiene. On 05/08/25 at 9:14AM, V12 stated that she did not perform hand hygiene at anytime when she kept getting up from assisting R22 to eat and opening the door to let the smokers in or after she assisted other residents back in from being outside smoking. V12 stated that she did not perform hand hygiene before serving R22's tray. V12 stated that she knows she grabbed R22's glass by the top of the glass around the mouth area. V12 stated that she has nerve damage in her neck and can't grab a cup by the side or the glass will fall out of her hand. V12 said that she grabs all resident glasses by the top around the the mouth area because she doesn't want to drop a cup. V12 didn't know if this was sanitary or not. V12 said that she should of performed hand hygiene each time she came back from opening the door to let the smokers in and every time she touched another resident. 3. R42's Admission Record dated 05/12/25 documents an admitted [DATE] and included diagnoses of systemic lupus and severe sepsis. R42's MDS dated [DATE] documented a BIMS score of 11, indicating moderate cognitive impairment and documented R42 requires set-up or clean-up assistance. R42's Care Plan documented a focus area of: R42 has impaired immunity r/t (related to) lupus with a revision date of 12/15/22. Interventions include in part: The resident is at risk for contracting infections due to impaired immune status. Keep the environment clean and people with infection away. On 05/06/25 at 12:18PM, V15 (Food Service Director) served R42 his tray. V15 grabbed R42's drinking glasses by the tops of the glass around the mouth area to set them down on the table. V15 did not perform hand hygiene before serving R42's tray and glasses. 4. R44's Admission Record dated 05/12/25 documents an admitted [DATE] and included diagnoses of Alzheimer's disease and type 2 diabetes mellitus. R44's MDS dated [DATE] documented a BIMS score of 03, indicating severe cognitive impairment. The MDS also documented R44 requires set-up or clean-up assistance. R44's Care Plan documents a focus area of: Altered nutrition and hydration risk, dx (diagnosis) of Alzheimer's' disease, diabetes. On 05/07/25 at 12:21PM, V15 (Food Service Director) served R44 his tray. V15 grabbed R44's drinking glasses at the top of the glass around the mouth area without performing hand hygiene prior to serving R44's tray. The facility policy titled Handwashing/Hand Hygiene undated documents under policy statement The facility considers hand hygiene the primary means of preventing the spread of infection. Under Policy interpretation and implementation, #7 Use of alcohol-based hand rub containing at least 62% alcohol: or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: B: Before and after direct contact with residents, O: Before and after assisting a resident with meals. The Long Term Care Facility Application for Medicare and Medicaid dated 05/05/25 documents 64 residents residing at the facility

Based on observation, interview, and record review, the facility failed to answer call lights timely and promote resident dignity during dining for 4 (R6, R19, R22, and R25) of 4 residents reviewed for resident rights in the sample of 46. Findings Include: 1. R25's Admission Record documented an admitted [DATE] with diagnoses that included hemiplegia affecting left non dominant side, peripheral vascular disease and generalized anxiety among others. R25's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating R25 is cognitively intact. R25's MDS also documented he was dependent on staff for toileting, showering, dressing and transferring. On 5/6/2025 at 8:15AM, R25's call light was noted to already be activated. R25's call light remained activated until staff answered the call light at 9:00AM. At 9:05AM, R25 said he had activated his call light at 7:00AM and the staff did not respond until two hours later at 9:00AM. 2. R19's Admission Record documented and admitted [DATE] and included diagnoses of sepsis, peripheral vascular disease and muscle wasting. R19's MDS dated [DATE] documented a BIMS score of 13, indicating R19 was cognitively intact. R19's MDS also documented she was dependent on staff for toileting, showering, dressing and transferring. On 5/7/2025 at 8:28AM, R19 activated her call light and at 8:50AM staff responded, 22 minutes later. At 9:00AM, R19 said she usually has to wait around 30 minutes for staff to answer her call light. Resident council meeting minutes dated 3/10/25, documented the resident council brought forth the concern of call light response times as a problem that needed to be addressed. On 5/8/2025 at 8:15AM, V3 (Assistant Director of Nursing/ADON) said staff are expected to answer call lights within 10 to 15 minutes and was not aware residents were having to wait so long. V3 said she considers 45 minute call light response time to be unreasonable. The Facility policy titled Call Light Guidance with revision date of 8/20/2022 documented resident call light shall be responded to within a reasonable amount of time. 41610 3. R6's Admission Record documented an admitted [DATE] with diagnoses that included dementia, type 2 diabetes mellitus, and hearing loss. R6's MDS assessment dated [DATE] documented no BIMS assessment was conducted due to the resident is rarely/never understood. R6's Bowel and Bladder assessment dated [DATE] documented: 1. a. void appropriately without incontinence: with 'never' marked. On 05/05/25 at 12:34PM, R6 was sitting in the dining room in her wheelchair with her pants wet from just below her waist to almost her knees. There was urine under her wheelchair causing a puddle over 12 inches across and over six inches wide. On 05/05/25 between 12:34PM and 1:33PM, R6 sat in the dining room eating her lunch while wet with a puddle of urine underneath her with several staff walking by her, not attending to her incontinence or cleaning the puddle of urine. On 05/05/25 at 1:33PM, V17 (Certified Nurse Aide/CNA) put a towel over the urine, went and acquired gloves, cleaned the urine and removed R6 and the towel from the dining room. On 05/05/25 at 1:36PM, V17 took R6 to get changed. On 05/08/25 at 2:00PM, V3 (ADON) stated, any resident that has an accident in the dining room, she would expect staff to try to take the resident to get changed and the urine on the floor should have been discreetly cleaned up. R6 should not have been left wet for an hour in the dining room, she should have been cleaned up and the urine discretely cleaned up. 48356 4. R22's Admission Record dated 05/08/25 documented an admitted [DATE] and included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominate side, aphasia following other cerebrovascular disease and type 2 diabetes mellitus. R22's MDS assessment dated [DATE] documented a BIMS score of 04, indicating severe cognitive impariment. R22's MDS also documented she requires supervision or touching assistance with eating. R22's Care Plan documented a focus area of: Altered Nutrition and hydration (Risk) r/t (related to) GI (gastrointestinal) disturbance. Another focus area documents: Self-Care deficit as evidenced by needs assistance with ADL'S (Activities of Daily Living). Interventions include in part: Eating -supervision to one-person physical assist required. On 05/06/25 at 12:25PM, during lunch meal, V12 (Certified Nurse Assistant) was standing up and giving several bites of food to R22, then walked over to the door to go punch in the code on the keypad to assist a resident in from smoking. V12 then went back to assisting R22 to eat while standing up. On 05/06/25 at 12:36PM, V12 was still standing up assisting R22 to eat and again walked over to open the door for several residents that were outside smoking. V12 returned to R22 and resumed assisting R22 to eat, again while standing. On 05/06/25 at 12:45PM, V12 had continued to stand and assist R22 to eat. V12 went to the door again to help residents come in from smoking outside. V12 returned and continued to stand while assisting R22 to eat. On 05/08/25 at 9:14AM, V12 stated that management at the facility told her that she needs to not sit down in the resident's chair because they are hard, and she is currently on work compensation for a back injury. V12 stated that she doesn't remember who told her that she couldn't sit in the resident chairs. V12 stated that she normally always stands up when assisting resident with eating. V12 stated that she was going over to open the door because that is what she normally does to let the smokers in. V12 also stated that she stands up when assisting residents with eating so if another resident falls in the dining room, she can get to them quicker. On 05/08/25 at 9:44AM, V2 (Director of Nursing/DON/Regional Nurse) stated that he was not aware of V12 having to stand to assist residents with eating. V2 stated that he has seen V12 sit down in other chairs. On 05/08/25 at 10:07AM, V2 (DON/Regional Nurse) stated that V12 doesn't have any sitting restrictions and should be able to sit and assist residents with eating. The facility policy titled Quality of Life-Dignity with a revised date of 10/09 documents Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality

Based on interview and record review, the facility failed to implement new interventions to prevent falls for 2 (R27 and R63) of 4 residents reviewed for accidents/supervision in the sample of 46. The Findings include: 1. R27's Admission record dated 05/08/25 documents an admitted [DATE] with diagnoses in part of lack of coordination, abnormal posture, unsteadiness on feet, disorder of bone density and structure, and repeated falls. R27's Minimum Data Set (MDS) dated [DATE] documents under Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 15, indicating R27 is cognitively intact. Under Functional Abilities and Goals, the MDS documents R27 needs supervision or touching assist with toileting and walking. A facility Initial Incident report in the electronic health record dated 04/28/25 documents R27 experienced a fall. This document includes a progress note of the incident that states: in part of CNA (Certified Nurse Assistant) called this nurse to hall et stated resident was observed on the floor in his room. Upon assessment, resident noted right side of bed A in room. Stated his bed was not made so he was going to lay down in the other bed. Unable to stated [sic] what he was doing other than attempting to lay down. Feet observed toward HOB (head of bed) with legs extended out and laying on right side facing the doorway. Denies hitting head. Fall un-witnessed. No visible injuries noted. Resident assisted back into bed via 2 staff and gait belt. Stated he wanted to lay down. Denies pain . R27's Care Plan documents a focus area of: At risk for falls and injuries r/t (related to) Medication: Psychotropic meds/diuretic meds/Cardiovascular meds/pain meds/impaired mobility/weakness with a revision date of 08/02/22. Interventions include therapy and nursing to educate resident on safe walking practices based on how is feeling at the time of ambulation (initiated on 09/13/24), call don't fall sign at bedside (initiated 07/03/24), diabetic medication review by MD (Medical Doctor) (medications changed and labs ordered) (initiated 03/03/23), encourage use of call light, keep call light within reach, keep environment clutter free, keep personal belongings within reach, and provide adequate lightening (all initiated on 07/22/22). There were no new interventions documented on R27's care plan after the fall on 4/28/25. On 05/05/25 at 11:31AM, R27 stated that he did have a recent fall and a history of falling. R27 stated that he doesn't know of any interventions that the facility has put in place to prevent him from falling again. On 05/07/25 at 10:35AM, V3 (Assistant Director of Nursing/ADON) stated that they don't have a root cause analysis done for R27's falls. V3 stated that there should have been one done on R27's fall and she doesn't know why there wasn't. On 05/08/25 at 11:33AM, V11 (MDS/Care Plan Coordinator) stated that R27 had no new interventions after his fall on 04/28/25. V11 stated that she wasn't working at the facility at that time as she only recently started at the facility. 49907 2. R63's Admission Record documents an admitted [DATE] and included diagnoses of Parkinson's disease without dyskinesia and type 2 diabetes mellitus without complications. R63's MDS dated [DATE] documented a BIMS score of 13, indicating that R63 is cognitively intact. R63's Care Plan documented R63 is at risk for falls and injuries related to Parkinson's. This focus area has an initiation date of 02/19/25. There are no new interventions documented on R63's current care plan after 03/18/25. A facility Incident Report with an incident date of 03/20/25 at 9:00pm, documents that while R63 was attempting to transfer herself, she fell on her knees resulting in abrasions to the left and right knee and a bruise . There were no new fall interventions listed on this document. A facility Incident Report with an incident date and time of 05/02/25 at 12:00pm, documents R63 reported that she was getting up and she fell approximately 5 days prior. R63 stated she did not report it to nurse as she didn't feel she was hurt. This report also added an injury 5/4/25 that a bruise was noted to R63's chin left side a few days post fall. There were no new interventions listed on this document. On 05/06/25 at 11:43am, R63 stated she has had some falls recently, but she couldn't be sure when they were or what the facility did. R63 stated she did go to the hospital after her first fall and the bruise she currently has on her chin is from a fall last week. On 05/07/25 at 10:35am, V3 (ADON) stated they do not have root cause analysis for R63. V3 confirmed that there were no new interventions for R63's most recent falls. The facility policy titled Accident and Incidents with a revised date of 09/07/23 documents in part under policy: The interdisciplinary team (IDT) will complete an investigation to determine root cause and implement appropriate interventions Facility policy titled, Accidents and Incidents with a revision date 09/07/23 documents the following under policy; All accidents/incidents involving a resident shall require an incident report .The interdisciplinary team will complete an investigation to determine root cause and implement appropriate interventions. In the section titled policy interpretation and implementation it documents in part, .appropriate interventions will be indicated in the incident report and implemented. The MDS (Minimum Data Set) nurse shall update the care plan with implemented interventions and communicate interventions with line staff.

Based on observation, interview and record review, the facility failed to administer pneumococcal immunizations as ordered by a physician for 2 (R2 and R21) of 5 residents reviewed for immunizations in the sample of 46. Findings Include: R2's Admission record dated 05/13/25 documented an admitted [DATE] and included diagnoses of Alzheimer's, unspecified atrial fibrillation, abnormal thyroid function, and thrombocytosis. R2's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) was not conducted as resident is rarely/never understood, and the staff assessment documented R2 has short- and long-term memory problems. R2's Care Plan with a revision date of 04/14/24 documented a Focus Area of Self-Care Deficit as Evidenced by: Needs assistance with ADL (Activities of Daily Living). R2's Order Review report documented Prevnar 20 Intramuscular suspension Prefilled syringe 0.5Ml (Milliliters) inject 0.5 ML intramuscularly every day shift for vaccination for 1 day. Order status documents Completed. The order date is documented as 04/12/24, Start date of 04/16/24, End date of 04/17/24. R2's Medication Administration Record (MAR) from 04/01/24 to 04/30/24 documents Prevnar 20 Intramuscular suspension Prefilled syringe 0.5ML (Milliliters) inject 0.5 ML intramuscularly every day shift for vaccination for 1 day with an order date of 04/12/24. The date of 04/16/24 has V25's (Licensed Practical Nurse/LPN) initials and the Letters MN. The Chart Code on the MAR documents MN=Medication not Available. R2's clinical Immunizations record documents Prevnar 20 Administration date 04/16/24 administered by V25 (LPN). On 05/08/25 at 2:24PM, R2's Prevnar 20 vial was observed in the refrigerator of the medication room with a delivery date of 04/15/24. Instructions document Prevnar 20 Intramuscular suspension Prefilled syringe 0.5Ml (Milliliters) inject 0.5 ML intramuscularly. On 05/08/25 at 2:35PM, V2 (Director of Nursing/DON) stated the reason R2's Prevnar 20 dated 04/16/24 was still in the refrigerator in the medication room was because someone didn't administer it and they would have to start the process over and get a new order to give the Prevnar 20 to R2. On 05/12/25 at 12:00PM, V25 (LPN) stated that she did not give R2 her Prevnar 20 vaccine. V25 stated that she signed the MAR that the medication was not available, as she was unable to find the Prevnar 20 to administer it to R2. V25 stated that she doesn't know why on the immunization record that it is documented that she gave R2 her Prevnar 20 because she did not give it. 2. R21's Admission Record documented R21 was [AGE] years old and admitted to the facility on [DATE]. This document also included diagnoses of chronic obstructive pulmonary disease, malignant neoplasm of bladder, acute kidney failure, and personal history of malignant neoplasm of breast. R21's MDS dated [DATE] documented a BIMS score of 11, indicating moderate cognitive impairment. R21's Care Plan with a revision date of 09/30/24 documented a focus area of Self-Care Deficit as evidenced by: Needs assistance with ADL's. R21's Order Review report documents an order summary for Prevnar 20 Intramuscular Suspension Prefilled syringe 0.5 ML (milliliters) inject 0.5 ML intramuscularly one time only for preventative . Order status documents Completed. The Order date is documented as 03/13/25, Start date of 03/17/25, End date of 03/20/25. R21's MAR form 03/01/25 to 03/31/25 documents Prevnar 20 Intramuscular Suspension Prefilled syringe 0.5ML (Pneumococcal 20-Valent Conjugate Vaccine) inject 0.5 ML intramuscularly one time only for preventative . Order date documents 03/13/25. On 3/17/25, V25's (LPN) initials were listed along with the MN. The Chart Code on the MAR documents MN=Medication not Available. On 05/08/25 at 2:24PM, R21's Prevnar 20 vial was observed in the medication room refrigerator with a delivery date of 03/13/25 and instructions document Prevnar 20 Intramuscular suspension Prefilled syringe 0.5Ml (Milliliters) inject 0.5 ML intramuscularly. On 05/08/25 at 2:35PM, V2 (DON) stated the reason R21's Prevnar 20 injection vial was in the medication storage refrigerator is because someone probably didn't give it and they would have to start the whole process over with getting consent, the order for the medication as well since it wasn't given. On 05/12/25 at 12:00PM, V25 (LPN) stated that she did not give R21 her Prevnar 20 vaccine. V25 stated that she signed the MAR that the medication was not available, as she was unable to find the Prevnar 20 to administer it to R21. V25 stated that she did not give R21 her Prevnar 20 injection. The facility policy titled Pneumococcal Vaccine with a revised date of 05/18/22 documents under purpose as To protect residents for the dangers for pneumonia infection. Under Policy Interpretations and implementations, #4. Pneumococcal vaccine will be administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol.

Based on observation, interview, and record review, the facility failed to ensure Transmission-Based Precautions were followed for 1 (R29) of 3 residents reviewed for Infection Prevention and Control in the sample of 46. Findings include: R29's Admission Record documented an admitted [DATE] and included diagnoses of osteomyelitis, unspecified, cutaneous abscess of left foot, cellulitis of left lower limb, and gangrene. R29's Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12, indicating that R23 is cognitively intact. R29's Physician's Order Sheet (POS) dated 05/12/25, documents an active order through 5/6/25 for Contact isolation r/t (related to): MRSA (Methicillin-resistant Staphylococcus aureus) to Lt (left) foot wound, every shift for MRSA. R29's Progress Note dated 5/5/2025 at 10:29 AM documented continues IV (intravenous) antibiotic therapy. Tolerating well, no s/s (signs and symptoms) reaction. Picc (peripherally inserted central catheter) line in place, patent. Remains on isolation precautions as ordered. On 05/05/25 at 2:47 PM, R29's room did not have any transmission-based precautions signage posted on or around the door. There was Personal Protective Equipment (PPE) noted outside the next room down from R29's room, but not right outside R29's room. There were no biohazard barrels observed in R29's room. On 05/05/25 at 2:52 PM, R29 stated he is on IV antibiotics for an infection in his foot. R29 stated no one wears gowns or anything when providing care for him. R29 stated he has been told he was on isolation before but wasn't really sure what that means. On 05/06/25 at 9:05 AM, R29's room was again observed to not have any transmission-based precautions signage posted on or around the door. There was PPE noted outside the next room down from R29's room but not right outside R29's room. R29's Progress Note dated 05/06/25 at 10:00am states, Spoke to (name of doctor) office. Orders obtained to d/c (discontinue) (antibiotic), d/c picc line, and d/c isolation. On 05/07/25 at 12:36 PM, V6 (Certified Nursing Aide/CNA) stated R29's hallway is her regular assignment and there were no precautions in place for R29 when he had his wound and PICC line. V6 stated they were not required to wear any PPE when providing care for R29. On 05/08/25 at 2:06 PM, V18 (Infection Preventionist) stated R29 was taken off isolation on 05/06/25 when his antibiotic was finished. V18 stated R29 was on contact precautions for MRSA. V18 stated there should be signs and PPE outside of a resident's room who is on any kind of precautions. V18 stated PPE should be worn when providing care for someone on contact isolation. Facility Policy titled, Initiating Isolation Precautions with a revision date of 12/06/21 documents in Policy interpretation and implementation, When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee): a. Clearly identifies the type of precautions, the anticipated duration, and the personal protective equipment (PPE) that must be used. b. Explains to the resident (or representative) the reason(s) for the precautions. c. Provides and/or oversees the education of the resident, representative and/or visitors regarding the precautions and use of PPE. d. Determines the appropriate notification on the room entrance door and on the front of the resident's chart so that personnel and visitors are aware of the need for and type of precautions. (1) The signage informs the staff of the type of CDC (Center for Disease Control) precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. (2) Signs and notifications comply with the resident's right to confidentiality or privacy. e. Ensures that protective equipment (i.e., gloves, gowns, masks, etc.) is maintained outside the resident's room so that anyone entering the room can apply the appropriate equipment. f. Ensures that protective equipment and supplies needed to maintain precautions during care are in the resident's room; and g. Ensures that an appropriate linen barrel/hamper and waste container, with appropriate liner, (red bags) are placed in the resident's room. 4. Transmission-Based Precautions remain in effect until the Attending Physician or Infection Preventionist discontinues them, which occurs after criteria for discontinuation are met.

Based on observation and interview, the facility failed to provide a clean and homelike environment for 2 (R49 and R54) of 4 residents reviewed for environment in a sample of 46. Findings include: On 5/6/25 at 9:20AM, a feces soiled bedpan was seen sitting in the bathtub of R54 and R49's shared bathroom. On 5/6/25 9:20AM, R54 was alert and oriented and stated he knew the staff stored his bedpan in the bathtub, but did not know they were not cleaning it before storing it. On 5/6/25 at 2:49PM, the same soiled bedpan was noted to be in R54 and R49's shared bathtub. On 5/7/25 at 8:15AM, the same soiled bedpan was noted to be sitting in R54's and R49's bathtub. On 5/7/25 at 11:30AM, the same soiled bedpan was noted to still be sitting in R54's and R49's bathtub. On 5/7/2025 at 11:30AM, R49 was alert and oriented and stated he was not aware of a soiled bed pan being left in the bathtub in his bathroom. R49 said he was upset by the soiled bedpan causing a foul odor in his room and asked the staff to remove it. On 5/7/25 at 11:45AM, V9 (Housekeeper) said a soiled bed pan should not be left in the resident's bathroom. V9 removed the soiled bed pan from R49 and R54's bathtub. On 5/8/25 at 12:15PM, V2 (Director of Nursing/DON) stated staff should not be leaving feces soiled bedpans in resident's bathrooms. The Facility policy titled Bedpan or Urinal Procedure (non-dated) documented after assisting resident with the bedpan, (staff are to) clean the bedpan, wipe dry and store the bedpan per facility policy. Do not leave (the bedpan) in the bathroom.

