Every finding on record at Paradigm at Faith Memorial

Based on observation, interview and record review, the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for 1 of 19 residents (Resident # 11) reviewed for care plan revision. --Resident # 11's care plan was not revised for skin condition. This failure placed residents at risk of not receiving proper individualized care.Findings include: Record review of Resident # 11's admission record revealed admission date 12/5/25 with diagnoses including COPD (Chronic Obstructive pulmonary Disease with long-term airway obstruction), ataxic gait (uncoordinated, unsteady walking), Diabetes (high blood sugar levels), heart disease with heart failure (inability of the heart to pump blood efficiently), muscle weakness (muscles fail to contract normally causing loss of strength. Record review of the Quarterly MDS dated [DATE] revealed Resident # 11 was sometimes understood and sometimes understands, BIMS of 9, indicting impaired cognitive skills, supervision required for ADLs, risk of pressure sores with no unhealed pressure sores, no venous or arterial ulcers, no other ulcers, wounds or skin problems. Record review of Resident # 11's clinical physician orders dated 1/6/26 revealed conduct weekly skin evaluation, notify MD of any new skin condition. Record review of Resident # 11's skin evaluation dated 4/18/26 revealed skin intact, no new areas, no pressure sores or non-pressure areas. Record review of the care plan for skin condition initiated 12/9/25, revised 12/17/25 revealed Resident # 11 had non pressure/surgical skin condition, with interventions to assess the wound bed and surrounding skin for signs of infection or other complications. Observation of Resident #11 on 4/23/26 at 10:30am revealed he was ambulating down the hallway to the smoking area, at the scheduled smoking time. Interview with Resident #11 revealed the nurse checks him every week to see if he has any sores and every week she says he is ok. In an interview with LVN D on 4/23/26 at 10:30 am, she said she works with Resident # 11, and she said he does not have any skin condition. She said he has a skin assessment every week, and there has never been any skin breakdown reported. She said he walks around without assistance and is a smoker. In an interview with LVN E, wound care nurse, on 4/23/26 at 10:45am, she said Resident # 11 does not have any skin conditions. She said he has a skin assessment every week and there has never been any skin breakdown so she does not do wound care for him. In an interview with MDS nurse on 4/23/26 at 12:15pm revealed Resident #11's care plan would need to be corrected because he does not have any skin condition. She said he might have had a rash when he was admitted , but there is no skin condition now. She said the risk of not having an accurate care plan would be inaccurate care for the resident. In an interview with the DON on 4/23/26 at 12:40pm revealed Resident # 11 did not have any skin condition, and the care plan for skin condition would have to be revised to reflect that. She said the interdisciplinary team would contribute to the care plan, and the risk of not having an updated care plan would affect the care for the resident. Record review of the facility policy Care Plan Revisions, revised 5/2022, revealed, in part: care plans will be reviewed and revised every quarter, when a resident experiences a status change, or as deemed necessary.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 1 medication fridges reviewed for storage of drugs.The facility failed to ensure that all medications were not expired. This failure could place residents at risk of receiving expired medications and not receiving the full therapeutic doses and effects of those medications. Observation on 4/21/2026 at 2:47 p.m. of the Station 1 Medication Room revealed one 25 mg Prochlorperazine suppository that expired 9/2024, six 650 mg Acetaminophen suppositories that expired 10/2025 and one Acetaminophen suppository that expired 9/2025. During interview on 4/21/2026 at 2:47 p.m., the DON answered correct when asked if medications were to be removed from the fridge when they expired. The DON said it was the nurse who checked the medication fridge temperature log's responsibility to check for expired medications in the medication fridge. The DON said the night shift nurses were responsible for checking the medication fridge temperature log. The DON said her and the ADON do rounds and checked the medication rooms and made sure the temperature log was completed and checked expiration dates on the insulins in the medication fridge. The DON said she was not sure what happened regarding the suppository medications being expired and not removed. Record review on 4/22/2026 at 2:20 p.m. of email from the Administrator that identified LVN C and RN A as the two regular night nurses who were at Station 1. On 4/22/2026 at 4:09 p.m. surveyor attempted to contact LVN C and left a message with the receptionist at the facility via phone to have LVN C call the surveyor. During interview on 4/22/2026 at 4:14 p.m., RN A said she usually worked Station 1 from 6 p.m. to 6 a.m. RN A said she usually checked the medication fridge at night and checked the temperature and made sure it was within range. RN A said she only checked the medication fridge's temperature and did not check for expired medications normally. RN A said if the medication fridge looked messy, she straightened it out or if she had to pull out an insulin she checked the expiration date. RN A said she did not know whose responsibility it was to check the medication fridge for expired medications. RN A said she did not recall seeing the container in the medication fridge that had the expired suppository medications. RN A said if she took medications out of the medication fridge, she always checked the expirations dates before administering the medications. When asked if she had any specific trainings/in-services regarding the medication fridge, RN A said that it was standard knowledge from her previous nursing experience and when she first started she was told to check the temperature on the fridge and keep the medication room neat. On 4/22/2026 at 4:27 p.m., surveyor contacted LVN C via phone in attempt to interview and LVN C answered and asked if she could call the surveyor back. During interview on 4/23/2026 at 8:33 a.m., the Consultant Pharmacist said there should not be any expired medications in the medication fridge as the medications should be removed and put in a separate area. The Consultant Pharmacist said she typically did spot checks of everything including the medication fridges and she did not see the container in the medication fridge that had the expired medications. The Consultant Pharmacist said she checked for expired medications or made sure the medications were in their designated