Based on record review and interview, the facility failed to ensure that services were provided within the professional scope of practice when nursing staff administered and documented multiple medications late to 3 (R8, R23, and R37) of 5 residents reviewed for medication administration in a sample of 46. Findings include: 1. R23's Admission Record documented an admitted [DATE] and included diagnoses of type 2 diabetes mellitus with diabetic neuropathy and depression. R23's Minimum Data Set (MDS) assessment dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R23 is cognitively intact. R23's Medication Admin Audit Report documents the following physician's orders: Desmopressin Acetate Tablet 0.1 MG (milligram), Give 1 tablet by mouth at bedtime, with a schedule date of 05/05/25 at 8pm, an administration time of 8:32pm, and a documentation time of 2:34am on 05/06/25, which was documented by V13 (Licensed Practical Nurse/LPN). Desmopressin Acetate Tablet 0.2 MG, Give 1 tablet by mouth at bedtime, with a schedule date of 05/05/25 at 8pm, an administration time of 8:33pm, and a documentation time of 2:34am on 05/06/25, which was documented by V13 (LPN). Metformin HCI Tablet 500 MG, Give 2 tablet by mouth two times a day, with a schedule date of 05/05/25 at 8pm, an administration time of 8:33pm, and a documentation time of 2:34am on 05/06/25, which was documented by V13 (LPN). Asmanex (120 Metered Doses) Inhalation Aerosol Powder Breath Activated 220 MCG/ACT (Mometasone Furoate (Inhalation)) 2 puff inhale orally two times a day, with a schedule date of 05/05/25 at 8pm, an administration time of 8:32pm, and a documentation time of 2:34am on 05/06/25, which was documented by V13 (LPN). Melatonin Oral Tablet 1 MG (Melatonin), Give 1 mg by mouth at bedtime, with a schedule date of 05/05/25 at 8pm, an administration time of 8:33pm, and a documentation time of 2:34am on 05/06/25, which was documented by V13 (LPN). Artificial Tears Ophthalmic Solution 1% (Carboxymethylcellulose Sodium (Ophth)) Instill 1 drop in both eyes at bedtime, with a schedule date of 05/05/25 at 8pm, an administration time of 8:31pm, and a documentation time of 2:34am on 05/06/25, which was documented by V13 (LPN). Gabapentin Capsule 100 MG Give 2 capsule by mouth three times a day, with a schedule date of 05/05/25 at 9pm, an administration time of 8:33pm, and a documentation time of 2:34am on 05/06/25, which was documented by V13 (LPN). On 05/06/25 at 09:06am, R23 stated it depends on which nurse is working as to whether he gets his medications on time. R23 stated it was early morning before he received the meds he should have received before bedtime last night. R23 stated it always happens with agency nurses, especially V13 (LPN). 2. R8's Admission Record documented an admitted [DATE] and included diagnoses of type 2 diabetes mellitus without complications and chronic obstructive pulmonary disease. R8's MDS assessment dated [DATE] documented a BIMS score of 9, indicating that R8 has moderate cognitive impairment. R8's Medication Admin Audit Report documents the following physician's orders: Tresiba FlexTouch Subcutaneous Solution Pen injector 100 UNIT/ML (milliliters) (Insulin Degludec) Inject 66 unit subcutaneously two times a day, with a schedule date of 05/04/25 at 8pm, with an administration time of 05/05/25 at 12:13am, and a documentation time of 12:19am on 05/05/25 by V24 (Registered Nurse/RN). This same medication was scheduled on 05/05/25 at 8pm with an administration date of 05/05/25 at 7:43pm, and a documentation time of 11:44pm by V13 (LPN). Doxycycline Hyclate Oral Capsule 100 MG (Doxycycline Hyclate), Give 100 mg by mouth every 12 hours, with a schedule date of 05/04/25 at 9pm, an administration time of 05/05/25 at 12:19am, and a documentation time of 12:19am on 05/05/25 by V24 (Registered Nurse-RN). This same medication was scheduled at 9pm on 05/05/25, with an administration time of 05/05/25 at 8:43pm and a documentation time of 11:44pm on 05/05/025 by V13. Lipitor Oral Tablet 40 MG (Atorvastatin Calcium) Give 1 tablet by mouth at bedtime, with a schedule date of 05/04/25 at 9pm, an administration time of 05/05/25 at 12:14am and a documentation time of 12:19am on 05/05/25 by V24 (RN). This same medication was scheduled for 9pm on 05/05/25, with an administration time of 05/05/25 at 8:44pm, with a documentation time of 11:44pm on 05/05/25 by V13. Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth at bedtime, with a schedule date of 05/04/25 at 9pm, an administration time of 05/05/25 at 12:19am and a documentation time of 12:19pm on 05/05/25 by V24 (RN). This same medication was scheduled for 9pm on 05/05/25, with an administration time of 05/05/25 at 8:43pm and a documentation time of 11:44pm on 05/05/25 by V13. On 05/06/25 at 09:09am, R8 stated he did not receive his PM medications from last night until two-thirty this morning. 3. R37's Admission Record documented an admitted [DATE] and included diagnoses of Chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. R37's MDS assessment dated [DATE] documented a BIMS score of 13, indicating R37 is cognitively intact. R37's Medication Admin Audit Report documents the following physician's orders: Furosemide Oral Tablet 40 MG (Furosemide) Give 40mg by mouth three times a day, with a schedule date of 05/05/25 at 8pm, an administration time of 05/05/25 at 8:37pm and a documentation time of 2:41am on 05/06/25 by V13. Norco Oral Tablet 7.5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours, with a schedule date of 05/05/25 at 8pm, an administration time of 05/05/25 at 8:37pm and a documentation time of 2:41am on 05/06/25 by V13. Spironolactone Oral Tablet 25 MG (Spironolactone) Give 1 tablet by mouth two times a day, with a schedule date of 05/05/25 at 8pm, an administration time of 05/05/25 at 8:37pm and a documentation time of 2:41am on 05/06/25 by V13. Melatonin Oral Tablet 3 MG (Melatonin) Give 2 tablet by mouth at bedtime, with a schedule date of 05/05/25 at 8pm, an administration time of 05/05/25 at 8:37pm and a documentation time of 2:41am on 05/06/25 by V13. On 05/07/25 at 11:13am, R37 stated she wished she received her medications on time. R37 stated that when V13 (LPN) works they rarely receive their medication before midnight. R37 commented that these medications should be passed around 7 or 8pm. On 05/08/25 at 9:39am, V3 (Assistant Director of Nursing/ADON) stated nurses are expected to be documenting the administration of medications as they are administering them, as that is according to professional standards of practice and reduces the risk of medication errors. The facility's Medication Administration Policy/Procedure with a revision date of 09/27/22 documents the following under Policy: Medications will be administered safely to residents within the facility by licensed nurses at the specified time/timeframe, following the recommended administration method and will be documented as required.

Based on interview, observation, and record review, the facility failed to ensure residents were assisted with activities of daily living (ADL's) in a timely manner for 3 (R6, R7, and R24) of 19 residents reviewed for ADL assistance in a sample of 46. Findings include: 1. R7's Admission Record documents an admitted [DATE] with diagnoses that included type 2 diabetes mellitus, dementia, unspecified psychosis not due to a substance or known physiological condition, chronic kidney disease, and history of transient ischemic attack and cerebral infarction. R7s Minimum Data Set (MDS) assessment dated [DATE] documents no Brief Interview for Mental Status (BIMS) score was conducted due to resident is rarely/never understood. Under the section for Functional Abilities and Goals, the MDS documented R7 needed supervision or touching assistance for eating, indicating helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. On 05/06/25 at 12:01 PM, R7's lunch was removed from the tray and placed in front of her. R7 was sitting in her wheelchair, asleep with her head leaned forward and to the side. Staff did not attempt to awaken R7 to eat her lunch at this time. On 05/06/25 from 12:01 PM to 12:40 PM, R7's food sat in front of her uncovered with R7 sleeping at the table and no staff attempting to wake her or see if she wanted to eat lunch. On 05/06/25 at 12:40 PM, V15 (Food Service Director) woke R7 up and encouraged her to eat her lunch. On 05/06/25 at 12:42 PM, V6 (Certified Nurse Aide/CNA) moved R7's food plate and drinks to another table then moved R7 to that table and assisted her with her lunch. On 05/08/25 at 1:57 PM, V15 stated she does not know why V6 moved R7's lunch to a different table to assist R7, she should not do that. On 05/08/25 at 2:00 PM, V3 (Assistant Director of Nursing/ADON) stated, staff should not wait 40 minutes to wake someone up and encourage them to eat; after 40 minutes their food would be cold. 2. R24's Admission Record documents an admitted [DATE] and included diagnoses of facial weakness following other cerebrovascular disease, dementia, type 2 diabetes mellitus, anxiety disorder, and major depressive disorder. R24's MDS dated [DATE] documented a BIMS score of 04, indicating R24 has severe cognitive impairment. Under the section for Functional Abilities and Goals, the MDS documented R24 needed supervision or touching assistance for eating, indicating helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. On 05/06/25 at 12:03 PM, R24 attempted to drink her chopped fruit fluff with her straw. The chopped fruit fluff was unable to move through the straw due to the thick consistency and chopped fruit. On 05/06/25, from 12:03 PM to 12:40 PM, R24 tried to eat her dessert with her straw and did not touch any of the rest of her food. On 05/06/25 at 12:40 PM, V16 (CNA Supervisor) asked R24 if she would prefer to use a spoon. V16 picked up R24's spoon, put it in her hand, and put the straw down on the table. V16 then encouraged R24 to eat some of her lunch. On 05/06/25 at 12:41 PM, R24 started eating her dessert and then continued to eat some of her other food. On 05/08/25 at 2:03 PM, V3 (ADON) stated staff should have noticed R24 had not eaten any of her lunch, was trying to eat her dessert through a straw, and should have and assisted R24 before allowing her to attempt to eat her dessert with through a straw for over 40 minutes. 3. R6's Admission Record documented an admitted [DATE] and included diagnoses of dementia, type 2 diabetes mellitus, and hearing loss. R6's MDS assessment dated [DATE] documented no BIMS score was conducted due to resident is rarely/never understood. R6's Bowel and Bladder assessment dated [DATE] documents: 1. a. void appropriately without incontinence: with 'never' marked. On 05/05/25 at 12:34 PM, R6 was sitting in the dining room in her wheelchair with her pants wet from just below her waist to almost her knees. There was urine under her wheelchair causing a puddle over 12 inches across and over six inches wide. On 05/05/25 between 12:34 PM and 1:33 PM, R6 sat in the dining room eating her lunch while wet with a puddle of urine underneath her and several staff walking by and not asking to change her or covering the puddle of urine. On 05/05/25 at 1:33 PM, V17 (CNA) put a towel over the urine, went and acquired gloves, cleaned the urine and removed R6 and the towel from the dining room. On 05/05/25 at 1:36 PM, V17 took R6 to get changed. On 05/08/25 at 2:00 PM, V3 (ADON) stated staff should have assisted R6 out of the dining room, cleaned her up, changed her clothes and brought her back to the dining room to eat the rest of her lunch. They could have put a cover over her food to keep it warm while they quickly changed her. V3 stated she would have expected housekeeping to discretely clean the urine from the floor. She would not want a resident to sit for an hour, wet in the dining room.

Based on interview, and record review, the facility failed to provide narcotic pain medications per physicians orders and failed to assess the effectiveness of non narcotic pain medication for 2 of 2 residents (R1, R3) reviewed for pain management in the sample of 14. This failure lead to R1 and R3 experiencing unrelieved pain up to 9 and 10 on a scale of zero to ten. Findings include: 1. R1's Face Sheet documented an admitted [DATE] and listed Diagnoses including Bipolar Disorder, Chronic Obstructive Pulmonary Disease, and Morbid Obesity with a Body Mass Index of Greater than 70. A Minimum Data Set, dated dated dated [DATE] documented that R1 has minimal deficits in cognition. R1's Care Plan dated 3/17/25 documented a problem area, The resident displays manipulative behavior related to a psychiatric disorder, with corresponding intervention,Educate resident on appropriate means of requesting help for self or others. The Care Plan also documented a problem area, The resident is on pain medication therapy, with corresponding intervention, Administer analgesic medications as ordered by physician. Monitor/document side effects and effectiveness every shift. R1's March Physicians Order Sheet (POS) documented orders for lidocaine 4 percent patch apply to bilateral knees topically in the morning, and norco 7.5-325 mg (milligrams). one tablet every 6 hours for pain. R1's March 2025 Medication Administration Record (MAR) documented that R1 did not receive the lidocaine patch on 3/11/25, 3/12/25 and 3/13/25 as it was not available. The same MAR documented that R1 did not receive the norco as it was unavailable from 3/17/25 at 2am until 3/19/25 at 2am, with the exception of one dose given at 2am on 3/18/25. This MAR documented that R1's pain in that time period ranged from 0 to 6, and Tylenol ER 650mg. one tablet every six hours was administered, with no documentation as to the effectiveness. Nurses Notes documented the following: 3/17/25 at 1:53pm: Script for Norco have been faxed to Physicians office to be signed, returned so that they can be forwarded to the pharmacy. 3/17/25 at 2:03pm: Call placed to the pharmacy. There still is not a script for the medication. Waiting on a script. There was no documentation in the Nurses Notes regarding pain levels or effectiveness of the tylenol. On 3/21/25 at 1:25pm, R1 was alert and oriented to person, place, and time. R1 stated earlier in the month she went without narcotic pain medication for two days due to an issue with the pharmacy not delivering it. R1 stated staff gave her tylenol but it was ineffective and her pain was ten on a ten scale during that time. R1 stated in this month there was also a problem with the facility not having received her topical lidocaine patches, which she went without for about 3 days. 2. R3's Face Sheet documented an admitted [DATE] and listed Diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Diabetes Type 2 and Bipolar Disorder. A Minimum Data Set, dated dated dated [DATE] documented that R3 has no deficits in cognition. R3's Care Plan dated 3/17/25 documented a problem area, The resident is on pain medication therapy related to chronic pain,with corresponding intervention, Administer analgesic medications as ordered by physician. Monitor/document side effects and effectiveness every shift. R3's March 2025 POS documented orders for tylenol oral tablet 325 mg. give 1 tablet by mouth every 8 hours as needed for pain, and hydrcodone acetaminophen oral tablet 5-325 mg. give 1 tablet by mouth every 6 hours as needed for chronic pain. R3's March 2025 MAR documented that R3 did not receive the hydrocodone on 3/3/25 at 12am and 6am nor on 3/4/25 at 12pm and 6pm, as the medication was unavailable. The same MAR documented that R3's pain in that period ranged from 3 to 9, that tylenol given on 3/4/25 for a pain level of 9 at 11:08am was ineffective, and that tylenol given on 3/4/25 at 6:02pm for a pain level of 9 was effective. Nurses Notes documented the following: 2/28/25 at 3:40pm: Message sent to pharmacy regarding Norco. To be sent with next delivery in morning. 2/28/25 at 6:33pm: Per pharmacy, 3 tablets remaining on script to be sent. Call made to Physician to notify of new script needed. Stated to have pharmacy call. Pharmacy notified and received spoke with Physician per pharmacy message. Message received that Physician has been contacted. On 3/22/25 at 6:15am, R3 was alert and oriented to person, place, and time. R3 stated sometimes his narcotic pain medication is not available because the nurses haven't ordered it. R3 stated he can't recall the level of his pain on a ten scale, but, Its gotten pretty bad. They gave me tylenol, but that didn't really cut it. On 3/27/25 at 10am, V2, Director of Nurses, stated the nurse responsible for passing medication is responsible for reordering the medications when needed. V2 stated if medications are missing, it might be a problem with agency nurses not following through with their responsibilities. V2 stated narcotic pain medications are generally available in the facility's emergency medication kit. V2 stated nursing staff probably accessed some of the doses of R1 and R3's pain medication from the emergency kit although it was not available in the medication cart. A Management of Pain Policy dated 5/16/22 documented, Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. We will achieve these goals through:Using pain medication judiciously to balance the resident's desired level of pain relief with the avoidance of unacceptable adverse consequences.

Based on interview and record review, the facility failed to provide adequate direct care CNA (Certified Nursing Assistant) staffing. This has the ability to affect all 66 residents living at the facility. Findings include: R1's Face Sheet documented an admitted [DATE] and listed Diagnoses including Bipolar Disorder, Chronic Obstructive Pulmonary Disease, and Morbid Obesity with a Body Mass Index of Greater than 70. A Minimum Data Set, dated dated dated [DATE] documented that R1 has minimal deficits in cognition. On 3/21/25 at 1:25pm, R1 was alert and oriented to person, place, and time. R1 stated call lights take up to an hour because the facility is short staffed, especially from 7pm to 7am throughout the week and on weekends. R12's Face Sheet documented an admitted [DATE] and listed Diagnoses including Multiple Sclerosis and Diabetes Type 2. A Minimum Data Set, dated dated dated [DATE] documented that R12 has minimal deficits in cognition. On 3/21/25 at 4pm, R12 was alert and oriented to person, place, and time. R12 stated there are a lot of CNA (Certified Nursing Assistant) call ins, and she is not getting twice weekly showers because they are understaffed. R12 stated she is sometimes left in a wet adult brief for an hour while her call light is on. R3's Face Sheet documented an admitted [DATE] and listed Diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Diabetes Type 2 and Bipolar Disorder. A Minimum Data Set, dated dated dated [DATE] documented that R3 has no deficits in cognition. On 3/22/25 at 6:15am, R3 was alert and oriented to person, place, and time. R3 stated, Sometimes they don't answer call lights all night long, for up to 6 hours. After supper you can pretty much forget about getting any help. They always say they are sorry, but they're short. On 3/26/25 at 10:05am, R14 was alert and oriented to person, place, and time. R14 stated on Saturday 3/15/25 after 7pm, his call light was on over 4 hours while he was wanting to be repositioned. R14 stated when staff responded they apologized and said they were short. On 3/26/25 at 8:25am, V10, CNA, stated there are lots of call ins on the 2pm-10pm shift especially on weekends. On 3/26/25 at 9:20am, V9, CNA, stated on Sunday 3/23/25, the 10pm-6am shift, which is to have at minimum 4 CNAs, only had 2 due to call ins. On 3/26/25 at 11:15am, V7, CNA, stated when she came in Monday 3/24/25, there were only 2 CNAs working the 10pm to 6am shift. V7 stated there were residents wearing two completely soaked adult briefs and most incontinent residents beds had to be completely stripped. V7 stated when staff complain to management, they are told they are not allowed to have more staff according to the census numbers. V7 stated there are frequently no CNAs assigned to A Hall, and CNAs on B and C Halls are told to, Take turns watching A Hall. On 3/26/25 at 1:45pm, V6, CNA, stated she and one other CNA and two nurses were the only staff in the building on 3/23/25 from 10pm to 6am. V6 stated they did the best they could but the reports from day shift about residents being soaked through is probably accurate. V6 stated they are to have 4 CNAs on the 10pm to 6am shift, but they have worked with only 3 several times. V6 stated no CNA's are assigned to A Hall anymore, and CNAs on the other halls are to, Take turns splitting it. On 3/26/25 at 2:30pm, V8, CNA, stated she works on a prn (as needed) basis, and she has worked all shifts on all halls, every day of the week. V8 stated management waits too late to get coverage when there are call ins. V8 stated residents have told her they try not to use their call lights because they know the CNAs are working short. V8 stated the facility's pay and benefit package are not competitive with nearby facilities. V8 stated she has worked at the facility over three years and has not received annual pay raises as she should have. On 3/27/25 at 7:40am, V17, Minimum Data Set Coordinator, stated she is at present the staff member responsible for scheduling CNA and nursing staff, although moving forward it will not be part of her duties. V17 stated they, Try to schedule 6 CNAs on the 6am to 2pm shift, with a Shower Aid Monday though Friday. V17 stated the Shower Aid does get pulled to the floor sometimes and CNA's have to do their own showers. V17 stated on the 2pm to 10pm shift, they are to have a minimum of 6 CNAs, and on the 10pm to 6am shift they schedule 4. V17 stated A Hall is split by the CNA's on B and C Halls, and the two nurses each take B or C Hall and one side of A Hall. When asked how effective the A Hall coverage is, V17 stated when CNA's are at the nurses station charting, they can easily see call lights going off on A Hall and respond if needed. V17 stated on Monday 3/24/25 she saw where there had only been 2 CNAs on the 10pm to 6am shift. V17 stated as the management staff covering that evening, V12, Assistant Director of Nurses, should have come in and worked if he could not find coverage. On 3/27/25 at 8:30am, V1, Administrator, stated the facility is always trying to hire more CNA staff. V1 stated the facility's pay and benefits are highly competitive compared with other facilities in the community. On 3/27/25 at 8:50am, V12, Assistant Director of Nurses, stated on 3/23/25 the 10pm to 6am shift, there were 2 CNA call ins and one no call no show. V12 stated he tried to find coverage, including agency staff, but was unable. V12 stated he did not come in to cover the shift as it is his understanding that is the responsibility of V15, CNA Supervisor. On 3/27/25 at 9:30am, V14, CNA/Shower Aid, stated she is frequently pulled from showers onto the floor due to call ins. On 3/27/25 at 10am, V2, Director of Nurses, stated she feels CNA pay and benefits are competitive as far as she knows. V2 stated on 3/23/25, V15 should have come in and covered the 10pm-6am shift, and she is not sure not sure why she didn't . On 3/27/25 at 10:50am, V15 stated on 3/24/25 she woke up in the morning to realize when reading the facility group chat that they had needed CNA coverage for the previous 10pm-6am shift. V15 stated she had been asleep when the chat was taking place. On 3/27/25 at 12:25pm, V18, CNA, stated working conditions at the facility are not good due to being constantly short staffed and pay and benefits not being competitive. Resident Council Meeting Minutes documented the following: 1/8/25: Department concerns: Nursing: Showers (not) being done. 2/5/25: Department concerns: Nursing: Showers (not being done). 3/5/25: Department concerns: Nursing: Call lights. A March 2025 Schedule documented that on 3/3/25, there were 3 CNAs working the 10pm to 6am shift; On 3/12/25, 3/12/25, and 3/14/25. This schedule documented that on 3/23/25, there were 2 CNAs working the 10pm to 6am shift. On all these dates, there was no CNA coverage assigned to the A Hall. The facility's Staffing Policy dated 6/13/23 stated, Purpose: To offer guidance to the facility on employee staffing. Policy: The facility has developed and assigned duty hours for the Nursing Services department, based on state/federal requirements and utilizing the staffing calculator. Policy Interpretation and Implementation: 1. Nursing service is provided twenty-four (24) hours per day, seven days per week. 2. Staggered work hours may be assigned by the Director of Nursing Services when necessary. 3. Departmental work schedules may be revised by the Director of Nursing Services when deemed necessary and appropriate to ensure that each resident's needs are met. A Facility Matrix dated 3/21/25 documented a total of 66 residents living at the facility.

Based on interview and record review, the facility failed to support resident dignity by the timely answering of call lights for 5 residents (R1, R2, R3, R12, R14) of 14 residents reviewed for dignity in the sample of 14. Findings include: 1. R1's Face Sheet documented an admitted [DATE] and listed Diagnoses including Bipolar Disorder, Chronic Obstructive Pulmonary Disease, and Morbid Obesity with a Body Mass Index of Greater than 70. A Minimum Data Set, dated dated dated [DATE] documented that R1 has minimal deficits in cognition and requires substantial or maximal staff assistance for toileting. R1's Care Plan dated 3/17/25 documented a problem area, (R1) is incontinent of bowel/bladder at times, with corresponding intervention, Check and change during personal care. On 3/21/25 at 1:25pm, R1 was alert and oriented to person, place, and time. R1 stated call lights can take up to an hour to be answered, especially during the evening and night on weekends. R1 stated when staff finally respond, they apologize and explain they are short staffed. R1 stated she needs help with toileting and has had bowel and bladder accidents while waiting on her call light, which she stated were, Humiliating. 2. R2's Face Sheet documented an admitted [DATE] and listed Diagnoses including Left Lower Leg Fracture and Epilepsy. A Minimum Data Set, dated dated dated [DATE] documented that R2 has minimal deficits in cognition and requires substantial/maximal assistance for toileting. R2's Care Plan dated 3/2/25 documented a problem area, Resident is incontinent of bladder, with corresponding intervention, Check and change during personal care. On 3/21/25 at 2:20pm, R2 was alert and oriented to person, place, and time. R2 stated on occasion she has waited over an hour on her call light. R2 stated she has never had a bowel or bladder accident while waiting, but, It's very upsetting and it's hard to hold it that long. 3. R12's Face Sheet documented an admitted [DATE] and listed Diagnoses including Multiple Sclerosis and Diabetes Type 2. A Minimum Data Set, dated dated dated [DATE] documented that R12 has minimal deficits in cognition and is totally dependent on staff for toileting. R12's Care Plan dated 2/8/25 documented a problem area, Resident is incontinent of bowel and bladder related to Multiple Sclerosis, with corresponding intervention, Check and change during personal care. On 3/21/25 at 4:00pm, R12 was alert and oriented to person, place, and time. R12 stated she has waited for an hour on her call light while she had on a wet adult brief and needed to be changed. R12 stated, Imagine how it feels when you are left in a wet diaper for an hour. It's not pleasant. 4. R3's Face Sheet documented an admitted [DATE] and listed Diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Diabetes Type 2 and Bipolar Disorder. A Minimum Data Set, dated dated dated [DATE] documented that R3 has no deficits in cognition and is totally dependent on staff for toileting. R3's Care Plan dated 3/17/25 documented a problem area, (R3) has functional bladder incontinence related to impaired Mobility/Cerebral Vascular Accident, with corresponding intervention, (R3) will decrease frequency of urinary incontinence. On 3/22/25 at 6:15am, R3 was alert and oriented to person, place, and time. R3 stated, Sometimes, they don't answer call lights all night long. I've had my call light on for up to 6 hours with no response. After supper you can pretty much forget about getting any help around here. Sometimes, I give up and start yelling for help. The staff don't like it when I do that and they say I am disturbing the other residents. 5. On 3/26/25 at 10:005am, R14 was alert and oriented to person, place, and time. R14 stated on Saturday 3/15/25 after 7pm, his call light was on over 4 hours while he was wanting to be repositioned. R14 stated when staff responded they apologized and said they were short. On 3/27/25 at 10:00am, V2, Director of Nurses, stated it is her expectation that call lights should be answered within a few minutes. V2 stated she was unaware residents were waiting hours on their call light. Resident Council Meeting Minutes documented the following: 3/5/25: Department concerns: Nursing: Call lights. A Resident Rights Policy dated 7/11/22 documented, Policy: Employees shall treat residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to A) A dignified existence. A Call Light Guidance Policy dated 8/20/22 stated, Purpose: To provide guidance to all facility staff on the use, response and placement of call lights. Policy: Resident call light shall be responded to within a reasonable amount of time. Responsibility: It is the responsibility of all staff to respond to call lights.

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 3 (R23, R10, R27) of 13 residents reviewed for medication errors in the sample of 34. This resulted in R23 experiencing a blood glucose level of 37, altered mental status and being transported by EMS (Emergency Medical Services) to the Emergency Department for evaluation and treatment. Additionally, this failure resulted in R27 experiencing anxiety and an increase in behavioral symptoms, requiring an inpatient psychiatric hospitalization . The immediate Jeopardy began on 4/9/24 when insulin was administered to R23 without first performing a blood glucose check as ordered. V53 (Chief Clinical Officer) and V66 (Regional Operations Clinical Consultant) were notified of the Immediate Jeopardy on 5/8/24 at 2:40 PM. The surveyors confirmed by observations, interview, and record review that the Immediate Jeopardy was removed on 5/8/24 but noncompliance remains at Level Two due to additional time needed to evaluate the implementation and effectiveness of in-service training. Findings Include: 1. Review of R23's Admission Record documented an initial admitted to the facility as 12/19/21. R23 is documented as being [AGE] years old, with diagnoses including, but not limited to: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy; Unspecified Asthma; Morbid (severe) Obesity due to excess calories; and Occlusion and Stenosis of Bilateral Carotid Arteries . R23's Order Summary Report documented an active physician order, with a start date of 11/4/23 for Accu Checks BID (twice a day). Before breakfast and before bedtime. Notify MD (Doctor of Medicine) if BS (blood sugar) <(less than) 60 or > (greater than) 400 two times a day. R23's active orders on 4/9/24 include the administration orders of, Humulin 70/30 Kwikpen (70-30) 100 UNIT/ML (milliliter) Suspension pen-injector. Inject 40 units subcutaneously in the morning for DM (diabetes mellitus) type 2 Victoza Solution Pen-Injector 18 MG (milligrams)/3 ML (Liraglutide). Inject 1.8 mg subcutaneously in the morning for DM. R23's Medication Administration Record for 4/1/24 - 4/30/24 documented no Accu Check results on 4/9/24 at 0600, with the entry of 9. 9 is documented as representing, Other / See Progress Notes. Progress Notes dated 4/9/24 at 5:25 AM document the notation regarding Accu Checks as Not administered. Additional review of the Medication Administration Record for 4/1/24 - 4/30/24 documented despite R23 not having a blood glucose level completed on the AM of 4/9/24, R23 was administered subcutaneously 40 units of Humulin 70/30 Insulin at 5:21 AM and 1.8 mg of Victoza at 5:17 AM. On 5/7/24 at 2:52 PM, V43 (Agency Licensed Practical Nurse, LPN) stated that she was the nurse that was working at the facility on 4/9/24. V43 stated that she was unable to check R23's blood sugar on the morning of 4/9/24, as she couldn't find any glucose monitoring strips to check it with. V43 stated she isn't sure the oncoming nurses name, since she only works at the facility as agency staff but reported to her that morning that R23's blood sugar hadn't been checked yet due to having no strips. V43 stated the nurse told her they would find some or go buy some. V43 stated she documented the blood sugar in the Medication Administration Record (MAR) as not taken. V43 stated she left for the shift and never heard anything further regarding any concerns presenting after the insulin administration. In an additional interview with V43 on 5/7/24 at 3:36 PM, V43 confirmed that the shift she worked was 6PM-6AM beginning on 4/8/24, with the shift ending at 6AM on 4/9/24. V43 stated along with herself, two other nurses were also working at the facility that night. V43 confirmed she did not contact the physician to provide notification of being unable to check blood sugar levels due to a lack of strips or receive further orders. V43 confirms she administered insulin without knowing residents current blood sugar levels. V43 stated she did this as one of the other nurses working that night, who she didn't know their name, stated they had contacted V1 (Administrator) regarding not having blood sugar testing strips available. V43 stated V1 reportedly said they would get some strips and have them checked that morning. On 5/8/24 at 10:13 AM V7 (LPN), stated that she recalled working the night of 4/8/24, into the morning of 4/9/24. V7 stated that she recalled there being a shortage of glucose testing strips that night. V7 stated that she was working C Hall and had just enough strips to check her resident's glucose levels on that hall. V7 stated that she did not know of any other strips available in the facility to share with other halls in the facility that were short of strips. V7 stated if she recalls correctly, V6 (Registered Nurse/RN) was working that night and had contacted V1 regarding the glucose testing supply shortage by phone. V7 stated to her knowledge, the facility was going to send someone to get more strips from the store and said they would just check the glucose levels of those still needing their levels checked later that morning after they obtained more strips. On 5/8/24 at 2:00 PM, V6 (RN) stated that she recalled working on 4/8/24 into the morning of 4/9/24. V6 stated she had searched the entire facility looking for glucose strips as nursing staff had identified there would be enough strips for C hall to complete their AM blood glucose checks, but none for A or B halls. V6 stated V2 (Director of Nursing) was notified and instructed V6 to just document the blood glucose checks as not being done, and she would send someone from day shift first thing in the morning to get more strips. V2 communicated that day shift would take care of performing the accu checks and insulin administration. V6 stated nursing staff were never instructed to administer insulin without completing a blood glucose check. On 5/7/24 at 12:25 PM, V56 (Certified Nurse Assistant/CNA) stated she was working the day that R23 was sent to the hospital after having a low blood sugar. V56 stated she believes she was entering R23's room to take her to breakfast and observed her with bubbles coming out of the side of her mouth, eyes closed, and not responding to physical or verbal stimuli. V56 stated she knows R23 is diabetic, so called for the nurse, V36 (LPN), who immediately responded. V56 stated she has no further knowledge of anything that occurred during R23's care at that time. On 5/7/24 at 10:00 AM, V36 (LPN) stated that it was before lunch time on the day the CNA came and got her and said that R23 wasn't responding. V36 stated she immediately went to check on R23 and found that she was very lethargic with her eyes open, but not talking. V36 stated that she took R23's blood sugar, receiving a result of 37. V36 said V2 then came to assist. V36 stated R23 was attempted to be given oral glucose gel as ordered but couldn't swallow and the gel was running back out of her mouth. V36 stated she went to call the ambulance and V2 went to get IV (intravenous) supplies and start the IV. V36 stated at the time the 37 blood sugar was taken, the facility only had two blood glucose strips in the entire facility available for use. One of the strips was used to obtain the 37 reading. V36 stated R23's blood sugar was not taken again until the ambulance arrived, and she isn't sure if the ambulance took the blood sugar reading when they arrived, or the facility used their last strip. V36 stated that V2 had got the IV started and was able to infuse dextrose. V36 stated that V58 (CNA Supervisor) left the facility with the bottle of the blood glucose strips came in to go to (local store) and try and buy more strips. V36 stated that (local store) did not sell the strips that could be used with the facility's machines so he purchased a glucose monitor and the strips that could be used until their new strips came in. V36 stated V58 is responsible for ordering the strips and does not know why there was a shortage at that time. V36 stated there are other diabetic residents in the facility besides R23 who require glucose monitoring. V36 stated she isn't sure what she would have done if someone else needed blood glucose monitoring when strips weren't available. V36 stated luckily nobody needed their glucose checked during the time there was a shortage of strips and V58 was hurrying as fast as he could. R23's Progress Notes dated 4/9/24 at 10:52 AM documented a Nursing Note that stated, Resident is in a very deep sleep, not responding when talking (sic) to her accu check is 37. Attempted to give glucose gel by mouth resident is spitting it out and won't swallow, attempted to give it with a syringe and she took in approximately half a tube. This nurse started getting her paperwork ready and called (name of local ambulance company) while V2 started an IV and dextrose. EMT (Emergency Medical Technician) arrived resident did open her eyes and spoke a few words BS (blood sugar) up to 83 at this time. Resident oof (out of facility) to ER (emergency room ). R23's local ambulance report dated 4/9/24 documented the ambulance company received the call for assistance needed at 10:32:01 AM. The call is documented as the facility reporting a female with low blood glucose. An ambulance is documented as being dispatched at 10:32:54 AM with lights and sirens. Upon their arrival to the facility at 10:40:56 AM, R23 is documented as being pale, warm, dry, PERRL (pupils equal reactive and responsive to light), airway patent, breathing adequate, but not responding to verbal stimuli. Upon EMS (Emergency Medical Service) arrival, the facility staff were observed administering D5 (5% dextrose) intravenously. Facility staff are documented as reporting R23 had been found cool and clammy, lethargic, with a blood sugar of 37 for an unknown amount of time that she had been that status. The facility is documented as reporting they initially tried to administer R23 oral glucose, but she wasn't able to swallow the solution. The facility reported starting a 22-gauge IV (intravenous) line to R23's right hand, administering approximately 50 mL (milliliters) of D5. The ambulance company is documented as taking R23's blood glucose level upon their arrival with her level now being 83. R23 departed the facility via EMS at 10:55:07 AM, arriving at the local hospital Emergency Department for evaluation and treatment at 11:09:26 AM. R23's local hospital report dated 4/9/24 documented R23 presented with a chief complaint of low blood sugar. Per the ambulance company, R23 was unresponsive, cold and clammy with staff blood sugar noted to be 37. Once EMS were on the scene, R23's glucose level was checked, with a level then of 83. 10% dextrose was started and blood sugar rechecked, now at 76. R23 is documented as being confused, as her normal status, but reports she doesn't think she ate anything that morning. A fingerstick glucose level completed at the hospital prior to discharge back to the facility was 104, with a normal reference range listed as 70-108. R23 is documented as discharging back to the facility on [DATE], with the diagnoses of Hypoglycemia and History of Diabetes, with no new orders. R23's Hospital Discharge Instructions includes the notation of Please make sure patient eats before she gets her insulin to help decrease the potential for low blood sugar episodes. R23's Eating & Amount Eaten log at the facility reviewed for 4/9/24 documented no meal intake in the 6AM - 2PM entry slot. R23's Progress Notes dated 4/9/24 at 3:27 PM documented, Resident returned from (local hospital) dx (diagnosis) hypoglycemia BS is now up, received paperwork to educate resident. On 5/8/24 at 9:02 AM, V62 (emergency room Physician) confirmed he was the physician who had seen R23 in the local emergency roiagnom on [DATE]. V62 confirmed R23 was seen for hypoglycemia needs. V62 stated in reviewing his notes, upon EMS arrival to the facility, it looks like R23's glucose level was up to 83, after the administration of IV dextrose. The glucose level was initially documented as being 37. V62 confirmed that R23's hypoglycemia could have been a direct result of insulin being administered without first checking the blood glucose level. V62 acknowledged with severe cases in a resident with diabetes, if abnormal glucose levels are not monitored, medications inappropriately given, or levels left untreated, there is a potential for death. On 5/7/24 at 12:58 PM V2 (Director of Nursing/DON) stated that she was notified by V36 (LPN) one morning after coming out of morning meeting that she needed help with R23. V2 stated that R23 was lethargic, and her BS was checked with a reading of 37. V2 stated R23 was not responsive enough to take the oral glucose gel, as they tried but it was just running out of her mouth. V2 stated V36 went to call the ambulance and she went to get IV supplies and start a Dextrose infusion. V2 stated by the time the ambulance arrived R23 was improving and more alert. V2 cannot say if the blood sugar was re-checked by the facility or the ambulance company. V2 stated other than that day she is not aware of any time when there has been a blood glucose monitoring strip shortage. V2 stated V1 was the staff member who sent V58 to (local store) to buy more glucose test strips. On 5/7/24 at 4:10 PM, V1 (Administrator) stated that she doesn't recall the specific date or who she was notified by regarding the need for glucose testing strips. V1 stated it could have possibly been V2 because she was looking for the facility payment card to send for strips to be bought. V1 stated she is not aware of anytime the facility has not had test strips available for use. V1 stated she never instructed staff to administer insulin without knowing the blood sugar. V1 stated her expectation is for staff to notify the physician for abnormal blood sugar levels as outlined in that resident's plan of care and not administer insulin without knowing the resident's blood sugar level. On 5/7/24 at 10:17 AM V58 (CNA Supervisor) stated he was aware of the time when there was a shortage of blood glucose testing strips at the facility. V58 stated he was sent to (local store) to buy more strips, but (local store) didn't carry the kind of strips needed. V58 stated he used the facility payment card to purchase an accu check machine and testing strips for the facility use. V58 stated the truck with supplies was due at the facility the next day, so the facility just needed supplies to hold them over a day. V58 confirmed he does the ordering of glucose strips for the facility and they just went through them faster than expected. R23's Plan of Care with a created date of 12/22/21 documented a focus area for (R23) has Diabetes Mellitus. The goal of this focus area is that (R23) will have no complications related to diabetes through the review date. Interventions/Tasks listed to help fulfill this goal include, Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. 2. Review of R10's Admission Record documented an original admitted to the facility as 5/10/19. R10 is documented as being [AGE] years old, with diagnoses including, but not limited to: Type 2 Diabetes Mellitus with Hyperglycemia; Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified; Peripheral Vascular Disease, Unspecified; Chronic Obstructive Pulmonary Disease, Unspecified. R10's Order Summary Report documented an active physician order, with a start date of 1/22/24 for Accuchecks and contact MD orders if diabetic (BS <60 or >400) before meals and at bedtime. R10's active orders on 4/9/24 include, Basaglar KwikPen Subcutaneous Solution Pen-injector 100 Unit/ML. Inject 60 unit subcutaneously every 12 hours for diabetes . Admelog SoloStar Subcutaneous Solution Pen-injector 100 Unit/ML. Inject 9 unit subcutaneously one time a day for diabetes AND Inject 18 unit subcutaneously one time a day for diabetes AND Inject 9 unit subcutaneously one time a day for diabetes. R10's Medication Administration Record for 4/1/24 - 4/30/24 documented no Accu Check results on 4/9/24 at 6:30 AM, with the entry of 9. 9 is documented as representing, Other / See Progress Notes. Progress Notes dated 4/9/24 at 5:37 AM document the notation regarding Accu Checks as Not administered. Additional review of the Medication Administration Record for 4/1/24 - 4/30/24 documented despite R10 not having a blood glucose level completed on the AM of 4/9/24, R10 was administered subcutaneously 18 Units of Admelog Solostar Insulin at 5:10 AM and 60 Units of Basaglar Kwikpen at 5:10 AM. R10's Plan of Care with a date initiated as 3/13/23 documented a Focus area of, The resident has Diabetes Mellitus. The Goal of this area is listed as, The resident will have no complication related to diabetes through the review date. Interventions/Tasks documented include, Accu Checks as ordered per M.D .Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. The facility policy titled, Insulin Administration via vial procedure (undated) documented the purpose of the policy is, To provide guidelines for the safe administration of insulin to residents with diabetes. Steps in the Procedure (Insulin Injections via Syringe) to include, .2. Check blood glucose per physician order or facility protocol. The policy titled Blood Glucose Monitoring with an issue date of 4/6/23 documented the purpose of the policy is, To provide staff with guidelines for the proper procedures in monitoring blood glucose, while monitoring blood glucose levels . The policy goes on to state, Blood glucose monitoring will be done on all residents with a Physician's order. Review of the current facility assessment dated for 2023/2024 documented Conditions Diseases the facility provides care for includes Diabetes (all types). Competencies included for this condition include but are not limited to insulin management. 32619 3. R27's Face Sheet documented an admitted [DATE] and listed diagnoses including Alzheimer's Disease, Depression, Anxiety, and Personal History of Suicidal Behavior. A Minimum Data Set, dated dated dated [DATE] documented a Brief Inventory for Mental Status Score of 2, indicating R27 has severe deficits in cognitive functioning. A Telephone Order Sheet dated 1/16/24 documented an order for hydralazine 25mg (milligrams) one tablet three times daily. R27's Current Order Review Report Dated 5/10/24 documents and order for Olanzapine (Zyprexa) Oral Tablet 2.5 MG (Milligrams) give one tablet by mouth in the morning related to dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance with a start date of 11/18/23. This same order report also documents and for for Olanzapine Oral Tablet 5 MG give one tablet by mouth at bedtime related to dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance with a start date of 11/17/23. A 1/16/24 Nursing Progress Note documented, Spoke with M.D. (Medical Doctor) re (regarding) resident is very anxious and agitated. N.O. (New Order) (given for) hydralazine 25mg 3 times daily. The next Nursing Progress Note in the record, dated 1/18/24 documented, Resident's husband was here visiting and addressed wife's increased agitation, and further documented, Notified (V27, Primary Care Physician), of the above situation and received orders to send to the ER (emergency room ) at (a local hospital) for a Psychiatric Evaluation. A Discharge Summary from a local hospital dated 1/26/24 stated, Date of Admission: 1/18/24. (R27) arrived (from the facility) with a complaint of altered mental status, increased anger and irritation. Husband informed ER staff that he wasn't happy that she was sent to ER because now he will have another bill to pay, (and) is upset because the nursing home doesn't have her medications that she needs. Discharge instructions: Stop taking (this) medication: hydralazine 25mg.(milligrams). (Increase) Zyprexa to 5mg one tablet twice daily. R27's January 2024 MAR (Medication Administration Record) documented that R27 received the hydralazine three times daily on both 1/17/24 and 1/18/24. This MAR also documented that R27 did not receive Zyprexa 2.5mg one tablet in the a.m. on 1/13/24 and 1/14/24. On 5/3/24 at 12:40pm, R27 was observed in the facility's dining room self-ambulating with the one-to-one supervision of V58 (Certified Nursing Assistant Supervisor). R27 was alert only to herself and was visibly upset and agitated. On 5/8/24 at 8:55am, V71, R27's Power of Attorney, stated R27 was sent to a local hospital behavioral health unit on 1/18/24 due to an increase in anger and irritability and, Not getting one of her medications, I'm not sure which one. On 5/8/24 at 10:20am, V36 (LPN) stated when she called V27 on 1/16/24, V27 had ordered hydroxyzine 25mg one tablet three times daily for anxiety, not hydralazine, but she must have written the order as hydralazine. V36 stated she was not aware of this error til now. V36 stated she was not aware of R27 missing any doses of Zyprexa. On 5/8/24 at 9:20am, V47 (Assistant Director of Nurses/ADON) stated she was not hired until March of 2024 and does not know anything about R27's medications. On 5/8/24 at 1:40pm, V2 (DON) stated she was hired in January 2024 after the errors occurred and she does not know anything about it. On 5/10/24 at 7:55am, V27 stated on 1/16/24 he had ordered Hydroxyzine 25mg one tablet three times daily for R27, not Hydralazine. V27 stated hydralazine is used for the treatment of hypertension, and hydroxyzine is used for the treatment of anxiety. V27 stated this was the first he was hearing about the medication error. V27 stated had he known, he would have discontinued the hydralazine and ordered R27's blood pressure to be monitored three times daily for 7 days, and if R27 had displayed any negative effects from the hydralazine he would have ordered her to be sent to the ER. V27 stated additionally, the facility had not notified him of the morning doses of Zyprexa not being available. On 5/10/24 at 10:00 am, V1 stated she was not aware of the medication error with the hydralazine, nor of R27 not getting the morning dose of Zyprexa for two days. According to information on The Physicians Desk Reference website, https://www.pdr.net/drug-summary/?drugLabelId=738, hydralazine is indicated for the treatment of hypertension. There is no documentation in this guidance to indicate hydralazine is used in the treatment of anxiety. A Medication Error Policy dated 7/16/23 documented, Medication/Treatment errors shall be documented as required. A medication error shall be defined as any variation in administration of medication from the physicians orders and/or facility policy. The Immediate Jeopardy that began on 4/9/24 was removed on 5/8/24 when the facility took the following actions to remove the immediacy. 1) Immediate actions taken for residents identified: R23 was sent to the ER and received care for hypoglycemia on 4/9/24. 2) How the facility identified other residents who could potentially be affected: All residents that are diabetic, have physician's orders for accuchecks, and receive insulin have the potential to be affected by the alleged deficient practice. 3) Measures put into place/ System changes: Facility staff were educated by phone or in person prior to start of scheduled next shift. Facility nurse staff will not be allowed to work until the following categories have been in-serviced: Licensed nursing staff were educated on the Accucheck policy by: (V72), RN Regional Nurse Consultant on 5.8.2024. with emphasis on obtaining and documenting as ordered. Licensed nursing staff were educated on Insulin Administration by: (V72), RN Regional Nurse Consultant on 5.8.2024 with an emphasis on insulin being administered as ordered and in accordance with current standards of practice. Education was provided for licensed nursing staff of what to do when they don't have appropriate or adequate diabetic supplies on 5.8.24 by: (V72) RN, Regional Nurse Consultant. Facility did an inventory for accucheck test strips with an estimated supply of 30 days. Illinois Department of Professional Regulation was contacted by: (V75), Chief Executive Officer via email on date 5.8.24 involving incident on 4.9.24. Facility has completed a full facility review of all residents that have diabetes with orders for accuchecks and insulin on 5.8.24, with reviews and updates to their plan of care as needed. Facility company management reviewed and/or revised any policies and procedures to ensure necessary care and services are provided to residents with Diabetes Mellitus on 5.8.24. Those polices consisted of: Medication Administration. Insulin Administration. Following Physician's orders. Accucheck policy. Change of Condition Policy. Medication Error Policy. Those that reviewed those policies were: (V53) RN, Chief Nursing Officer (V72), RN Regional Clinical Consultant (V66), Regional Operations/Clinical Consultant (V75), Chief Executive Officer. 4) How the corrective actions will be monitored: The Director of Nursing or designee will complete random audits of 5 residents per week for a period of 8 weeks of the following categories: 1.) Accucheck was completed per physician's orders and documented. 2.) Insulin was administered as per physician's orders and documented. 3.) Appropriate and adequate supplies to complete per physician's orders. Any issues with accucheck completion of insulin administration will be addressed per policy and ad hoc education will be provided at that time. Results of the above reviews will be discussed at a weekly quality assurance meeting for a period of 4 weeks and will provide additional education as needed and implement interventions for improvement until resolution. Date of Removal: 5/8/24

Based on observation, interview, and record review the facility failed to ensure residents assessed as being a high risk for elopement were adequately supervised and then failed to identify this same resident as an elopement risk after an elopement for 1 of 3 (R1) residents reviewed for accidents and supervision in the sample of 34. This failure resulted in R1, who had a history of confusion and was assessed as being a high risk for elopement, exiting the facility without staff knowledge, at an unknown time, walking 4.4 miles to a neighboring town along a busy highway where he was located by facility staff at 7:00 AM on 4/13/24. The Immediate Jeopardy began on 4/13/24 when R1 exited the facility without staff knowledge. R1 walked approximately 4.4 miles and was found by facility staff at 7:00 AM on 4/13/24. V1 (Administrator) was notified of the Immediate Jeopardy on 4/29/24 at 1:57 PM. The surveyors confirmed by observations, interview, and record review that the Immediate Jeopardy was removed on 4/13/24, but noncompliance remains at Level Two due to additional time needed to evaluate the implementation and effectiveness of in-service training. Findings Include: 1. R1's Admission Record with a print date of 4/16/24 documents R1 was admitted to the facility on [DATE] with diagnoses that included disorders of circulatory system, diabetes with hyperglycemia, hypertension, hypercholesterolemia, atrial fibrillation, and tobacco use. R1's MDS (Minimum Data Set) dated 2/6/24 documents a BIMS (Brief Interview for Mental Status) score of 14, which indicates R1 is cognitively intact. R1's hospital records dated 1/29/24 documents R1 was taken to the local emergency room by a friend and stated R1 was more confused than normal. Pt (patient) alert to person and place only. Disoriented to time. Pt is currently homeless and has been staying with friends. They are trying to get patient into (name of homeless shelter) Patient has been approved but they cannot accept him until tomorrow at 1:30 for intake .Pt states he has a home, but no running water or electricity. Suggested that pt return to his home for tonight as temperatures are not below freezing and go to (homeless shelter) tomorrow for intake R1's hospital records document under neurological assessments R1 is alert and oriented to person, place, and time. R1's hospital records dated 1/30/24 documents on 1/30/24 at 2:57 PM, (R1) .with a past medical history that includes- DMII (diabetes mellitus), HLD (hyperlipidemia), HTN (hypertension), MRSA (methicillin resistant staphylococcus aureus) abscess, a-fib (atrial fibrillation) RVR (Rapid Ventricular Response), DKA (diabetic ketoacidosis) ---presents to the ER (emergency room ) c/o (complaints of) being found walking through town and had soiled himself. Was going to be intake to (name of homeless shelter) today, but they canot (sic) take a dementia resident. He is asking to go to a SNF (Skilled Nursing Facility). The hospital record documents under Medical Decision Making .Details: Adult protective services caseworker (V46). On 4/30/24 at 11:18 AM, V46 (Adult Protective Services) stated that on 1/29/24 R1 was evaluated at the emergency room (ER) and was discharged . V46 stated R1 was supposed to go to a homeless shelter but either had forgotten or didn't call them. V46 stated R1 was found by friends wandering outside in the cold. V46 stated R1 was covered in feces and urine and had gotten frost bite. V46 stated R1 didn't recognize his friends so they contacted the police who contacted V46 on 1/30/24. V46 stated R1 was taken back to the hospital, and she felt like R1 needed placement in a long-term care facility. V46 stated she spoke with the ER physician, and he agreed. V46 stated after R1 was admitted to the facility on [DATE], she followed up with him at the facility. V46 stated she could recall the specific day but at that time R1 looked good, he was clean, and had friends at the facility. V46 stated she closed out R1's case since he was in the facility. V46 stated when she would see R1 he would not remember her, and she would have to remind him who she was. When asked if she would consider R1 safe to come and go independently from the facility, V46 stated, she would say so, but her concern would be R1 getting linked up with someone who would take advantage of him. V46 stated that is what happened with his home and stuff. R1's regional hospital Progress Notes dated 1/30/24 documents, SW (Social Work) informed that patient is in ED (Emergency Department) and requesting nursing home placement. Per chart, patient was accepted to homeless shelter yesterday, but they could not accept until today. Patient was found today by friend confused and wondering the streets. SW met with patient who confirms would like nursing home placement Patient states would prefer to stay in (name of town) but is agreeable to whatever facility can accept him at this time (Name of facility currently residing in) has accepted. Nurse updated patient. Facility to transport On 5/1/24 at 4:06 PM, V55 (Director of Social Service Regional Hospital) stated R1 was evaluated at the emergency roiagnom on [DATE] and was accepted by a local homeless shelter, but they didn't have an opening until the next day. V55 stated R1 had a home but it had no running water. V55 stated R1 was going to stay at his home that night and then go to the homeless shelter the next day. V55 stated R1 came back to the hospital the next day. V55 stated a different social worker saw R1 and his mentation had gotten worse so they decided it would be better for R1 to be placed in a nursing home. V55 stated R1 got really confused. V55 stated the physician didn't say he was confused it was the social workers assessment. R1's current Care Plan documents a Focus area of Potential Risk of Elopement-Exit seeking behavior Date Initiated 3/22/24. This Focus area documents the following interventions dated 3/22/24, Place Electronic Sensor device to alert staff of exit attempt (or if unavailable, place on 1:1 observation) Routinely check device placement, check battery function, eval (evaluate) effectiveness .Identify any patterns or exacerbating factors .Maintain adequate I.D. (identification) .Monitor residents interactions with peers to identify escalating tension, frustration or aggression; Intervene .Monitor whereabouts regularly; Recognize any unsafe condition or escalating patterns .Provide redirection and diversion as needed .Respond to any alarm activation promptly .try to identify reasons when possible. Address physical needs such as hunger, thirst, pain, toileting, hot/cold, emotional needs, fear/distress, loneliness, worry . R1's Elopement Risk Assessments dated 3/8/24 documents a score of 02, indicating R1 is not at risk for elopement. R1's Progress Notes document on 3/22/24 at 8:02 PM, alarm sounding to side area yard that is fenced in. Nurse immediately went to alarm outside and found resident confused holding the fence on the inside of the yard, not leaving the premises. Head to toe assessment completed with no injuries noted to resident. Resident was immediately redirected to inside the building without any aggression or hesitation. Wander-guard was immediately placed on resident left ankle with 2 finger breadths noted. Resident placed on 15 minutes checks related to safety. MD (physician) and emergency contact notified with no concerns voiced at this time. Nursing management notified, and MDS notified for care-plan placement. R1's Order Recap Report dated 3/24/24 to 5/31/24 includes the following orders, Place wanderguard on resident for safety r/t (related to) exit seeking behaviors,. Wanderguard check function Q (every) weekday shift every Fri (Friday) for Wandering, Wanderguard - Check placement every shift for monitoring, all have a start date of 3/22/24. R1's Community Safety Awareness Summary dated 3/22/24 documents a handwritten assessment that documents R1's prior living arrangements as homeless, that he lived alone and came to the facility for medical condition of frostbite. R1 is documented as having secondary comorbidities that include diabetes with no history of substance or alcohol abuse. The assessment documents R1 is alert and oriented to person, place, and time and makes decisions independently. This assessment documents R1 doesn't have difficulty focusing attention, is not easily distracted, doesn't have difficulty keeping track of what is said and is not on any antidepressants, antianxiety, sedative hypnotics, narcotic pain medications, or psychotropics. This assessment documents R1 is safe to ambulate independently and can cross a street independently with or without a light. It documents no potential risks and that R1 is safe to leave the facility on pass. This assessment is signed by V1 (Administrator), V2 (DON), V48 (MDS Coordinator) and V28 (Social Services Director). On 4/30/24 at 3:56 PM, V1 (Administrator) stated the Community Risk assessment dated [DATE] was signed by V2 (DON/Director of Nursing), V48 (MDS Coordinator), and V28 (Social Services Director/SSD). V1 stated they were all at the facility doing the assessment. When asked if she remembered what time it was done, V1 stated it was done early, sometime in the morning. R1's Documentation Survey Report VT2 dated March 2024 documents a behavior of wandering on 3/22/24 evening shift. The next Elopement Risk Assessment for R1 found in the record was dated 4/3/24 and documents a score of 18, which indicates R1 is at high risk of elopement. On 4/19/24 at 10:52 PM, V22 (Anonymous) stated on 3/22/24 R1 was outside and attempting to leave the grounds, and she convinced him to stay because it was cold outside. V22 stated R1 thought he was in a different town and didn't know he was in the town the facility is located in. V22 stated R1 did not have any health issues that would have caused the confusion. On 4/24/24 at 1:49 PM, this surveyor reviewed R1's 3/22/24 progress note and asked V2 (DON/Director of Nursing) if there were alarms on the outside gate. V2 stated there were not. V2 stated she didn't know if she was contacted related to the incident on 3/22/24 that she would have to check into what this surveyor was talking about. This surveyor reviewed the progress note again with V2 and asked if that helped her remember. V2 stated R1 is not a high risk for elopement. When asked if she was aware R1 had been assessed as being at high risk for elopement V2 stated if it was at night, then no. On 4/24/24 at 3:24 PM, this surveyor reviewed with V1 (Administrator) R1's 3/22/4 progress note where R1 was outside leaning on the fence, confused, and was assessed as being at risk for elopement. V1 stated she didn't know what else was going on that night and V4 (Physician/Co-Medical Director) said he was doing it as a safety measure. V1 stated V4 (Physician) saw R1 prior to him being at the facility. When asked if she knew what happened on 3/22/24, V1 stated she read the note and she remembered the nurse saying R1 was outside holding on to the fence, but the note didn't say if R1 was trying to get out. V1 stated R1 was assessed as being a high risk for elopement at that point due to safety until he could be assessed. V1 stated V4 always wants to come in and look at the residents and talk to them. When asked if V4 came to the facility and assessed R1 after the 3/22/24 incident, V1 stated she wasn't sure. On 4/19/24 at 9:40 AM, V24 (Dietary Aid/Cook) stated she was driving to work the morning R1 eloped and thought maybe she saw a resident walking by a restaurant in the next town over from the facility. V24 stated she called the kitchen around 6:00 AM and talked to V8 (Cook) and asked her to check on R1. V24 stated they checked to see if R1 was at the facility. When asked if anyone from administration had spoken with her after the incident, V24 stated, No. On 4/18/24 at 10:55 AM, V8 (Cook) stated she was working on the morning of 4/13/24 and she came to work around 5:00 AM. V8 stated she got a call from V24 (Dietary Aid/Cook) around 5:30 AM, who said they may have seen R1 walking in the next town near a restaurant. V8 stated they searched the facility and couldn't find R1. V8 stated she believed someone drove to the next town and found R1 after that. On 4/16/24 at 3:39 PM, V9 (Certified Nursing Assistant/CNA) stated she came to work on 4/13/24 at approximately 5:45 AM and started working at 6:00 AM. V9 stated everyone was doing their normal routines and there was no indication a resident had eloped. V9 stated she was checking resident's vital signs and V26 (LPN/Licensed Practical Nurse) was passing medications like nothing was wrong. V9 stated a kitchen staff member (maybe V8/Cook) walked down the hall and after that V26 stated they needed to start looking for R1. V9 stated V26 looked a little frantic at that point. V9 stated she was told V24 (Dietary Aid/Cook) thought she saw R1 walking on the road toward the next town over. V9 stated after hearing that she realized she may have also seen R1 on her way to work but didn't see the person close enough to know if it was R1. V9 stated she told V26 she may have also seen him on her drive to work and V26 told her to go get R1. V9 stated she left the facility and drove to the next town. V9 stated she stopped at a gas station/store to see if they had seen R1. V9 stated they had seen a man walking but he had continued to walk. V9 stated she left that area and continued to drive and when she got to the interstate, she saw R1 walking under the overpass. V9 stated she parked her car and asked R1 what he was doing. V9 stated R1 said he had some in laws that lived by one of the local restaurants and he was going to see them. V9 stated she told R1 he scared them, and he got in her car, put the seat belt on, and she started to drive back to the facility. V9 stated she asked R1 what time he left the facility, and he told her about 10:00 PM the night before. V9 stated R1 said he had gone to the woods looking for a walking stick then to the railroad tracks where he found a piece of board and used that for his walking stick. V9 stated R1 told her a factory worker gave him a bag of chips and he sat and ate them. V9 stated R1's wander guard wasn't on him anymore, but she didn't know what happened to it. V9 stated R1 was in good spirits when she found him, but he said his feet and legs were very sore. V9 stated she picked R1 up at 7:00 AM and got him back to the facility at 7:08 AM. V9 stated they looked for his wander guard and couldn't find it and while she was giving her statement to administration, they put another one on him. V9 stated V26 (LPN) gave her statement to administration first and V26 told them she noticed R1 was missing between 4:30 and 5:00 AM, but she (V26) had no reason to think R1 had left the building. V9 stated V26 didn't tell anyone she couldn't find him. V9 stated the first person to realize R1 was gone was V24 (Dietary Aid/Cook) who saw him walking on the highway. V9 stated V7 (LPN/Licensed Practical Nurse) who was also working said she saw R1 around 4:00 AM coloring. V9 stated there is no way he walked that far in 30 minutes. V9 stated V7 (LPN) didn't know R1 was missing until she got the phone call from V24 around 6:44 AM. V9 stated V7 then started notifying administration. When asked if she had any concerns with how the incident was handled. V9 stated, Yes, it seems strange to me we had a resident missing and no one knew he was gone. V9 stated if they were doing bed checks every two hours, they should have known R1 was gone. V9 stated when V26 realized R1 was missing at 4:30 or 5:00 AM and didn't do anything about it, to me that is neglect. According to Google maps https://www.google.com/search?q=google+maps&rlz=1C1GCEB_enUS1019US1019&oq=google+maps&gs_lcrp=EgZjaHJvbWUqEggAEEUYOxiDARixAxjJAxiABDISCAAQRRg7GIMBGLEDGMkDGIAEMg0IARAAGIMBGLEDGIAEMhAIAhAAGIMBGJIDGLEDGIAEMhAIAxAAGIMBGJIDGLEDGIAEMgYIBBBFGDwyBggFEEUYPDIGCAYQRRg8MgYIBxAFGEDSAQgyNzg4ajBqN6gCALACAA&sourceid=chrome&ie=UTF-8 it would take the average person one hour and thirty-three minutes to walk from the facility to the location R1 was found which was 4.4 miles away. The path R1 walked was on US highway 50 which is a busy two-lane highway that is not well lit and merges into a four-lane highway once it nears the next town. This surveyor attempted to contact V26 via telephone on at least three occasions with no answer and no return phone call. V26 is an agency nurse so is unable to be contacted at the facility. On 4/18/24 at 10:26 PM, V7 (LPN/Licensed Practical Nurse) stated she worked from 7 PM to 7 AM on 4/12/24 and 4/13/24. V7 stated on the morning of 4/13/24, before 6:40 AM, she answered the facility phone and someone who she believed was V24 (Dietary Aid) told her they thought they saw R1 walking. V7 stated she checked with R1's nurse, started doing a head count, and had the CNA's looking for R1. V7 stated she called V49 (Wound Nurse), who didn't answer so she called V48 (MDS/Care Plan Coordinator), who answered, and then she called V1 (Administrator). V7 stated she started walking around outside the facility and when she came back in R1 was there. V7 stated she couldn't recall if she had seen R1 throughout her shift. V7 stated she does not work on R1's hall she always tries to stay on her hall close to the residents she is assigned to. On 4/18/24 at 11:11 PM, V17 (CNA) stated she was working night shift on 4/12/24 when R1 left the facility. V17 stated she really didn't know what happened. V17 stated R1 was coloring around 12:30 or 1:00 AM but she couldn't recall if she saw R1 after that. V17 stated R1 is very independent and does everything himself. V17 stated the nurse working on R1's hall was an agency nurse and she asked about R1 before 6:00 AM. V17 stated they went outside and R1's nurse went back in before she did. V17 stated then day shift arrived, and she left at 6:00 AM. V17 stated no management staff had talked to her about what occurred. On 4/19/24 at 10:10 PM, V18 (Anonymous) stated she was working night shift on 4/12/24. V18 stated she didn't think R1 had a wanderguard on. V18 stated R1 likes to roam around, and she thought he was aware of the door codes. V18 stated she did have eyes on R1, and she thought R1 could have left when they started getting residents up on the morning of 4/13/24. V18 stated she didn't hear any alarms sound which is why she said she didn't think R1 was wearing a wanderguard. V18 stated she was in R1's room tending to his roommate quite a few times through the night. V18 stated on the morning of 4/13/24 she was in R1's room around 1:00 AM and then around 3:30 AM. V18 stated R1 was in his bed at those times. V18 stated she saw R1 go to the couch around 4:45 or 5:00 AM. When asked how she became aware R1 was gone from the facility, V18 stated she got a call from management and when they asked if she was working, she told them no thinking they were talking about when R1 attempted to leave a few weeks prior. When asked if anyone from management followed back up with her, V18 stated they had not. V18 stated when she came back to work on 4/13/24 there was a manager there due to a call in and they told her to do 15-minute checks on R1 and to check the door alarms. On 4/19/24 at 10:31 PM, V20 (CNA) stated she was working on 4/12/24 when R1 left the facility. V20 stated it was a normal night and she didn't realize R1 was missing until she left around 6:30 AM. V20 stated she saw what she thought was R1 walking down the main street in the next town over. V20 stated R1 was near the interstate walking with a stick. V20 stated she called the facility and spoke with an unknown nurse and asked them to see if R1 was at the facility. V20 stated the nurse said she would and never called back. V20 stated she didn't work on R1's hall that night but she did see R1 in passing around 1:00 or 2:00 AM. V20 stated V48 (MDS/Care Plan Coordinator) called her around 8:00 AM and asked if she had heard any alarms and if she had seen R1. When asked if there was any training after the incident, V20 stated she wouldn't say training. V20 stated they had them sign a paper, but administration didn't talk with night shift. V20 stated she knows staff were talking about a nurse knowing R1 was missing about an hour before she (V20) called the facility. V20 stated she thinks they aren't noticing things like they should. V20 stated she didn't really talk with R1 much, just some small talk. V20 stated they don't get information on residents' cognitive status. V20 stated they just tell them if they are alert and oriented. V20 stated R1 seemed aware of what was going on and could carry on small conversations, but she wouldn't say he would be able to take care of himself. V20 stated she could tell R1's cognitive levels weren't at full function. On 4/19/24 at 10:21 PM, V19 (CNA) stated he was working on the night of 4/12/24 and finished his bed checks around 5:30 AM. V19 stated he got mandated to stay and worked until about 8:30 AM. V19 stated he found out around 6:30 AM that R1 wasn't in the facility. V19 stated they locked the facility down and looked for R1. V19 stated he did remember seeing R1 around 2:30 or 3:00 AM in the dining room coloring and watching tv. V19 stated administration had asked him to give a statement. V19 stated a few months back R1 said he was going to leave so they placed a wanderguard at that time and R1 was on 15 minutes checks. On 4/23/24 at 10:01 AM, V33 (Agency LPN) stated she was working on the night of 4/12/24 when R1 eloped. V33 stated R1 wasn't her resident, and she wasn't aware R1 was gone until she had left the facility. V33 stated an unknown nurse came to her around 5:45 or 5:50 AM and asked if she had seen R1. V33 stated she wasn't sure who the nurse was talking about. V33 stated the nurse described him to her and she realized she knew who R1 was. V33 stated she had seen him around 10:00 PM in the dining room coloring pages. V33 stated he was at the table closest to the doors on the right. V33 stated she saw him again in the dining room when she went to the snack machine around 12:00 or 12:30 AM. V33 stated after that she was at the nurse's station. V33 stated she shared this with the nurse and the nurse didn't look worried, so she thought she was just looking for him for morning medications. V33 stated she didn't know the nurse, but she didn't look concerned and didn't come back to say R1 was missing. V33 stated she left the facility and was getting ready to pull her car out when an unknown lady pulled in and said through her car window that she (V33) needed to write a statement. V33 stated she asked her what she needed a statement for, and the lady responded for the elopement. V33 stated she asked her what elopement and the lady responded that R1 was found by the overpass. V33 stated she thought they were talking about the one right outside the building and told the lady she would give the statement that night when she returned to the facility. V33 stated no one left a note for her or said anymore about a statement. V33 stated she was ear hustling when she returned to work, and they were saying R1 got out and was all the way in the next town. V33 stated the aids were saying they didn't even know R1 was missing. V33 stated she told the CNA's that was why it was so important for them to count the residents and even if they didn't need bed checks to make sure they were laying eyes on their residents. When asked if she was aware of any policy related to checking residents, V33 stated she thought it was a state regulation that they should be doing that. V33 stated she figured they would all know that it doesn't matter if they are independent, they still need help. On 4/16/24 at 2:34 PM, R1 was in the dining room participating in activities. After he was finished with the activity this surveyor asked if I could speak with him. R1 stated we could talk in the common area. R1 appeared clean and well-groomed with no obvious signs of distress. When asked if he had left the facility, R1 stated he did yesterday around 8 or 9 pm. R1 stated he didn't tell anyone he just started walking to (name of next town). R1 stated it took him all night. R1 stated he was trying to figure out where to go when a lady from the facility found him. R1 stated he had a bracelet (Wanderguard) on his ankle, but it got cut off. R1 stated he was almost to (name of next town) when he ran into a fell a and this fell a asked if he wanted him to cut it off. R1 stated the guy cut it off with his (the guys) knife. R1 stated he didn't remember if the door alarm sounded when he left the facility. R1 stated it worked today when they had me test it out. R1 stated the facility staff had him walk in front of the door to see if it worked. When asked if he had a wanderguard on at that time, R1 stated yeah and pulled his pant legs up. There was no electronic monitoring bracelet on either leg. R1 stated, Oh no, they didn't put it back on. R1 stated when he left the facility, he went out the dining room door and left when a bunch of people went out. R1 stated he figured that was the best time to leave. R1 was asked the following questions and gave the following responses. What day is it? I don't know. Season? It is supposed to be winter, but we didn't have much of a winter. Who is the president of the United States? Trump. I know it is the middle of an election year. What year is it? I don't know. What meals have you had today? I know I had breakfast. The kitchen treats me good, and they come check on me. R1 stated he didn't know why he left the facility, and he didn't really have a plan when he left. R1 stated he knew he was in the next town over and he knows people who live there but he couldn't remember where they lived. R1 stated, Memory loss is what I have problems with lately. R1 stated when he left the facility it was warm and not raining. R1 stated he wasn't injured while he was gone. R1 stated he met some guy who was going to work while he was out, and they sat down and shared a cigarette. R1 stated he (the unknown guy) was the one who cut his bracelet (electronic monitoring device) off. R1 stated when he got back to the facility the staff talked to him about how he was doing. When asked if the facility staff talked to him about what to do if he wanted to leave again, R1 stated, They didn't go into detail. R1 stated if he wants to go for a walk he just goes into the courtyard. When asked if the facility staff talked to him about signing out if he leaves again, R1 stated, No, they didn't they just mentioned to talk to someone if I wanted to leave. On 4/18/24 at 9:52 AM, R1 was sitting in the dining room/common area at the facility. R1 appeared clean and well-groomed with no signs of obvious distress. R1 was not able to tell this surveyor what the date, month, or year it was. R1 stated he was [AGE] years old. R1 is [AGE] years old. When asked what season it was, R1 stated he would need to know what month it was, and he usually just looks outside. When asked if he had breakfast R1 stated he had. When asked what he had for breakfast, R1 stated, just breakfast is all I can say. Then R1 stated he had hash browns, eggs, toast, coffee, and a donut or cookie. When asked if the facility spoke with him after he left the facility, R1 stated he couldn't remember if they did or not. R1 stated, My memory isn't that good. I am struggling with memory. When asked how long he was gone from the facility R1 stated, Most of the night. R1 stated he left around 7 or 8 PM but did stop and talk to a couple of people on the way. On 4/18/24 at 10:55 AM, V8 (Cook) stated she worked on 4/18/24 and served breakfast. V8 stated she remembered what she served to R1, and it was two biscuits, two sausages, double scrambled eggs, two bowls of cereal, milk, and juice. V8 stated there were no cookies or donuts served to R1 that she was aware of. R1's progress notes do not document any note dated 4/13/24. R1's Progress Note dated 4/14/24 documents, Continues on 15-minute visuals r/t (related to) elopement attempt. Wander guard in place and functioning. No attempts made during this shift. ROM (range of motion) WNL (within normal limits) per residents' normal functions. Denies any c/o (complaints of) pain or discomfort. No injuries noted. Respirations even and non-labored on room air. No s/s (signs or symptoms) of acute distress noted at this time. Currently resting quietly in bed with call light and frequently used items within easy reach. This note is struck out and documents, Strike Out Reason: Incorrect Documentation. Strike Out Date: 4/16/2024. R1's Elopement Risk Assessments dated 4/13/24 document a score of 18 which indicates R1 is at high risk of elopement. R1's QAPI (Quality Assurance Performance Improvement) Ad Hoc (As needed) Form dated 4/13/24 documents, Meeting Attendees: V2 (DON/Director of Nursing), V48 (MDS/Care Plan Coordinator), V47 (ADON/Assistant Director of Nurses), and V51 (Physical Therapy Assistant). Identified Opportunity for Improvement/Deficient Practice: Elopement 1. Immediate Corrective Action for those affected by the deficient practice: 4/13/24 Resident located and returned to facility. Head to toe assessment, no injuries noted, nursing assessment complete. 4/13/24 MD (physician) notification- Completed. 4/13/24 Wanderguard on and functioning- Completed. 4/13/24 Investigation initiated. - Completed. 4/13/24 Staff educated on wandering/elopement policy and responding to door alarm immediately-door alarms, supervision, wanderguard verifications- ongoing. 4/13/24 Trauma, pain, skin, elopement risk, abuse risk assessments completed, resident put on 15 min visuals for 72 hours. 2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents Elopement assessment- Residents at risk- care plan reviewed with appropriate interventions in place or initiated. Elopement books updated with current assessments. Elopement assessments will be completed upon admission with additions to care plan and elopement books as indicated, i.e., high/moderate risk. 3. Measures put into place/systematic changes to ensure the deficient practice does not recur. 100% Staff in-servicing on Elopement Policy, door alarms, supervision of residents, wanderguard verifications. 100 % Residents completed Elopement Assessment with Care Plan Reviews and Interventions Implemented as indicated. Nursing staff will visualize resident q (every) 2 hours. 4. Plan to monitor performance to ensure solutions are sustained. Nursing staff or designees will audit door alarms for functionality and sound every shift until reviewed by QA Committee. Administrator or DON will audit 2 hour rounding daily for compliance until review by QA Committee. R1's Order Recap Report dated 3/24/24 to 5/31/24 includes the following orders: Wanderguard check function Q (every) week every day shift every Fri (Friday) for Wandering . with a start date of 3/22/24 Wanderguard-Check placement every shift for Monitoring . with a start date of 3/22/24, 15-minute visual checks r/t (related to) exit seeking behaviors every shift . With an order date of 4/15/24. Accu checks and contact MD (physician) orders Notify MD if BS (blood sugar) less than 60 or greater than 400 before meals and at bedtime. R1's MAR (Medication Administration Record) dated 4/1/24 to 4/30/24 documents the wanderguard and 15-minute check, physician orders are signed as administered as ordered by the physician. R1's physician order to check R1's accu check before meals and at bedtime is signed administered as ordered each day and shift except 4/13/24 at 6:00 AM, indicating all accu checks were done as ordered except the one ordered for 6:00 AM on 4/13/24. On 4/24/24 at 1:49 PM, V2 (DON) stated she was out of town on 4/13/24 and wasn't involved in the incident. On 4/24/24 at 4:11 PM, V1 (Administrator) stated on 4/13/24 at 6:35 AM, V9 (CNA) stated she was notified R1 was missing by staff member (gave initials of staff member). When asked who that staff member was, V1 stated she would have to look. (Initials were never verified and didn't match staff currently working in the facility). V1 stated at 6:44 am, V7 (LPN) was notified R1 was possibly seen near a restaurant by V24 (Diet[TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure residents were free from sexual abuse for 3 of 3 (R2, R9, R11) residents reviewed for abuse in the sample of 34. This failure occurred on [DATE] when V4 (Physician/Co-Medical Director) asked to see and touch R9's genitalia (inappropriate word for female genitalia), while R9 was sitting in the lobby of the facility near the front doors. R9 stated this had been going on for a few months, she would get upset by V4's behavior, her anxiety would rise before he was scheduled to visit, and she began wondering if she had said something to initiate this behavior and began blaming herself. R9 stated she was afraid to tell anyone because it would be her word against his and no one would believe her. The Immediate Jeopardy began on [DATE] when V4 was witnessed by this surveyor making inappropriate sexual comments to R9. V1 (Administrator), V53 (Chief Clinical Officer), and V54 (Resident Services-Corporate) were notified of the Immediate Jeopardy on [DATE] at 4:20 PM. The surveyors confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE] but noncompliance remains at Level Two due to additional time needed to evaluate the implementation and effectiveness of in-service training. Findings Include: 1. On [DATE] at 12:50 PM, this surveyor was sitting in the beauty shop waiting on a staff member to interview. This surveyor heard a male voice and a female voice start a conversation. They were not in the line of sight of this surveyor but were close enough to the beauty shop to hear their conversation. He asked if she was leaving. She told the man no she was just sitting. The conversation continued between the male and female voice and then the male voice asked her if he could see her pu**y and then asked if he could touch her pu**y. This surveyor stepped to the door and both the woman (later identified by staff as R9), and the man identified by this surveyor as V4 (Physician/Co-Medical Director) were there. R9 was sitting on a seat located just outside the beauty shop door and near the front doors of the facility. V4 was standing in front of R9. V4 exited the facility and this surveyor sat down next to R9, after asking V37 (RN/ Registered Nurse) who was coming for an interview to wait just a minute. This surveyor asked R9 if she knew who the man was and she said he was the doctor who comes to the facility. This surveyor asked R9 if V4 said something unusual to her and she said, Oh, that is just how he is, and shrugged her shoulders. On [DATE] at 12:51 PM, V37 (RN) identified the resident sitting in the lobby speaking with V4 as R9. On [DATE] at 1:15 PM, R9 agreed to speak with this surveyor and wanted to talk in the beauty shop. This surveyor asked R9 if V4 had said something inappropriate to her. R9 stated he had and that he had done it before. This surveyor asked R9 if we could get a staff member to speak with us and she agreed. V2 (DON/Director of Nurses) was the first staff member this surveyor located in the conference room. V2 went with this surveyor to the beauty shop where R9 was waiting. This surveyor informed V2 this surveyor heard V4 say something inappropriate to R9. R9 told V2 that V4 had asked to touch her breasts and vagina and had been asking it for several months. R9 told V2 she thought V4 was joking at first but that it had gotten worse. V2 left with R9 to report the allegation to V1 (Administrator). The facility Verification of Incident Investigation/Administrative Summary date of incident [DATE], documents under Brief description of the incident/event: An allegation was made by the (state survey agency) surveyor that she overheard V4 (Physician/Co-Medical Director) make an inappropriate sexual comment to resident (R9). Administrator notified and investigation immediately initiated. (V4) exited the facility immediately after alleged incident and then was informed by staff that he could not return to facility pending outcome of investigation .Resident has been observed, assessed and/or interviewed, showing potential effects related to allegation. Such affects have been addressed and care plan has been updated A comprehensive investigation was initiated on [DATE]. (State survey agency) surveyor alleged that (V4) asked resident (R9) if he could see her pu**y. Upon interviewing (name of state surveyor) she stated that she heard (V4) state that but did not hear if R9 said anything prior to that. (State Surveyor) was unsure of general conversation or what was said in between or what had been said prior to that. (State Surveyor) stated she observed (V4) in front of (R9) but there was no contact observed by (State Surveyor). (R9) stated in her interview that (V4) asked to see her breasts and vagina. (R9) said that it had been going on a couple of months and she had never told anyone. (R9) denies saying anything sexual to (V4) on [DATE]. (V4) was interviewed and stated as he was leaving the facility (R9) was near the front door and asked him if he wanted to touch her tits and pu**y. (V4) stated he repeated to her what she said for clarification and then he advised (R9) that he absolutely did not want to touch her and never would do so. Interview with V48 (MDS Coordinator, RN/Registered Nurse) in which she stated that there have been several times where (V4) stated to (V48) that he would not go to (R9's) room without someone with him as she often comes off as inappropriate in a sexual manner, speaks of multiple boyfriends while attempting to display herself flirtatiously. Review of records note on visit on [DATE] that (V4) notes in his medical visit with (R9) that she tends to flirt with all the males and that is not a secret. She tells you that. She says she has many boyfriends. Also noted, She flirts with all the men and does show them dirty pictures on telephone and that is the first I knew about it today. Residents interviewed denied (V4) had said anything inappropriate and had no concerns with his care. Staff interviewed had not witnessed (V4) say anything inappropriate to residents but had been witness to (V4) stating he did not want to go into (R9's) room by himself due to her inappropriate behavior. The facility does not substantiate the allegation as (V4) stated he was repeating what she said and that (R9) propositioned him. There are notes of (R9's) behavior noted in previous MD (physician) progress note on ,d+[DATE] and staff have also heard (V4) express concern of going by himself due to her flirtatious behavior prior to this allegation. The residents and staff have not had any concerns with (V4's) care. (R9) denies he stated the word pu**y, and her account is not the same as what was reported. (R9) remains at baseline and has had no negative psychosocial outcome .Follow-Up Actions Taken: Trauma Assessment completed. Abuse assessment completed. Discussed the choice of changing attending Physician with resident and decision was made by resident to change. Psychosocial assessment and follow up in progress. Care plan was reviewed and updated by IDT (Interdisciplinary Team). (V4) is assisted on rounds for all residents and will continue to be assisted by a licensed nurse while in the building. There is an x next to Responsible Party, Attending Physician, (name of survey agency)/Licensing and Certification, Ombudsman, Local Police Department; indicating they were notified of the allegation with no dates or times of notifications documented. On [DATE] at 10: 20 AM, R9 was interviewed and was found to be alert and oriented times three. R9 denied hallucinations, delusions, and paranoia. When asked if she had anxiety R9 stated, depends. When under stress, it goes up a lot. R9 stated V4 had been her primary care physician since she was admitted to the facility. R9 stated at no time during her interactions with V4 did he appear confused or disoriented. R9 stated V4 sees her a lot, he is here about every week or every other week. R9 stated she felt like she was getting good care from V4 and there was nothing unusual in his interactions with her until a few months ago. R9 stated that is when V4 started telling her, You are pretty, and asking, Do you have a boyfriend. R9 stated, I felt at first like he was trying to make me feel good and raise my spirits. But then he started saying, I have never seen you naked, maybe I need to. R9 stated, He (V4) did not say that (he needed to see me naked), and then give me a physical exam and I did not believe he was talking about giving me an exam. I felt like he was suggesting something sexual. I felt like his behavior was inappropriate for a doctor. I told him there was no reason to see me naked and I told him if I did need a physical exam, I would have another doctor do it, not him. R9 stated, V4 began to get worse with his comments, saying he wanted to play with my pu**y and breasts. R9 stated she previously stated V4 used the word vagina but the actual word he used was pu**y but she was ashamed to say that word. R9 stated, I told him he was going too far in saying things like that and he would laugh and act like it was a joke. R9 stated she would get upset by V4's behavior and her anxiety would rise before he was scheduled to visit wondering, what will he say or do today? R9 stated she began wondering if she had said something to initiate this behavior and blamed herself. R9 stated he had never actually touched her except to take her pulse. R9 stated V4 did not threaten her not to tell, but he told her, This conversation is between us, its personal, not professional. R9 stated she was afraid if she told staff, it would be her word against his and nobody would believe her. R9 stated, I just wanted to try to handle it by myself. R9 stated V4 never said anything inappropriate in front of staff, and usually staff were with him. R9 stated after V4 was done seeing everyone he would, sneak back into my room when they weren't looking. R9 said she was glad the surveyor heard what V4 said so that now he will stop. R9 stated staff called her in the office after the surveyor reported what she heard and questioned her about it and had a bunch of papers she had to sign. R9 stated she felt like staff felt as though I had led him on in some way, although nobody actually said that. R9 stated staff did not tell her they reported it to the police and the police had not contacted her. R9 stated she would not be comfortable with V4 as her physician and the facility had told her they would get her another physician. R9 stated R11 is a younger resident and she had asked R11 if she had ever experienced V4 saying or doing anything inappropriate to her and R11 stated V4 had been telling R11 she was pretty. On [DATE] at 1:45pm, V52 (Family Member) stated, on [DATE] or [DATE], She (R9) told me that her physician (V4) made inappropriate comments to her. She (R9) said she was sitting out in the front lobby area by the entrance, and he (V4) was leaving, and he (V4) said something to the effect of 'I want to see your boobs and vagina and touch your body.' V52 stated mom is friendly and told V52 that she was worried that by being friendly she somehow brought his behavior on. V52 stated she told R9 his (V4) conduct was inappropriate and she had not done anything to cause it and it was not her fault. V52 stated this was the first time R9 said anything about him acting that way. V52 stated she didn't think R9 had any residual effects from the incident aside from being somewhat stressed out about it. V52 stated she didn't think R9 understood the severity of what he did until the surveyor heard it and came out and asked her about it. V52 stated R9 had no history of sexually inappropriate behaviors. V52 stated R9 has no history of making up allegations against staff. V52 stated she believed her mom as there is no reason not to. On [DATE] at 3:13 PM, when asked if he could describe what happened with R9 on [DATE], V4 ((Physician/Co-Medical Director) ) stated, R9 always propositions him. V4 stated it was not the first time. V4 stated he said, absolutely no and walked out the door that day. When asked if he recalled the conversation, he had with her that day in the lobby he said she was asking him to touch her. V4 stated he could not really remember what was said but something like that. V4 stated that R9 was always flirting. V4 stated R9 was always asking him to touch her. V4 stated he would tell her to go away, and she would come up and flirt. V4 stated most of the time it happened in the cafeteria. V4 stated when he would see residents someone (staff) was with him but that didn't matter to R9, she would find him. V4 stated he didn't think R9 was cognitively with it. V4 stated the facility reported she had alcoholic dementia. When asked how many times R9's behaviors occurred, V4 stated in excess of 10 times. V4 stated it was documented in R9's progress notes. When asked if he could recall the dates of those notes, V4 stated no that is what the facility told him. V4 stated he wasn't sure how long he had been R9's doctor but it had been maybe a few years. V4 stated he was not her doctor prior to R9 coming to the facility. V4 stated he only sees residents in nursing homes. V4 stated the last word he said to R9 was absolutely no, and has not seen her since. V4 stated he wasn't sure if he was still R9's doctor. On [DATE] at 2:05 PM, R22 stated none of the female residents have made inappropriate sexual comments to him, nor shown him inappropriate material. R22 stated R9 told him, a couple of weeks ago, that she was upset because she was having problems with her doctor saying things to her he shouldn't say, saying he wanted to see her naked or to see her t**ties or something like that. R22 stated he told R9 she needed to tell somebody, but she didn't want to. R22 stated, from what I've heard he's (V4) a big flirt. On [DATE] at 10:00 AM, V3 (CNA/Certified Nursing Assistant) stated the last abuse in-service they had was maybe a couple of weeks ago, she's not sure. V3 stated she had never witnessed R9 being provocative or sexually inappropriate with any male staff or residents. V3 stated she had never seen R9 dress inappropriately. On [DATE] at 10:05 AM, V56 (CNA) stated the last abuse training they had was this past Friday. V56 stated she had never witnessed R9 being inappropriate or sexually inappropriate with male staff or residents, nor dressing suggestively. On [DATE] at 10:10am, V57 (CNA) stated they went around with a training for the staff to read and a sign in sheet about abuse within the past week. V57 stated she had seen R9 showing male residents' stuff on her phone, but hadn't seen what they were looking at, so she can't say whether it was sexual in nature. V57 stated she had not seen any inappropriate sexual behavior on her part toward staff or residents. V57 stated she had not witnessed R9 dress inappropriately. R9's Admission Record with a print date of [DATE], documents R9 was admitted to the facility on [DATE] with diagnoses that include unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, anemia, alcoholic hepatitis. R9's MDS (Minimum Data Set) dated [DATE] documents R9 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R9 is cognitively intact. This same MDS documents under Mood that R9 is assessed as having little interest or pleasure in doing things, feeling down and depressed, trouble falling and staying asleep, and feeling bad about yourself- or that you are a failure or have let yourself or your family down. This same MDS documents R9 has no behaviors, and no potential indicators of psychosis. R9's current Care Plan documents a Focus Area of (R9) displays attention seeking behaviors which can be disruptive, insensitive and/or disrespectful to staff and peers. [NAME] (sic) for immediate gratification. Date Initiated: [DATE] . Interventions for this care area initiation date of [DATE] include, Assure the resident that staff are more than willing to address legitimate concerns .Educate resident on appropriate means of requesting help for self or others .If the residents use We statements intervene by saying Please speak for yourself. Please use 'I.' Tell me what YOU want. Let other residents speak for themselves. Inform the resident that he/she may share his thoughts, needs and feelings with on (sic) identified staff member .Psych eval and tx (treatment) as necessary Remind resident that if emergent situation exists, staff will call 911 as appropriate .Set Limits . R9's Care Plan documents a Focus Area of Anxiety: As manifested by Situational anxiety. Date Initiated: [DATE], Created on: [DATE]. This Focus Area documents interventions dated [DATE] that include, Anti-anxiety medication as ordered .Encourage resident to identify and express causes of anxiety .Encourage to participate and discuss personal care . There is no Focus Area for sexually inappropriate behaviors documented in R9's Care Plan. R9's Abuse Risk assessment dated [DATE] documents the following risk factors were identified; history of chemical or substance abuse, persistent anger, fear, or anxiety, diagnosis of dementia, history of unsanitary living conditions, and attention seeking behaviors. R9's Behavior Monitoring and Interventions Report dated [DATE] documents, No results found for selected parameters. R9's Physician/Order Progress notes signed by V4 (Physician/Co-Medical Director) document the following: [DATE]- Purpose of Visit: This lady is back to normal, totally cognitively intact. Takes care of all activities of daily living. I forget why she is here, but the examination is totally, totally normal. I am asking (V48) MDS/Care Plan Coordinator, who knows her well, how much of this is related to alcohol? Probably a lot but we are unsure. She is getting ready to go back home and that I hope is not a problem. There is no documentation of inappropriate sexual behavior on this physician progress note. [DATE]- Purpose of Visit: She takes care of all activities of daily living. She is getting ready to go home is what I have said before, but she is not home. She appears to have some cognitive impairment but what can she do for herself? Everything. Physical exam, review of systems, laboratory, medication. Now we are not sure about her going home. I looked at medications. [DATE]- Purpose of Visit: toxic encephalopathy, malnutrition, alcoholic hepatitis without ascites, difficulty walking, altered mental status. She is back to normal. 15 out of 15 MMSE (Mini Mental State Examination) I watched her walk So, she has all of the above problems, now solved so to speak . She specifically is on no psychotropic . This physician progress note does not document any sexually inappropriate behaviors. [DATE]- Purpose of Visit: she was admitted actually with toxic encephalopathy, alcoholic hepatitis without ascites, malnutrition, difficulty walking, altered mental status. Her cognition returned to pretty well normal. This toxic encephalopathy was apparently related to alcohol. She is up and about, taking care of all activities of daily living, telling me she can fry chicken real well because she ran a golf course restaurant which specialized in barbeque, and I am sure this is true. Actually, the heart, lungs, and abdomen negative. She will be going according to the daughter to an assisted living, so most of these have been resolved I want to make sure I have her on vitamin D. I looked at all the medicine she is on, and she is on appropriate vitamin D. I do not really see anything that we need to discontinue. Now, the question is when she goes home, will she start drinking again, an unanswerable question. Of course, when she goes to assisted living, it might a (sic) little more difficult to get. There is no documentation of inappropriate sexual behavior on this physician progress note. [DATE]- Purpose of Visit: She was admitted with inability to care for self. I am seeing her for routine care plus a itchy dry place anterior aspect of the right lower leg just above the ankle. She has obviously been scratching it because of scratch marks. She says she is not. I think this is dry skin. I asked (V48), care plan coordinator, has she cleared cognitively since admission. Yes, dramatically. She does everything by herself. She is ready for discharge but there is no home for her. I say that because she was admitted with toxic encephalopathy, alcoholic hepatitis, ascites, malnutrition, altered mental status, difficulty walking. This appears, as I have said before, quite normal. I watched her walk. She had normal gait and balance. Used a wheeled walker. Is not falling. Review of systems totally negative. I looked at many blood pressures, pulses- they are all normal. She is doing not well, very well. She is on vitamin D, Artificial Tears, Dulcolax, Iron, folic acid, loratadine, Milk of Mag, omeprazole, Tylenol, B1, zonisamide. There is no documentation of inappropriate sexual behavior on this physician progress note. [DATE]- Purpose of Visit: She is homeless. She has a daughter who just had a baby, and she tends to flirt with all the males and that is not a secret. She tells you that. She says she has many boyfriends, but I am seeing her for routine required evaluation. She has a history of toxic encephalopathy apparently due to excessive alcohol. I have talked about that before. But actually, she does everything herself; feeds, clothes, bathes herself. Does she have any problems: I do not think so. She flirts with all the mean (sic) and does show them dirty pictures on her telephone, and that is the first I knew about it was today. She has actually recovered it appeared form alcoholic encephalopathy but the heart, the lungs, the abdomen negative. She wants nothing. And she will probably be a permanent resident here. Her vital signs look good. Heart, lungs, abdomen as stated negative. She has been to behavioral health at (name of regional hospital). They said she had dementia with aggressive behavior. I do not see that, and she certainly does not have aggressive behavior. Inappropriate behavior. She is on very minimal medication. She is on iron with no recent laboratory. [DATE]- handwritten note that documents, stable, history of alcohol, cares for self, homeless. [DATE]- handwritten note that documents, Needs to go home, oriented x (times) 4, exam all ok, Ok to go home. [DATE]- handwritten note that documents, Does everything, Dx alcoholic encephalopathy . [DATE]-handwritten note that documents, Can care for self- can live alone Past diagnosis alcoholic dementia now BIMS 15 Ok to DC (discharge). I told her return if she wish. There is no documentation of inappropriate sexual behavior on the physician progress notes dated [DATE], [DATE], [DATE], and/or [DATE]. R9's Progress notes from [DATE] to [DATE] contain no documentation of inappropriate sexual behavior, boyfriends, or sharing inappropriate material with anyone. R9's progress notes document a late entry dated [DATE] that documents, Alleged allegation of inappropriate statements made to resident from physician. Resident was taken to a safe area, surveyor reported to DON (V2), DON (V2) reported to ADMIN (administrator/V1), confirmed resident was safe, and physician was immediately suspended from facility until further notice of investigation and findings. R9's Progress Notes document continue to document the following [DATE], Spoke to resident in regards to her MD (physician). Resident stated she would like to have a different MD that is in the (name of town) area for when she discharges to home. Physicians in (name of town) reviewed. Resident did decide she would like to use (name of physician) as her facility physician. MD contacted and did accept. [DATE] 7:37 PM, Spoke to V4 and advised that facility had completed investigation and allegations are unfounded at facility level. Furthermore, advised V4 facility continues to await response from (State Survey Agency). R9's electronic medical record including care plan, progress notes, behavior tracking, and tasks do not document any behaviors including sexually inappropriate behaviors were being tracked and/or occurred. 2. On [DATE] at 3:15 PM, R11 stated V4 is her primary care physician, and he sees her about once per month. R11 stated R9 told her a few days ago that she was sitting in the front lobby area when V4, Talked to her bad, he said he wanted to play with her breasts and finger her vagina. R11 stated A bunch of us residents have talked about V4 being a big flirt. R11 identified R2 a resident who passed away and R31 a resident who moved as being some of the residents who discussed V4 being a flirt. R11 stated V4 would say to them, You're a pretty woman, what are you doing in here? R11 stated, R2 and R31 interpreted that as him trying to lift their spirits. R11 stated V4 had also told her she was pretty. R11 stated, a few months ago he told me his wife had died and in the same conversation he told me he was going to write me a prescription for a boyfriend, and I felt like he was hinting for a date. R11 stated, The last visit I had with him, not sure what the date was. I was uncomfortable, he started talking about his car, how fast it goes, what a good deal he got on it, how nice it is, and I thought, is this [NAME] trying to ask me for a date? R11 stated V4 had never touched her inappropriately and staff were always with him in her room. R11 stated she believed R9 when she told her about her encounter with V4. R11 stated she had known R9 pretty well for a while now and from what she had seen R9 is not the type of person to make stuff up or be dramatic to get attention. When asked how she felt about continuing to have V4 as her physician, R11 stated, I never wanted him in the first place, everybody knows he's a quack. I asked him why my legs swell up and he said, it's because your fat. On [DATE] at 9:40 AM, R31 denied concerns with V4. R11's Resident Information sheet with a print date of [DATE] documents R11 was admitted to the facility on [DATE] with diagnoses that include malignant neoplasm of long bones, diabetes, asthma, morbid obesity, hypertension, mass and lump right lower limb, sleep apnea, major depressive disorder, adjustment disorder with anxiety, post-traumatic stress disorder, anxiety disorder, panic disorder, malingering, chronic cluster headache, leiomyoma of uterus, and bone transplant. R11's current Care Plan documents a Focus Area of This resident has the potential for abuse/neglect r/t (related to) Depression diagnosis, psychiatric diagnosis or manifestation, including delusions, paranoia, and hallucinations, Underlying factors that increase vulnerability; including such as dementia, confusion, poor judgement, wandering and giving away personal property. The interventions for this Focus Area include assess coping skills and support system, consult psychiatry as indicated, encourage to discuss feelings, give choices regarding personal care, monitor/documents any signs/symptoms of potential self-harm or harm directed at others, notify physician of any at risk behavior, perform risk assessments as needed, set limits to ensure safety. R11's diagnoses listed in her record do not include a diagnosis of dementia. R11's behavior tracking sheet for April and [DATE] documents no behaviors were observed. R11's progress notes document the following [DATE] 5:18 PM, Resident involved in allegation of abuse. [DATE] 5:20 PM, Call placed to V4 to advise him that he would not be able to come to building as resident has made an allegation that V4 made her uncomfortable during a visit and she feels that he wants a date with her. V4 expressed understanding that he cannot come to facility at this time. [DATE] 5:47 PM, (name of officer) Badge number 45 was at the facility and did interview resident. (Name of officer) did come to my office and notify me that resident did refuse to write a statement. (Name of officer) did question resident in regard to accusation and resident denied any sexual verbal comments from V4. (Name of officer) notified me that he would make a statement if needed and I could stop by the (name of local police) for a copy this week. Will follow up this week to obtain a copy. The Dispatched Event Details (police report) documents on [DATE] at 5:50 PM, V2 (DON) called and reported an allegation of verbal sexual abuse. Under Supplemental Event Notes the report documents, .On [DATE] at approx. (approximately) 6PM, I was dispatched to (name of facility). Upon arrival, I met with the Director (V2/DON). She explained that 2 of the residents had made allegations that a Dr (doctor) had made sexual advances to them. I went and talked to the first one, (R11). I asked what had happened, she said the Dr. had joked around with her but had never said any thing sexual in nature to her. She said he had said some things that made her uncomfortable but nothing sexual. I asked her to write a statement and she declined to make a statement. I then talked to (R9) she said the Dr. had asked to see her breasts and vagina. I asked what she said, and she said she didn't say anything and that there was a state inspector that overheard him say it. I then had her write a statement. 3. R2's Admission Record with a print date of [DATE] documents R2 was admitted to the facility on [DATE] with diagnoses that include osteomyelitis, diabetes, malignant neoplasm of colon, morbid obesity, and peripheral vascular disease. R2's MDS dated [DATE] documents R2 is independent with decision making. R2's Progress Notes dated [DATE] document, .Resident (R2) was taken to an appointment with (name of physician), her O2 sats were down and they were unable to get them up therefore resident was sent to the ER (emergency room ) at (name of regional hospital). On [DATE] at 12:37 PM, V3 (Family Member) stated R2 passed away at the hospital on [DATE]. On [DATE] at 9:20 AM, V32 (Family Member) stated R2's physician (V4) made a comment to R2 one time when she had something wrong with her bladder. V32 stated V4 told R2 that she needed more sex. The facility Abuse Policy dated [DATE] documents, Purpose: To provide guidance and Procedures to the facility and staff to assure the residents remain to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Responsibility: the administrator and/or designee is the facility abuse coordinator for the facility. It is the responsibility of all facility staff to assure that all residents remain to be free from abuse, including injuries of unknown origin, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. It is all staff responsibility (sic) report any allegation or witnessed abuse immediately to the Administrator (Abuse Coordinator). Abuse Policy: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Procedure: conducting pre-employment screening of employees and pre-admission screening of residents, orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse neglect, exploitation, and misappropriation of property. Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment. Identifying occurrences and patterns of potential mistreatment, identifying concerns of residents allegations of deprivation of goods and services by staff, immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and [TRUNCATED]

Based on interview and record review, the facility failed to ensure residents with psychiatric diagnoses, who were at risk of elopement, were accurately assessed and appropriately supervised for 1 of 3 (R2) residents reviewed for accidents and supervision in the sample of 17. This failure resulted in R2, who has a diagnosis of schizoaffective disorder and a history of suicidal ideation's exiting the facility without staff knowledge on [DATE] sometime between 4:45 AM and 5:30 AM. R2 was located slightly more than two tenths of a mile from the facility at approximately 6:30 AM, sitting outside an abandoned building on top of a truck camper shell, in the rain. R2 had to cross a busy highway to get to this location. This failure resulted in an Immediate Jeopardy, which was identified to have begun on [DATE] when R2 exited the facility with out staff knowledge. R2 walked approximately two tenths of a mile and was found by staff approximately one hour later. This past noncompliance occurred from [DATE] to [DATE]. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 10:26 AM. The surveyors confirmed by observations, interview, and record review that the Immediate Jeopardy was removed and the deficiency was corrected on [DATE]. Findings Include: R2's Elopement report dated [DATE] documents, Resident was not located in her room and had been having some odd behaviors up ambulating (sic). Resident was assessed ambulating in the hallways. Resident was observed at 4:54 AM in the dining room by our transport driver. At approx. (approximately) 5:00 AM resident was not able to be located and staff were attempting to do a visual check on resident. At this time Management notified and local authorities to do a search of the resident's location. Resident Description: Resident stated she had gotten her jacket and just needed to take a walk. Resident is baseline independent with care. Resident does sign self out for outings, and shopping with family. Resident stated it was just a hard morning and she had been thinking about her deceased husband and friends. Under Immediate Action Taken this same report documents, Immediately sent out team on foot and vehicle to locate resident. At this time resident was located at 6:30 AM walking in the alley of the post office in (name of town). She stated she was not in a good head space and attempting to clear her head. Resident was sent out to ER (emergency room ) for evaluation due to increased depression No injuries observed at time of incident. Mental status, Predisposing Environmental Factors, and Predisposing Situation Factors are not assessed on this report. This report documents under Notes, ADHOC (as needed) QAPI (Quality Assurance and Performance Improvement) completed, timeline completed, wander guard placed, door alarms checked, door code changed, elopement assessment completed, elopement policy education, 15 min (minute) check policy education, door alarm education. R2's Admission Record with a print date of [DATE] documents R2 was admitted to the facility on [DATE] with diagnoses that include epilepsy, diabetes, hypertension, insomnia, chronic kidney disease, schizoaffective disorder, unspecified psychosis, macular degeneration, bipolar disorder, major depressive disorder, and cataracts. R2's MDS (Minimum Data Set) dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. This same MDS documents under Section C 1310 Delirium, R2 has inattention and disorganized thinking. R2's current Care Plan documents a Focus Area dated [DATE] of, (R2) has a history of self-harm ideations and/or behaviors. This appears related to recent loss of spouse/caregiver and son. She has a mental health dx(diagnosis)/Cancer dx and poor impulse control. These problems are manifest by voicing thoughts if (sic) self-harm. (R2) has been evaluated/is currently being evaluated in (name of local hospital) . The interventions for this care area dated [DATE] include Arrange for assessment by mental health professional, as warranted . As warranted conduct/carryout: daily monitoring, room safety checks, behavior tracking/monitoring looking for any changes, evaluate mental/mood status/thought content. As warranted conduct a room check and remove any sharp objects, alcohol/drugs (including over the counter medications), cleaning supplies (that could potentially be poisonous) and any other objects that in the health care professionals may pose a potential threat to safety. Engage resident in activities that she may enjoy to encourage resident spending time in a productive manner. This same care plan documents a Focus Area dated [DATE] of, Potential Risk of elopement exit seeking behavior (w/(with) purpose to leave). Interventions for this Focus Area, date initiated [DATE], date created [DATE], include, Place electronic sensor device to alert staff of exit attempt (or if unavailable, place on 1:1 observation: Routinely. Check Device Placement, Check Battery Function, Eval (evaluate) effectiveness . Identify any patterns of exacerbating factors .Maintain adequate I. D Provide re-direction and diversion as needed Respond to any alarm activation promptly .try to identify reasons when possible. Address physical needs such as hunger, thirst, pain, toileting, hot/cold, emotional needs, fear/distress, loneliness, worry . R2's Elopement Risk assessment dated [DATE] and [DATE] document a score of 02, which indicates R2 is not considered at risk of elopement. R2's Elopement Risk assessment dated [DATE] documents a score of 16, which indicates R2 is considered at high risk of elopement with IDT (Interdisciplinary Team) recommendations for a wander guard to be placed. R2's Elopement Risk assessment dated [DATE] documents a score of 02, which indicates R2 is not considered at risk of elopement. This assessment documents under IDT (Interdisciplinary) Notes: Unable to complete due to resident went out to the hospital. R2's Elopement Risk assessment dated [DATE] documents a score of 14, which indicates R2 is considered at high risk of elopement. R2's progress notes document on [DATE] at 8:15 AM, Resident (R2) sent to ER (emergency room ) for Psych (psychiatric) evaluation, DR (doctor) and POA (power of attorney) notified of patient transfer to (name of local hospital) . There is no documentation in R2's progress notes related to R2 leaving the facility without staff knowledge. R2's emergency transport Patient Care Record dated [DATE] documents at 7:40 AM the ambulance service received a call from the facility for a patient who had eloped earlier that morning and was having homicidal and suicidal ideations. Patient made no statements to EMS (Emergency Medical Services) . Patient has a history of eloping .Patient (R2) answered questions for EMS with good cooperation R2's local hospital record dated [DATE] to [DATE] documents on [DATE], Precipitating Factor/event for this admission: (R2) .was admitted due to the fact she got aggressive with staff at (name of facility) and tried to elope. Patient (R2) has a history of schizoaffective disorder. Patient (R2) believes her family was killed because of a sexual act when she was young. Patient (R2) believes she is responsible for multiple deaths. It was reported patient made suicidal statements, but the patient (R2) denies this now. Presenting Problem: Patient (R2) is delusional believing she is the reason people are dying. Duration of Problem: gradually getting worse over the past month. Reason for Admission: Danger to self . Under Surrogate Decision Maker/Power of Attorney R2's medical records document R2 is not able to make informed decisions regarding his/her care and treatments. R2's electronic health record documents a Task of Behaviors with a check mark next to no behaviors observed from [DATE] to [DATE]. On [DATE] at 1:18 PM, R2 was sitting in a chair in her room and appeared clean and well-groomed with no obvious signs of distress. R2 stated she had been at the facility about a year and a half. R2 stated she had left the facility last night ([DATE]) because My mind said, just get out of here. R2 stated she didn't remember where she went. R2 stated she walked back into the facility, and she didn't remember any alarms sounding. R2 stated it was the last time she would do that and when asked why, R2 stated, because they will find you. R2 stated they found her down the road. R2 stated she wasn't hurt, and she was gone for about an hour. R2 stated it was raining and she couldn't recall if it was light outside. R2 stated she wasn't sure if it was last night (,d+[DATE]) or the night before. R2 then stated it was Tuesday ([DATE]) when she left. On [DATE] at 8:54 AM, R2 stated when she left, she used the front door and she put the code in, so it didn't alarm. When asked how she knew the code to the door, R2 stated someone at the facility had told her but she couldn't remember who it was. On [DATE] at 1:59 PM, V22 (CNA-Certified Nursing Assistant/Shower Aid) stated she was the one who realized R2 was missing on [DATE]. V22 stated around 5:30 AM (this time does not coincide with the time documented in the elopement report) she went to R2's room to get her for a shower. V22 stated R2 wasn't in her room so she asked the staff if they knew where R2 was. V22 stated she told them she couldn't find R2, and they started looking for her. V22 stated the nurses acted like they really didn't care that she was missing. V22 stated when they realized she wasn't in the building they got in their cars and started looking for R2. V22 stated around 6:00 AM she asked V11 (LPN/Licensed Practical Nurse) if she had called administration and the local authorities and V11 said she hadn't. V22 stated she wasn't sure who called administration but V3 (ADON/Assistant Director of Nurses) came to the facility shortly after that. V22 stated R2 had never attempted to elope before. V22 stated R2 didn't usually sign out to go out in the community alone and she didn't think R2 would be safe to be in the community by herself. On [DATE] at 4:45 PM, V13 (LPN) stated on the night of [DATE] there were four CNA's and two nurses working. V13 stated she had sent two other residents to the hospital and between 3:30 and 4:00 AM she was in R2's room checking on her roommate and R2 was in bed at that time. V13 stated she left R2's room and went back to her hall to notify V2 (DON/Director of Nurses) about R2's roommates' condition and to call the lab. V13 stated she was notified by staff at an unknown time that R2 was missing. V13 stated everyone started looking for R2 and when an unknown day shift nurse came in, she notified administration. V13 stated R2 didn't have an electronic monitoring device such as a bracelet and had not attempted to elope in the past. V13 stated R2 is alert and oriented but gets in moods sometimes. V13 stated the door alarm codes are to be changed monthly but it has been the same code since [DATE]. V13 stated no alarms sounded during the time frame R2 would have left the facility. V13 stated R2 has never signed out and left the facility when she was working. On [DATE] at 6:10 AM, V11 (LPN) stated she was working on the morning of [DATE]. V11 stated she saw R2 at 9:30 PM and then again at 4:00 AM, walking with coffee. V11 stated she didn't see her again after that. V11 stated at 4:30 AM (this time does not coincide with the elopement report and/or V22's interview), she was alerted R2 was missing. V11 stated she called V5 (MDS Coordinator) who was on call, and V5 notified everyone else. V11 was not able to explain the time discrepancy with her interview related to the time she was notified R2 was missing and/or the time she notified V5. V11's written facility statement does not document when she was notified R2 was missing. When asked where she documented this information V11 stated she didn't document it. V11 stated she assumed administration documented it all. V11 stated R2 was not an elopement risk and had never attempted to elope before [DATE]. V11 stated R2 didn't normally sign herself out and she thought R2 would be safe by herself in the community. V11 stated it was raining the day R2 eloped and when it started raining, she thought surely R2 will be back now. On [DATE] at 10:59 PM, V28 (CNA) stated she was working on [DATE] when R2 eloped. V28 stated there were four CNA's working and when that happens, they split the hall R2 is on. V28 stated two CNA's take (A) hall and the left side of (B) hall, and two CNA's take (C) hall and the right side of (B) hall. V28 stated she believed there were 34 residents on the full hall she had and 16 on her side of the hall they split. When asked if they had enough staff to meet the needs of the residents, V28 stated, My personal opinion, no. V28 stated they can't keep an eye on residents if the residents are up and wandering. V28 stated they have residents with multiple behaviors, and it is hard to monitor them and ensure their safety. V28 stated they did a bed check on R2's hall around 3:30 AM and R2 was in bed at that time. V28 stated they went to the next hall and were doing bed checks on those residents. V28 stated around 5:30 AM an unknown day shift CNA came to them and was looking for R2 for a shower. V28 stated they got worried, so they stopped what they were doing and started looking for R2. V28 stated R2 had never attempted to exit the facility before this. On [DATE] at 11:15 PM, V29 (CNA) stated she was in R2's room between 3:00 and 3:30 AM and R2 was in bed asleep. V29 stated she finished the bed checks on R2's hall then went with V28 (CNA) to the other hall to do bed checks. V29 stated V22 (CNA/Shower Aid) asked them if they knew where R2 was, and they told her R2 was in bed. V29 stated then another staff (unknown) again asked where R2 was. V29 stated at that time they stopped what they were doing, and it was all hands on deck with everyone checking the building for R2. V29 stated then it was chaos. V29 stated they never heard a door alarm go off. V29 stated she had never seen R2 up wandering at night. V29 stated as far as she knew R2 had not had exit seeking behaviors in the past. When asked if she knew how R2 had left without staff knowledge, V29 stated she heard R2 knew the code to the front door. When asked how R2 would know the code, V29 stated, I honestly don't have an answer for that. On [DATE] at 11:26 PM, V30 (CNA) stated she was working on [DATE] when R2 eloped. V30 stated she was working with another CNA on one hall doing bed checks and the other two CNAs were on another hall doing bed checks. V30 stated she saw R2 in bed with her eyes closed around 3:10 AM. V30 stated after she finished her bed check, she took a break, took the linens out and around 4:15 AM, she started getting people up. V30 stated at approximately 5:30 AM, V22 (CNA/Shower Aid), asked if they knew where R2 was. V30 stated she asked V22 if she had checked the bathrooms and the other side of the bed to make sure R2 hadn't fallen on the floor and V22 stated she had checked. V30 stated they all started searching rooms and outside the facility. V30 stated around 6:15 or 6:20 AM, they were told R2 had been located. When asked if she had any concerns with how the facility handled the elopement, V30 stated she felt like the local police should have been notified she was missing immediately, and she didn't know if they had been. V30 stated she didn't believe they had enough staff to monitor the residents. V30 stated with four CNAs they have to pull the CNA off R2's hall to help with bed checks on the other halls. V30 stated that leaves R2's hall unattended. On [DATE] at 11:42 PM, V31 (CNA) stated on the night R2 eloped she was working on another hall and split R2's hall with the other CNA's. V31 stated there were residents with behaviors that night, call lights, bed checks were awful, and they had to do laundry. V31 stated she saw R2 around 2:47 AM and again around 3:40 AM. V31 stated R2 was in bed but did get up and go to the bathroom. V31 stated she didn't realize R2 was gone until V22 (CNA/Shower Aid) asked where R2 was. V31 stated she told V22 to check R2's room and she said she had. V31 stated she called V12 (Transportation Aid) to see if she had taken R2 somewhere. V31 stated V12 told her she had seen R2 at the front door with her jacket on and R2 was walking back towards her room. V31 stated she asked V12 why she didn't tell anyone and V12 told her because they were doing bed checks. V31 stated she knew this occurred after 5:00 AM because V12 was gone with a dialysis patient who had to be at dialysis at 5:30 AM. V31 stated they all started looking for R2. V31 stated the nursing staff called administration. When asked if she had any concerns with how it was handled, V31 stated she did. V31 stated they (administration) weren't really concerned, then they wanted to blame the CNA's. V31 stated they have 90 something residents at the facility and can't be on two halls at one time. V31 stated after they left the facility the administration posted on WhatsApp that they needed a statement from them. When asked how she thought R2 left without staff knowledge V31 stated R2 is with it sometimes, she could know the door code. V31 stated they don't ever change the codes and the side door where residents smoke doesn't lock. V31 stated residents can just open it up and walk out. V31 stated with so many residents with so many behaviors, we can't watch them all. V31 stated we can't check on them properly. On [DATE] at 11:08 AM, V12 (Transportation Aid/CNA) stated she clocked in on [DATE] and went down to get a resident who was going for dialysis. V12 stated about 4:45 AM, she noticed R2 with her coat on walking towards her room. V12 stated she left the facility around 5:12 AM to transport the other resident to dialysis. V12 stated she left the facility around 5:12 AM and drove straight across the highway. V12 stated after you cross the highway and go around the curve there are abandoned buildings and she saw someone sitting on a camper shell with a coat on and the hood of the coat pulled up. V12 stated it caught her attention because it was raining hard. V12 stated she took the other resident to dialysis and got a call at 5:45 AM asking her if she had R2. V12 stated she told them she didn't and that was when she knew the person on the camper shell was probably R2. V12 stated she went back and started searching for R2 where she had seen the person and then was notified, they had located R2. V12 stated she wasn't aware of R2 attempting to leave the facility prior to this incident. On [DATE] at 3:07 PM, V9 (LPN) stated she came to work around 5:45 AM on [DATE] to complete some charting before she started her shift. V9 stated she was at the time clock and V33 (Housekeeper) asked her if she had heard R2 was missing. V9 stated she went straight to the nurse's station and unknown staff were standing at the nurse's station. V9 stated she asked them if anyone had seen R2, and they said the last time they saw R2 was at the 4:30 AM bed check. V9 stated she did a sweep of the facility and didn't locate R2, so she sent staff out to look for her. V9 stated she called V2 (DON). V9 stated R2 doesn't leave the facility without family or staff. V9 stated if R2 wasn't in a manic state she would be capable of leaving the facility and returning by herself. V9 stated she spoke with R2 when she returned to the facility and R2 said she didn't know why she did it. V9 stated she wasn't sure what the facility staff did to locate R2 prior to her arriving to the facility at 5:45 AM. V9 stated she sent R2 to the hospital for evaluation and R2 was admitted . V9 stated R2 had suicidal and homicidal ideations. V9 stated R2 returned after 3 days and now has a wander guard on to alert staff if she attempts to leave. On [DATE] at 9:54 AM, V33 (Housekeeper) stated she came into to work on [DATE] and an unknown staff member asked if she had seen anyone walking on the highway as she drove to work. V33 stated they told her someone was missing. V33 stated, V36 (Housekeeping/Laundry Supervisor) told them all to start looking and to look until R2 was located. V33 stated this was at approximately 5:45 am. V33 stated she checked the barn, looked in rooms, cars, and then triple checked everywhere until R2 was located. On [DATE] at 10:10 AM, V36 (Housekeeping/Laundry Supervisor) stated she was working as a housekeeper on [DATE] and was cleaning the nurse's station when an unknown CNA stated they couldn't find R2. V36 stated she thought maybe she was in a bathroom or the pavilion. V36 stated this was between 5:30 and 6:00 AM. V36 stated she had them check those places and then when they couldn't find her, she got everyone to stop what they were doing and to start searching for R2. V36 stated she told the nurses to call V1 (Administrator) about a half hour later. On [DATE] at 3:45 PM, V5 (MDS Coordinator) stated she was notified of R2 eloping by V11 (LPN) at 5:59 AM. V5 stated she was the first one in administration who was notified of the incident. V5 stated V12 (Transportation Aid/CNA) saw R2 at approximately 4:45 AM walking towards her room. V5 stated then V12 took a different resident to dialysis and when she was coming back from dropping that resident off, she saw someone sitting outside the post office on a truck camper topper. V5 stated when V12 got back to the building and was told R2 was missing V12 went back to see if the person on the camper topper was R2. V5 stated, V12 had first seen this person at 5:12 AM when she left the facility. V5 stated R2 has never been an elopement risk and they changed the codes on the front door after this incident. On [DATE] at 9:07 AM, V5 (MDS Coordinator) stated at 5:59 AM on [DATE] she got a phone call from V11 (LPN) telling her they couldn't locate R2. V5 stated she asked if they had looked everywhere, and she told her she would message the administration team and be right there. V5 stated she texted V18 (Wound Nurse) and V2 (DON). V5 stated she got to the facility around 6:15 AM and saw CNA's walking around outside the facility. V5 stated some went to the local gas station to see if R2 was there and others got in their vehicles to look for R2. V5 stated she and V18 went to the post office to see if she was there since V12 had seen someone sitting there when she was taking a resident to dialysis. V5 stated R2 was there and was talking about killing everyone and how she wanted to die herself. V5 stated R2 agreed to walk back to the facility so they started walking. V5 stated once they got R2 back to the facility they had a staff member with her 1:1 until they sent her out to the local hospital for evaluation. V5 stated R2 was not assessed as being an elopement risk and had never attempted to elope prior to [DATE]. On [DATE] at 1:26 PM, V6 (CNA) stated she came to work on [DATE] around 5:52 AM and was sitting in her car. V6 stated there was a knock on her window and other unknown facility staff asked if she had seen R2. She told them she had not, and they left her vehicle and was looking around facility grounds. V6 stated they searched for about 45 minutes and then found R2 and brought her back to the facility. When asked if R2 had ever attempted to elope before, V6 stated R2 had tried but hadn't succeeded. V6 stated R2 does have behaviors like that. V6 stated R2 is usually alert and oriented but she thought R2 was having behaviors that day. V6 stated they monitor R2 more when she is having behaviors. On [DATE] at 2:47 PM, V7 (CNA) stated she was not aware of R2 attempting to elope before the incident on [DATE]. V7 stated R2 does have behaviors and she didn't think R2 would be safe in the community by herself. V7 stated R2 has a tendency of saying she doesn't want to be here anymore, and she wants to kill herself. On [DATE] at 2:53 PM, V8 (CNA) stated she wasn't aware R2 was an elopement risk and as far as she knew R2 had never attempted to elope before the incident on [DATE]. V8 stated she had never seen R2 leave the facility and she wasn't one to sign out and go out and about in the community independently. On [DATE] at 9:02 AM, V15 (Maintenance Director) stated he got to the facility after R2 had returned on [DATE]. V15 stated he reviewed the elopement binders. V15 stated he believed R2 observed someone putting the door codes in and that is how she left without alerting the staff. V15 stated he implemented a procedure to change the door alarm codes monthly. V15 stated R2 could have also left through the door the smokers use since it isn't coded but does have a wander guard alarm on it. On [DATE] at 9:07 AM, V18 (LPN/Wound Nurse), stated on [DATE] she got a call from V9 (LPN) around 6:00 AM notifying her R2 was missing. V18 stated she went to the facility and when she drove past the post office, she saw V12 (Transportation Aid) walking around looking for R2. V18 stated she met V5 (MDS Coordinator) at the facility and they started driving around looking for R2. V18 stated they drove in front of the post office and R2 was there. V18 stated V5 got out of the car and attempted to get R2 to get in the car with her but she wouldn't. V18 stated they walked with R2 and when they got almost back to the facility R2 stated she wasn't going in. V18 stated they were able to get R2 back in the building by telling her a peer was waiting for her to eat breakfast. V18 stated once they got R2 back in the facility they placed her on 1:1 until they sent her to the hospital. V18 stated R2 had never attempted to leave the facility before other than when she went on outings with her family. On [DATE] at 2:28 PM, V4 (Family Member) stated the facility notified her R2 eloped. V4 stated R2 had never attempted to leave the facility before. V4 stated R2 said she just went nuts. V4 stated R2 never goes out of the facility independently and wouldn't be safe in the community. V4 stated R2 knew the door code and she thought R2 may have seen family enter the code when they left the facility. V4 stated after R2 eloped, she asked the facility to change the code, and they did. On [DATE] at 10:05 AM, V2 (DON) stated she had worked at the facility since [DATE] and had been DON since [DATE]. V2 stated she got a call at 5:59 AM from V9 (LPN) that R2 was missing. V2 stated staff had searched all the rooms and outside the facility. V2 stated R2 had been missing about an hour. V2 stated around 6:34 AM, she was almost to the facility and V18 (LPN) stated they were bringing R2 back to the facility. V2 stated R2 was assessed, placed 1:1, and because of the comments she was making they sent her out to the hospital for evaluation. When asked if an investigation was done on how R2 left the facility without staff being aware, V2 stated from her understanding R2 always signed out with family so they assumed she knew the code and changed it. When asked if anyone ever asked R2 how she left, V2 stated she didn't. V2 stated she wasn't aware of R2 attempting to elope in the past and wasn't able to answer if R2 would be safe in the community alone. On [DATE] at 4:07 PM, V1 (Administrator) stated she got a call from the facility, and they said V12 (Transportation Aid) had seen R1 in the dining room but didn't think anything of it since R2 gets up and goes out with family at times. V1 stated V12 didn't leave until after 5 and didn't see R2 leave while she was at the facility. V1 stated V12 took the other resident to dialysis and when V12 returned to the facility, other staff asked V12 if she had seen R2. (This does not coincide with the other interviews ). V1 stated V12 told them she saw someone outside when she took the other resident to dialysis. V1 stated staff got in their cars and drove to where V12 saw this person. V1 stated they also called R2's family to see if she had gone with them. V1 stated when they asked R2 why she left R2 stated her head was full and she wanted to go for a walk. V1 stated R2 said she was thinking about her deceased husband and her roommate. When asked if the local police were notified, V1 stated she had but they didn't respond immediately. V1 stated if R2 had been missing more than an hour she would have called the county officials. V1 stated she notified all the managers, regionals, and all staff. When asked if she talked with all staff on midnight shift and day shift after R2 eloped, V1 stated she didn't remember but she would think they did speak with all of them. V1 stated R2 will sign herself out and goes with family and doesn't always tell someone when she is leaving. V1 stated R2 had never done anything like this before and was not an elopement risk. V1 stated R2 was assessed at risk of elopement after this incident. When asked if four CNA's and two nurses were enough staff to monitor the residents on night shift, V1 stated, it was, and they use the state required minimum staffing sheet to determine their staffing numbers. This surveyor reviewed staff interviews with V1 and noted it was ,d+[DATE] minutes after R2 was missing before administration was notified. V1 began looking through her phone and stated the earliest notification she could find was 5:58 AM. V1 stated she thought 30 minutes was an acceptable time frame because it gave staff time to look in other rooms. On [DATE] at 11:06 AM, V20 (SSD/Social Services Director) stated she reviewed the resident sign out logs and R2 had not signed out on the morning of [DATE]. On [DATE] at 9:29 AM, V20 stated after R2 eloped they went through the elopement binders and made sure copies of the policies were available for the staff. V20 stated they checked all the wander guards and changed the door codes. V20 stated she thought they changed the door codes quarterly prior to this. On [DATE] at 1:00 PM, when asked if she had been made aware R2 eloped, V32 (Physician), stated she knew R2 had been sent to the local emergency room for behaviors recently, but she didn't remember them notifying her she had eloped. When asked if she would consider R2 an elopement risk she stated, Yes, she has a diagnosis of schizophrenia so if she gets something in her mind that she wants to leave, I can see her doing that. Would you consider her safe in the community by herself? No. The facility Protecting Residents: Wandering/Elopement Risk policy dated [DATE] documents, All residents are assessed for risk of unsafe wandering and/or elopement and those who are identified as at risk will be assessed for utilizing the safety intervention of a Wander Guard bracelet to prevent unsafe exit from the center. In facility that do not have Wander Guard systems, an alternate method of protecting residents is used. Procedure: All residents are assessed using the Elopement Risk Assessment V-2 in (name of electronic health records) at the time of admission, quarterly, and with changes in condition, especially those affecting cognition, or with changes in behavior If a resident exhibits exit seeking behaviors or expresses the desire or determination to leave and if that resident is not cognitively able to support independent decision making, a new Elopement Risk Assessment and review by the interdisciplinary team will be conducted. Other safety interventions may be utilized pending the assessment. The facility shall not utilize Wander Guard or other similar interventions on a resident who is able to give consent based on cognitive level without further assessment to protect that resident's right to personal autonomy and decision making. This would include a BIMS assessment and CRSHC Safety Awareness Assessment, both in (name of electronic health record), consultation with a physician or psychiatrist and IDT review. A care plan problem, focus, and intervention are placed in the residents' clinical record that specifies the intervention to be used to protect a resident who is at risk for unsafe wandering or elopement . non-Wander guard Protections: any systems of locking door or units is monitored on an ongoing by staff to assure it is operating correctly The facility Missing Resident Procedure (Code Pink) dated ,d+[DATE] documents, The following procedure is utilized when a resident is determined to be missing. 1. Code Pink is announced/staff notified if no overhead system is used. 2. Note the time that the resid [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure staff were trained and the facility had the necessary equipment to meet the needs of a resident with a tracheostomy for 1 of 1 resident (R3) reviewed for tracheostomy care in the sample of 17. This failure resulted in R3 becoming short of breath shortly after admission with the facility unable to locate the necessary equipment to provide oxygen to R3 via the tracheostomy, causing R3 to be anxious and scared and then being transferred to the local hospital for oxygenation. Findings Include: R3's Admission Record with a print date of 3/21/24 documents R3 was admitted to the facility on [DATE] with diagnoses that include local infection due to central venous catheter, bacteremia, asthma, malignant neoplasm base of tongue, malignant neoplasm of larynx, tracheostomy, heart failure, depression, anxiety, hypertension, and atrial fibrillation. R3 is in the assessment period so her MDS (Minimum Data Set) did not document a Brief Interview for Mental Status score. However, upon interview R3 was alert and oriented to person, place, and time. R3's current Care Plan documents a Focus area dated 3/16/24, Admission Baseline the interventions for this Focus area include, Resident is able to self-care for trach including suctioning, and The nurse will follow the MD (physician) orders for specialty care with oxygen, trach, suction. Both interventions are dated 3/16/24. R3's Order Summary Report dated 3/21/24 includes the following physician orders dated 3/17/24, Change tracheostomy (trach) ties each day shift and as needed, clean or change inner cannula every day, oxygen at 2 liters per minute via tach mask as needed, trach site care with normal saline. May use trach kit every day shift and as needed for excessive drainage, trach: assess breath sounds every shift and as needed, change canister and tubing weekly and as needed, change trach tube every day shift every month and as needed, check oxygen saturation every shift and as needed, licensed nurse may reinsert trach tube as needed for dislodgment, may use trach dressing drain sponge to cover trach site or leave open to air, observe trach site/stoma for redness, bleeding, swelling, increased secretions, drainage, and skin breakdown every shift, and tracheostomy care every shift and as needed: clean or change inner cannula when needed. This same report includes the physician order dated 3/18/24 of tracheostomy site dressing change as needed if soiled as needed related to tracheostomy status. R3's progress notes include the following: 3/15/24 at 4:33 PM, Resident (R3) arrived at facility with her uncle in a private car. Mouth pink and moist LCTA (lungs clear to auscultation) trach in place, BS (bowel sounds) present x (times) 4 ABD (abdomen) soft nontender. Bruising from needle sticks to both arms, no excoriation or open areas noted. 3/15/24 at 11:20 PM, The patient (R3) is being transferred out to hospital r/t (related to) SOB (shortness of breath). Patient (R3) is requesting to be sent out because she is having trouble breathing and complaining of chest pains. The nurse attempted to call the doctor twice. No answer. Awaiting doctor to return call. The nurse reached out to DON (Director of Nursing) and made her aware of the situation. DON stated to send the patient (R3) out per patients request at this time. SPO2 is at 90%, T (temperature) 97.8, R (respirations) 20, B/P (blood pressure) 128/76. 3/16/24 at 5:19 PM, Client (R3) returned to facility with less than 23 hrs. (hours) stay at (name of local hospital) . R3's emergency transport Patient Care Report dated 3/15/24 documents the following, .dispatched immediate response via private-line 911 to (name of facility) for report of a .female trach patient with shortness of breath. Nursing home is having difficulty with patient's oxygen/trach equipment. EMS (emergency medical services) arrives on scene and patient (R3) is found sitting alone in her wheelchair at the main nurse's station. Patient (R3) waves down EMS as they approach, and she tells them that they are here for her. ALS (Advanced Life Support) assessment. Female (R3) is alert and oriented x 4. She has a tracheostomy, but she can speak when she occludes it with her fingers. Patient (R3) presents with slightly increased work of breathing. She is able to speak relatively clearly with short sentences. She is not connected to any oxygen at this time. Skin is pink, warm, and dry. Pulse strong and regular. She tells EMS that the nursing home staff is having difficulty connecting her oxygen to the supplied devices from her discharge today. Patient (R3) has been at (name of regional hospital) receiving treatment for an infection of her port which had to be removed. She has been discharged to (name of facility) for rehabilitation and has been at the nursing home for 7 hours. Patient (R3) requests EMS assistance connecting her oxygen equipment. EMS wheels patient in her wheelchair to her room. Nurse meets EMS in the room. Various pieces of equipment are found lying on the bed and in bags. There is a simple mask, a Venturi/aerosol trach-mask, and other miscellaneous oxygen tubing's. Nurse explains that the provided equipment is from her discharge from (name of regional hospital) and provided by family and she is not familiar with use of this particular equipment. Lungs sounds reveal rhonchi in upper fields and clear lower fields. Patient (R3) has had a productive cough from time to time where she can clear her own airway by coughing. EMS asks if there's any suction equipment available if patient (R3) needs suctioning of her airway. Nurse claims there are no suctioning devices. Vitals are measured. Patient (R3) is maintaining adequate room air oxygen saturation. For several minutes, EMS examines the available equipment in an attempt to make something work. The preferred aerosol mask is attached to a 1-liter bottle of sterile water which, also has the necessary adapter to attach to the oxygen concentrator. Due to the large size of the bottle, it cannot fit on the concentrator. There are no smaller sterile water bottles available that will fit to the adaptor piece. The only other option is to use a simple mask which can also fit over the tracheostomy and provide supplemental oxygen. EMS explains to patient that supplemental oxygen, even if provided using improvised equipment might be what she needs to help ease of difficulty breathing and provide the comfort she seeks. Patient (R3) adamant (sic) refuses to let EMS try this and claims, it doesn't work, and she doesn't get enough air. EMS explains that if this is placed over her tracheostomy, it will work in providing oxygen as there is no reason it shouldn't work. Patient does not require supportive ventilation as she breathes with adequate rate and depth spontaneously. The simple mask would only increase the oxygen concentration entering her lungs as she breathes. EMS also adds that she is maintaining adequate oxygen saturation without any supplemental oxygen and current findings may be about her baseline with her history of COPD (chronic obstructive pulmonary disease). Despite these pleas, patient (R3) will not allow for use of the simple mask and demands that the aerosol mask be used. EMS explains that until the proper equipment can be provided, this demand cannot be met. Patient (R3) and family member who was in contact with the nursing home prior to EMS arrival request that patient (R3) be taken to (name of local hospital). Cot is prepared in hallway. Patient (R3) wheels self to hallway and she is able to stand and turn to cot, with minimal assistance Transport completed without incident. R3's local hospital records dated 3/16/24 documents under Chief Complaint, (R3) is a .female who present with no symptoms from (name of facility). Patient (R3) was sent to (name of hospital) due to the nurse at that facility not being comfortable with tracheostomy care The following is a note from (name of hospital nurse) who spoke with V34 (Marketing Director) who is the director at (name of facility). Received call from (V34), Director at (name of facility). (V34's facility title is Marketing Director) He offered deepest apologies to staff of (name of hospital) for confusion at his facility that resulted in patient being sent to this hospital. He stated, the nurse on duty just wasn't comfortable with a trach patient. I don't know why. I have all the equipment here for patient. RN (Registered Nurse) that was uncomfortable is no longer an issue, and patient may return to (name of facility) at any time .This RN verified with V34 that he would like this information put into note in patients' chart, verbal agreement given. On 3/19/24 at 10:00 AM, R3 was in her room, lying in bed, with no obvious signs of distress. R3 was receiving oxygen via her tracheostomy. R3 stated she didn't really want to talk but was willing to answer a question. This surveyor asked R3 about the night she went to the hospital and R3 stated the facility staff couldn't figure out how to hook her oxygen up, so they sent her out. R3 stated she wasn't in distress and wasn't sure if the facility had the right equipment. On 3/18/24 at 4:45 PM, V13 (LPN) stated the facility recently accepted a resident (R3) who had a tracheostomy. V13 stated R3 came to the facility with no supplies, and they had to send her out because they couldn't get R3 oxygenated with the supplies the facility had. V13 stated there was another nurse V25 (LPN) who wasn't comfortable providing care for someone with a tracheostomy. V13 stated V25 told administration and they didn't get her any training. V13 stated the facility didn't even have trach kits. On 3/19/24 at 3:39 PM, V25 (LPN) stated she provided care to R3 for 2-3 hours on the day she admitted to the facility (3/15/24). V25 stated R3 got to the facility and stayed in the dining room, since she arrived around dinner time. V25 stated an unknown staff member let V25 know R3 was having trouble breathing and wanted some oxygen. V25 stated she started searching the supply room to try to find everything they needed. V25 stated, It was kind of a fail. V25 stated she kept going into the dining room to ensure R3 was ok and because R3 was scared. V25 stated R3's oxygen saturations fell into the upper 80's. V25 stated she didn't feel like R3 was in any danger but at the same time R3 was scared and kept saying, I can't breathe. V25 stated the other nurses working that day assisted her and then R3 had her call V26 (Family Member). V25 stated V26 came to the facility and asked her what she wanted him to do since he didn't have the needed equipment at his house either. V25 stated V26 thought to call the hospital R3 had discharged from, and he drove to the hospital in a neighboring town and got supplies. V25 stated R3 did have a simple mask on over her trach with normal oxygen tubing. V25 stated R3 told her it wasn't going to work but that was what we had to work with. V25 stated R3 did calm down some after V26 arrived at the facility. V25 stated she was sent to the hospital after V25's shift ended. V25 stated she didn't have the supplies needed to apply oxygen when R3 arrived at the facility. On 3/21/24 at 9:37 AM, V39 (CNA/Certified Nursing Assistant) stated when R3 got to the facility she wanted to sit in the dining room. V39 stated she walked past the dining room around 4:00 PM and R3 said she was having problems breathing. V39 stated R3 was really panicky and couldn't catch her breath. V39 stated she told the nurse, and they went to look for the equipment needed for the trach. V39 stated they didn't have the equipment so a family member of R3's went to the hospital and got what they needed. V39 stated she left around 6:00 PM or switched halls so she didn't have anymore contact with R3. On 3/19/24 at 3:59 PM, V26 (Family Member) stated he got a call from the facility that they were going to send R3 to the hospital because they didn't have the equipment they needed. V26 stated he went to the facility and spoke with V25 who said they didn't have the equipment and probably wouldn't be able to get it since it was the weekend. V25 stated he called the hospital R3 discharged from and then drove to the neighboring town and got the equipment. V26 stated R3 was fine when he left the facility and then they sent her to the hospital later. On 3/19/24 at 10:20 PM, V13 (LPN) stated V25 was the nurse on shift when R3 arrived at the facility and then V13 came on shift and got report from V25. V13 stated she was the nurse who sent R3 to the hospital. V13 stated she called R3's physician but had to leave a voicemail and explained in the voicemail they didn't have the equipment they needed to provide oxygen for R3 and R3 had requested they send her to the hospital because she was having trouble breathing. V13 stated R3's oxygen saturation was at 90% when she checked it and at 93% when the EMS arrived. V13 stated all the equipment V26 brought to the facility worked but the bottle was too long to attach to the concentrator. V26 stated the bottle of sterile water wasn't fitting into the compartment on the concentrator so they couldn't attach it. V13 stated they had two other bottles that also didn't work. V13 stated EMS attempted to get it to work and another nurse attempted to get it to work but it wasn't fitting on the concentrator. V13 stated R3 had a non-rebreather mask over her trach but said that wasn't working for her. V13 stated she sent V2 (DON/Director of Nursing) a text message that R3 was requesting to be sent to the hospital and explained the sterile water didn't fit into the concentrator, that R3 had oxygen on, was getting a little air, but was saying she was having trouble breathing, and her oxygen saturation was at 90%. V13 stated V2 sent a message back to send R3 to the hospital. V13 stated the messages were not in the computer system but they were on WhatsApp, the communication app the facility staff were using. On 3/21/24 at 10:37 AM, V37 (Paramedic) stated he transported R3 from the facility to the hospital on 3/15/24. V37 stated he got called to the facility for a resident who was short of breath, and they were having difficulty managing the resident with a tracheostomy. V37 stated when he arrived and got to the main nurse's station he was met by the resident (R3) flagging him down. V37 stated R3 stated she was having some shortness of breath, but the main problem was she was having issues with the concentrator. V37 stated R3 took them to her room and nurse (unknown) told them they were trying to get R3 hooked up to oxygen. V37 stated there were three main pieces. V37 stated there was a one-piece vent circuit that wasn't usable, just an extension and a Venturi or aerosol mask. V37 stated this mask was appropriate for R3 to get oxygen. V37 stated on the end of that where it would connect to the concentrator there was a bubbler on. V37 stated it was like a one-liter bottle and it was too long to fit with the way the connections were. V37 stated it physically would not fit on the machine. V37 stated the third piece was a simple mask. V37 stated this is a mask you would normally use on your nose/mouth. V37 stated the facility nurse was going to use it and put it over the trach so R3 could get oxygen since the aerosol mask was not an option. V37 stated they tried different bubblers, but they wouldn't fit on the aerosol mask. V37 stated R3 adamantly refused the simple mask. V37 stated as far as he knew they didn't have any other equipment options at the facility. V37 stated he had never seen a trach resident at the facility in the six years he has been a paramedic for that area. V37 stated the nurses were very uncomfortable with the trach and unfamiliar with the equipment. V37 stated the nursing staff had already tried everything he did but didn't seem very comfortable or knowledgeable with tracheostomy care. V37 stated there was also no suction equipment in the room. V37 stated R3 had some rhonchi. V37 stated he asked the nurse if R3 needed suctioning at all and the nurse said she didn't have any suctioning there. V37 stated as soon as they got to the hospital with R3 she coughed up a decent size mucus plug and needed suctioning. V37 stated if R3 hadn't been taken to the hospital it would have been an issue. On 3/19/24 at 10:37 AM, V27 (RN/Registered Nurse) stated she was not working the night R3 admitted to the facility. V27 stated she was working on the day R3 returned to the facility from the hospital and told V2 (DON/Director of Nursing) she wasn't comfortable with trach care. V27 stated V2 told her R3 was pretty independent with the trach and if she needed anything to call her. V27 stated another nurse who was familiar with trach's showed her how to suction because she had an order to suction and didn't know how to do it. V27 stated, We should have been trained before she (R3) got here, and we weren't at all. V27 stated this is the first trach patient she has ever provided care to. On 3/20/24 at 9:38 AM, V34 (Marketing Director) stated when there is a potential resident he gets the referrals from the hospital, puts the information in the system and then they look at things such as payor source and background checks. V34 stated they will at times do a bedside evaluation and talk to the resident and/or family. V34 stated he was familiar with R3, and they had accepted her because V1 (Administrator) knows her well. V34 stated everyone else (other facilities) denied her. V34 stated he looked in the computer system around 5:00 PM (this time does not match the time of the other interviews) and saw they had sent R3 back to the hospital. V34 stated V5 (MDS Coordinator) told him R3 was in the dining room and her oxygen saturations were in the 90's, she was very anxious, so they sent her out. V34 stated he called the hospital to let them know they could accept her back. This surveyor reviewed the hospital record documenting V34's conversation with the hospital. V34 stated a nurse at the facility who was uncomfortable with the care was saying they didn't have supplies and because of that he said we would make sure we had the supplies at bedside. V34 stated they never had a problem caring for a resident with a tracheostomy before. V34 stated it had been a couple of years since they had a resident with a trach. When asked if he talked with staff prior to accepting R3 to see if they needed training prior to the admission, V34 stated he didn't. V34 stated he thought it would be clinical who would do that. When asked if he would know the equipment needed for a resident with a trach, V34 stated that would be a clinical question. On 3/20/24 at 9:54 AM, V5 (MDS Coordinator) stated she was a little bit familiar with R3. When asked what the admission process was, V5 stated V34 gets a referral and then lets the team know the referral is there then a member of the nursing team reviews it and says if the person is appropriate for the facility. V5 stated she didn't remember who reviewed R3's information. V5 stated they had residents with a trach before but wouldn't or couldn't say how long ago just said, It is not a very frequent thing. V5 stated they did have a training on trach care about a year ago. V5 stated if they have a resident with a unique need, they will do an in-service with staff prior to the admission. V5 stated she wasn't at the facility when R3 admitted but she knew they had supplies and she told V2 (DON) where to look for them. V5 stated she remembered R3's referral because the report had been called over from the hospital one day and then they held R3 at the hospital for an extra day. V5 stated when the hospital called report, they said R3 was independent with trach care, was mainly on room air, and only used oxygen as needed. V5 stated she knew V2 had set up another in-service for trach care. V5 stated if she had been working, she would have reached out to a manager and asked to be shown what to do and to my knowledge that didn't happen. On 3/20/24 at 10:05 AM, V2 (DON) stated she started working at the facility on 1/29/24 and took the DON position on 2/2/24. V2 stated they were originally told by the hospital R3 was not on oxygen. V2 stated R3 got to the facility and was short of breath. V2 stated the nurse attempted to put a mask on R3 and she didn't like the mask the facility had. V2 stated R3 got very anxious and wanted to go to the hospital. V2 stated she said to send her if she wasn't comfortable. V2 stated she wasn't familiar with where everything was located at the facility. V2 stated they didn't tell her the type of mask R3 had on. V2 stated she spoke with other managers (V5 and V18), and they said they had everything at the facility. When asked if she had any conversation with the nursing staff about it, V2 stated when R3 came back to the facility, we made sure the hospital sent specifically what she wanted with her so, R3 could be comfortable coming back. V2 stated they spoke with the nurse working the night R3 was admitted and told her where the equipment was located, and they also have extra supplies in the shed outside. This surveyor confirmed with V2 they had all the equipment for oxygen including, sterile water, tubing, and mask on 3/15/24 when R3 admitted to the facility and V2 stated, Yes. When asked if there was ever any conversation with the nursing staff about needing training on trach care, V2 state, At the expense of sounding rude or heartless they are nurses in long term care, and trach's do come but after this incident I did reach out to get training set up again. On 3/20/24 at 4:07 PM, when asked about staff being trained on tracheostomy care, V1 (Administrator) stated, they are licensed nurses to do their capabilities within their work ethics and if they aren't comfortable, they can come get us to get training provided. We have it anytime they need from (name of online training program), it is a real person and any of us would be happy to go down and help them. V1 stated she was on the phone with nursing staff and verified all the equipment was there and was on the phone with the hospital. V1 stated she also had the manager on duty, V36 (Laundry/Housekeeping Manager) in R3's room going over all the items with her. V1 stated, No one was uncomfortable, everyone was fine, and everyone had the equipment. V1 stated they had a venturi mask and R3 refused to use it and that is why they went to the hospital to get her a different mask. V1 stated we had venturi masks at the facility. On 3/25/24 at 10:10 AM, when asked if she assisted nursing staff with finding supplies for R3's trach care, V36 (Laundry/Housekeeping Supervisor) stated when R3 came back from the hospital (3/16/24) she spoke with V1 (Administrator) on the phone to verify they had everything they needed to meet R3's needs. On 3/20/24 at 1:00 PM, V32 (Physician) stated she wasn't familiar with R3 since she had just admitted to the facility. V32 stated she was not R3's physician prior to her admission to the facility. This surveyor explained the scenario to V32 and asked if there was any potential negative outcome for R3, V32 stated there is a lot of potential negative outcome. V32 stated it could have devastating consequences if the facility doesn't have the necessary equipment for the trach. This surveyor then asked V32 if she had ever seen nurses who had not worked with trach's before and if so, would they need to be trained prior to caring for a resident with a trach, V32 stated it is very reasonable for a nurse who hasn't cared for a trach to need to be trained on how to do it. The facility Inservice Education Record dated 6/7/23 documents the subject of the training as trach orders and has a list of who attended. V13 (LPN), V25 (LPN), and V27 (RN) are not documented as attending the meeting. The training attached to this meeting documents staff was trained on how to set up tracheostomy orders in the electronic health record system. The facility annual training calendar does not include training on tracheostomies. The facility undated Tracheostomy Care procedures documents, The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas. The procedure documents under General Guidelines 7. A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times. This procedure does not address the specific equipment needed to supply oxygen.

Based on interview and record review, the facility failed to safely transport a resident in a wheelchair to prevent an accident for 1 of 3 residents (R3) reviewed for accidents in the sample of 3. This failure resulted in R3 sustaining a fall from R3's wheelchair that resulted in a laceration to the bridge of the nose, requiring treatment of glue to the nose at the local hospital emergency room . This past non-compliance occurred between 9/16/23 and 9/22/23. Findings include: R3's undated Admission Record documents that R3's initial admitted to the facility was 12/01/19, with current admitted [DATE]. R3's diagnoses listed on this document include, but are not limited to Chronic Obstructive Pulmonary Disease, Morbid (Severe) Obesity Due to Excess Calories, Atherosclerosis of Native Coronary Artery of Transplanted Heart Without Angina Pectoris, Generalized Anxiety Disorder, Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, Parkinson's Disease, Cognitive Communication Deficit, Chronic Diastolic (Congestive) Heart Failure, Spondylolysis, Lumbar Region, and Essential Hypertension. R3's MDS (Minimum Data Set) dated 8/28/23 documents that R3 has a BIMS (Brief Interview of Mental Status) of 03, which indicates that R3 has severe cognitive impairment. The same MDS documents under Section GG that R3 uses a wheelchair for mobility. Section GG also notes that R3 requires supervision or touching assistance (helper provides verbal cues and/or touching /steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) to wheel 50 feet with two turns and to wheel 150 feet. R3's Occupational Therapy Treatment Encounter Note with dates of service of 5/3/23 document the following: Precautions: Fall risk. Does not follow commands consistently due to cognition. Contraindications = No contraindications present Patient sitting up in w/c (wheelchair) in dining room for lunch and propels self throughout facility using BLEs (bilateral lower extremities). The facility's Verification of Incident Investigation/Administrative summary documents R3 having a fall with injury on 9/16/23 at 1440 (2:40pm), with a description of Injuries as laceration to bridge of nose. The Summary of Investigative Findings documents (R3) is an [AGE] year old female who in (sic) mostly wheelchair bound with transfer to and from bed as well as bathroom. Resident ability to perform ADLs (Activities of Daily Living) is very limited. Resident is confused at times. CNA (Certified Nurse Assistant) was assisting in pushing resident to dining room when resident put feet down abruptly, when wheelchair stopped abruptly resident went forward in wheelchair slowly to the floor. Small laceration to bridge of nose, no bleeding noted to area. Mild pain noted and resident not following commands. MD (Medical Doctor) and POA (Power of Attorney) notified. Orders received. Resident not moved and EMS called for transport to ER (emergency room ). Upon assessment at ER resident noted to have small laceration to bridge of nose, glue used to close wound. CT (computerized tomography) and x-ray reports clear. Resident was transferred back to facility same day, states that glue will wear from nose and to monitor. On investigation, noted resident was wearing shoes which abruptly stopped the wheelchair on tile floor. Follow-Up Actions Taken: Follow up and monitor resident for pain, assess laceration to nose every shift, will assess resident footwear for proper footwear, provided education to staff of abrupt stopping of wc (wheelchair), educated staff on wheeling resident slowly when assisting to locations in wheelchair. The facility investigation document further documented that V2's (CNA) statement remained same that he was taking R3 to lunch in wheelchair when she abruptly put feet down causing wheelchair to stop and resident slid from chair Inservice put in place following investigation stating that ALL residents that are propelled by staff need to have foot rests in place. Education provided. R3's Care Plan documents a Care Plan focus of At risk for falls and injuries r/t (related to) Medications: Medical Factors: Cognitive Impairment, Dementia, Hx (history) of falls .Poor safety awareness, Unsteady Gait, Visual Impairment, Weakness that was initiated on 3/13/23. Interventions include instruct to avoid sudden position changes and observe for unsteady gait and balance both initiated on 3/13/23. An intervention added on 9/20/23 includes educate staff on resident having leg rests on chair at any time she is being assisted by staff for locomotion. R3's Care Plan documents another focus area of (R3) has had actual falls and is high risk for additional falls r/t dementia/generalized weakness that was initiated on 12/02/19 and revised on 05/06/19. Interventions include to anticipate and meet R3's needs and ensure R3 is wearing appropriate footwear both initiated on 12/02/19. R3's Care Plan also documents a focus area of (R3) has Parkinson's disease initiated on 3/13/23 and revised on 05/02/23. Interventions include Monitor/document/report to MD PRN (as needed) s/sx (signs/symptoms) of Parkinsons complications: Poor balance .Poor coordination .Tremors, Gait Disturbance, Muscle cramps or rigidity, Decline in ROM (range of motion) .Decline in cognitive function. An additional Focus Area notes Decline with bilateral lower extremity related to joint mobility initiated on 03/04/22 and revised on 3/23/22. On 9/26/23 at 9:16 am, R3 was observed sitting in her wheelchair at the dining room table. One foot pedal to the right side of wheelchair was observed. A small, well approximated cut was noted to the bridge of her nose with green/yellow/dark purple bruising observed to bilateral eyes. R3 was wearing footwear and stated these are the shoes she prefers. R3 was alert to person and place and confirmed that she did recently have a fall out of her chair. R3 said she wasn't sure exactly what happened, she just fell forward out of her chair. R3 was not able to provide details regarding the fall but described it as an accident. On 9/26/23 at 11:40 AM, V2 (CNA) stated that he was the CNA pushing R3 in her wheelchair when she fell . V2 stated that R3 was in her room sleeping in her chair and he went by and woke her up to head to the dining room for lunch time, he believes it was. V2 stated that later he went back by R3's room and she was still sitting in there, so he offered to assist her. V2 stated that normally R3 propels herself throughout the facility but she just seemed drowsy, so he was trying to be nice and help her out. Stated R3's normal status is mildly confused but appropriately follows commands. V2 stated that R3 had stated ok, and he instructed her to hold her feet up, which she did. V2 stated they were by the nurse's station and one of R3's feet hit the floor causing her to fall forward out of her chair onto the floor. V2 stated he yelled for a nurse, and several staff immediately responded. V2 stated since R3's fall the facility has completed a facility wide in-service that if a resident seems drowsy or isn't their normal self, to apply foot pedals during transport. On 9/26/23 at 8:05 AM, V1 (Administrator) stated that R3 did recently have a fall. V1 said that R3 normally propels herself throughout the facility, making the use of foot pedals contraindicated as previously evaluated by therapy. V1 stated upon investigation, it was noted that R3 was drowsy, recovering from illness, so staff were assisting R3 to the dining room as a courtesy. R3 suddenly put down her feet and fell out of her chair. V1 stated that training was conducted with staff that if residents are requiring assistance with being pushed in their chairs throughout the facility, to apply foot pedals, to prevent any further similar falls. V1 stated all notifications were made regarding R3's fall and there have been no further incidents or concerns regarding R3's fall. On 9/26/23 at 10:50 AM, V4 (Director of Nursing/DON) stated that R3 did have a recent fall after putting her feet down while being pushed (in wheelchair) by staff. V4 stated that R3 is not someone who usually requires transportation assistance, as she propels herself. V4 stated R3's cognitive status is mild confusion. V4 stated an investigation was completed regarding the fall and it was decided since R3 was experiencing a drowsy state that day, that when staff are propelling residents, foot pedals will be applied to the chair for transport. V4 stated R3 has experienced no pain or lasting negative effects from her fall. V4 stated R3 was transported to the local ER for treatment. On 9/26/23 at 10:56 AM, V5 (Certified Occupational Therapy Assistant/COTA) stated that R3's normal status is that she propels herself throughout the facility, therefore foot pedals would not be recommended. V5 stated given R1's poor cognitive status and mobility level, she would also consider it to be a fall hazard for R1 to have foot pedals on her chair all the time. V5 stated that she has performed previous evaluations on R3 and would consider this incident to not be a predictable accident. On 9/26/23 at 11:05 AM, V6 (CNA) stated that she frequently works with R3 and that R3 propels herself around the facility. V6 said she has recently completed training that foot pedals are to be applied to (wheel)chairs if the resident is drowsy so that their feet remain off the ground and don't experience any further falls. On 9/26/23 at 11:10 AM, V7 (CNA) stated she frequently works with R3 and that she cannot think of a time she has ever had to assist R3 with transport as R3 normally easily propels herself in her wheelchair throughout the facility. V7 said R3 does have altered cognition and is frequently confused. V7 said since R3 fell , she completed training regarding applying foot pedals to resident's wheelchairs that do not have them if they are experiencing a change in their normal status, such as being tired. A facility Inservice/Education Record dated 9/22/23 documents Summary of Content: Residents that are in wheelchairs MUST have foot rests in place while pushing to and from destinations. May remove if resident propels self, but if pushed by staff foot rest to be in place. Prior to the survey date, the facility took the following actions to correct the deficient practice: 1. A Quality Assurance and Performance Improvement (QAPI) meeting was held on 9/18/23. Attendees included Administrator, Director of Nursing, Assistant Director of Nursing, Social Services Designee, Medicare Coordinator, Wound Nurse, Restorative Aide, and Human Resources. 2. The QAPI plan documented that rounds will be made on hallways frequently to assess resident status, residents in wheelchairs that are propelled by staff will have foot pedals in place, and CNA's and other staff will be able to identify high risk residents. Audits will be conducted, and improvement will be measured by facility having a decrease in falls during the duration of QAPI and to follow. All residents will have foot pedals in place and/or readily available (ex; residents that propel self as well as assisted by staff at times). 3. Measures put into place/systematic changes to ensure the deficient practice does not recur: V4 provided Wheelchair Safety in-service to all staff regarding ensuring footrests are in place when pushing residents in wheelchairs. Completed on 9/22/23. 4. Plan to monitor performance to ensure solutions are sustained: Will assess monthly in QAPI.

Based on interview and record review, the facility failed to ensure a resident with a high risk for falls had fall interventions in place for 1 of 3 (R2) residents reviewed for falls in a sample of 12. This failure resulted in R2 falling, receiving a fractured left hip, in which R2 was admitted to the hospital for surgical repair of left hip. Findings include: R2's facility document titled, Profile documents R2 was admitted on [DATE] with a diagnosis of Type 2 Diabetes Mellitus with Diabetic [CONDITION(S)]. R2's facility document titled, Minimum Data Set (MDS) dated [DATE], section C, Brief Interview for Mental Status (BIMS) score is 9, moderately impaired cognition, section G, Functional Status, extensive assistance x 1 person physical assistance with bed mobility, transfers, and ambulation. R2's Admission Nursing Assessment, dated 9/21/2022, documents 4h. Notes: pressure pads applied to wheelchair and bed. R2's Fall Risk assessment dated [DATE], documents Fall Risk Score: 15, (High Risk). R2's Care Plan documents, At risk for falls and injuries related to medications, medical factors (Arthritis, Cognitive Impairment, Dementia, History of falls, Incontinence, Pain, Poor safety awareness, Unsteady gait, and Weakness) with a start date of 9/21/2022. R2's Care Plan Fall Interventions: Assess toileting needs, Encourage use of call light, Keep call light within reach, Keep environment clutter free, Keep personal belongings within reach, Low Bed, Observe for side effect of meds, Observe for unsteady gait and balance, Provide adequate lighting, Provide verbal safety cues, Provide/Reinforce use of non-skid wear, and Wear Clean eye wear with a start date of 9/21/2022 and Pressure pad alarm and night light in room with a start date of 11/07/2022. A progress note entered into R2's medical record dated 9/21/2022, at 12:40 p.m., by V2 (Director of Nursing), documents in parts Resident arrived to facility via facility wheelchair with facility driver .82 y/o female who admitted to the (local hospital) on July 28th due to recurring falls and was found to have a urinary tract infection Does try to get up on own so pressure pad alarms placed in wheelchair seat and bed. A progress note entered into R2's medical record dated 10/31/2022, at 3:00 a.m., by V8 (Licensed Practical Nurse) documents, CNA (Certified Nursing Assistant) states that resident was yelling for help and upon entrance to room, resident noted to be sitting on left buttocks/left elbow. Resident assessed for injuries and upon assessment, resident noted with mild tenderness to left outer hip. Able to bend bilateral knees, no rotation noted, no shortening noted. Resident denies hitting her head, no evidence. Call light within reach. Resident assisted back to bed via gait belt and educated on importance of calling for help. Verbalized understanding. Will ensure that sensor pad put in place. On 11/17/2022, at 4:28 p.m., V1, (Administrator), stated that R2's fall intervention of a personal alarm and night light was implemented on 10/31/2022. V1 was not aware of R2 having had this intervention before 10/31/2022. On 11/16/2022, at 9:45 a.m., V8, (Licensed Practical Nurse), stated that she was working on 10/31/2022, during the night shift and came to assess R2 after her fall. V8 stated when she entered R2's room, she observed R2 sitting on her left buttock/left elbow. V8 stated she assessed R2 for injuries and upon assessment, R2 noted to have mild tenderness to her left outer hip. V8 stated that R2 was able to bend bilateral knees, no rotation or shortening noted on left or right hip/leg. V8 stated that R2 denied hitting her head. V8 stated that R2's call light was within reach, she was wearing her non-skid foot wear, her bed was in the low position. V8 stated that her personal alarm was still in her wheelchair and not placed in her bed before R2 had her fall. V8 stated that R2 was assisted back to her bed, pressure alarm was put in place prior to putting R2 back to bed and R2 was educated on the importance of calling for help. V8 stated that R2 told her she was trying to help her roommate because her roommate was yelling out. A progress noted entered into R2's medical record, dated 11/07/2022, at 12:35 a.m., by V27 (Licensed Practical Nurse), documents R2 complained of increased left leg and left hip pain. V28, (primary physician), notified of condition and V28 requested x-rays of left leg and left hip to be done in the facility. R2's x-ray report dated 11/07/2022, at 9:36 a.m. by V29 (local physician), documents Displaced fracture involving the femoral neck is present. A progress note entered into R2's medical record dated 11/07/2022, at 1:10 p.m., by V2 (Director of Nursing) documents Resident exiting facility via stretcher in route to local emergency room . R2's History and Physical Examination from the local hospital dated 11/07/2022, by V30, (local physician), documents R2 was admitted to the local hospital for open reduction internal fixation surgery to left hip. A progress noted entered into R2's medical record dated 11/11/2022, at 6:45 p.m., by V31, (Licensed Practical Nurse), documents R2 readmitted back to the facility at 3:15 p.m. On 11/16/2022, at 1:00 p.m., V16, (Certified Nurse Aide), stated that R2 used a personal alarm while she was in bed and while she was up in her wheelchair before her fall on 10/31/2022. On 11/21/2022, at 12:45 p.m., V32 (Certified Nurse Aide), stated that R2 used a personal alarm in her bed and wheelchair before her fall on 10/31/2022. On 11/17/2022, at 3:00 p.m., V2, (Director of Nursing), stated she completed R2's admission assessment and documented pressure pads applied to wheelchair and bed. V2 stated she was not aware that R2 did not have her pressure alarm applied while she was in bed the night she had her fall on 10/31/2022. R2's medical record was reviewed and R2 has had no other falls since her admission to the facility of 9/21/2022.