places if the medications were discontinued. The Consultant Pharmacist said she was not sure who was responsible at the facility for removing expired medications from the medication fridge. The Consultant Pharmacist said regarding having expired medications in the medication fridge, that most medications do not have harmful effects past the expiration date, but the medication would not be as effective, and you would not know how much medication was being given as the resident might be only getting half the dose of the medication. The Consultant Pharmacist said she trained the facility staff to check the expiration date before giving medications so that expired medications should not be given to residents. During interview on 4/23/2026 at 10:37 a.m., the ADON said there should not be any expired medications in the medication room or medication fridge. The ADON said they try to catch everything, but things may slip through the cracks. The ADON said if there were expired medications they call pharmacy and let them know and the pharmacy would send out a new batch. The ADON said the night shift was supposed to check the medication fridges for expired medications. The ADON said any medication that was expired were destroyed. The ADON said it was everybody's responsibility including hers to follow up regarding checking for expired medications in the medication fridges. The ADON said she tried to check the medication room and medication fridges every couple of days. The ADON said when nurses were first on the floor after orientation, they should have received education regarding expectations regarding the medication rooms and fridges. The ADON said regarding having expired medications in the medication fridge, if an expired medication was administered there could be potential harm to the resident and depending on their body mechanics. During interview on 4/23/2026 at 11:04 a.m., the DON said there should not be expired medications in the medication fridge and the medications should be discarded. The DON said she rounded on the medication rooms sporadically. The DON said when she checked the medication fridge, she checked the temperature log and did not check each individual medication. The DON said a possible effect on the residents regarding expired medications being in the medication fridge was that it could be accidentally given if the medication was not checked prior to administration and the medication would not be effective. Record review of facility's policy Medication Administration and Management revised 6/2019 revealed outdated medication is destroyed or returned to the pharmacy according to applicable state rules and regulations and a new supply obtained when necessary.

Based on interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 1 of 3 Residents (Residents #2) and 3 of 4 staff (LVN B, MA A, and PTA A) reviewed for infection control. LVN B, MA A, and PTA A failed to document and/or report feces found on Resident #2's mouth/teeth, face, beard, hand, fingernails, and pillow sheet to the resident's nurse. These failures could place residents at risk for spread of infection and cross contamination.The findings included: Record review of Resident #2's Facesheet generated on 01/04/2026 reflected a [AGE] year old male who admitted to the facility on [DATE] as his own responsible party (RP) with medical diagnosis of schizoaffective disorder (a mood disorder featuring periods of hallucinations, delusions, and disorganized thinking) depressive type, gastro-esophageal reflux disease (a condition where the stomach acid frequently flows back into the esophagus (canal that connects the throat to the stomach), irritating its lining, causing symptoms like heartburn, regurgitation (food/fluid coming up), bipolar disorder (a serious mental illness causing extreme shifts in mood, energy, and activity levels, ranging from manic highs (euphoria, irritability, high energy) to depressive lows (sadness, hopelessness, low energy). Record review of Resident #2's Minimum Data Set (MDS) dated [DATE] reflected the resident had a Brief Interview for Mental Status (BIMS) of 11 out of 15 reflecting the resident had moderate cognition impairment. (A score of 13-15 would indicate intact cognition.) Resident #2 required assistance with toileting, and was incontinent for bladder and bowel, had social isolation. Resident received a Preadmission Screening and Resident Review (PASRR: in-depth assessment reviews records, interviews individuals/families, and involves mental health/ID professionals to create personalized placement and treatment plans) with a positive level II diagnosis that noted he had serious mental illness. Record review of Resident #2's December 2025 Medical Administration Record (MAR) reflected he was prescribed Ondansetron HCI tablet 4 milligrams (mg) to be taken every 6-hours (hrs) by mouth (PO) as needed (PRN) for nausea and vomiting. Order date of 12/18/2025 at 11:06 a.m. As of 01/07/2026 at 04:45: p.m. Resident #2 had not been administered any Ondansetron. Record review of Resident #2's January 2026 MAR reflected he was prescribed Ondansetron HCI tablet 4mg to be taken every 6 hours by mouth as needed (PRN) for nausea and vomiting. Order date of 12/18/2025 at 11:06 a.m. but had not received any of his doses as of 01/07/2026 at 04:45: p.m. Record review of Resident #2's Care Plan reflected:Focus:Resident #2 had any focused behaviors of eating or smearing feces. Resident #2 had been identified as having a PASRR positive status r/t to a severe mental illness relating to signs and symptoms on admission with a revision date of 12/29/2025.Focus:Resident #2 had a behavior of smearing his feces and was at risk for further increased episodes and injury.Goal: Resident #2 will have decreased behaviors and episodes through behavioral monitoring and interventions, dated 01/04/2026.Interventions/Tasks:Resident to be encouraged to attend social activities of preference, explain procedures using terms/gestures the resident can understand, give medications as ordered, monitor labs, report results to Medical Doctor (MD), monitor and chart behaviors as they occur and report progress/declines to MD, observe for early warning signs of behavior - approach in a calm manner, call by name, remove from unwanted stimuli, and provide psychiatric consult as ordered. Record review of Resident #2's Progress Note dated 01/05/2026 at 08:45 p.m. reflected Nurse Practitioner (NP) A evaluated Resident #2 for a chief complaint of diarrhea with no new orders in place. Record review of Resident #2's Progress Note dated 01/05/2026 at 08:53 p.m. reflected MD noted Resident #2 had reported having loose stools occurring approximately once daily, and resident would be monitored for signs of dehydration and/or electrolyte imbalance. Labs ordered today including comprehensive panel to assess electrolyte status. Will continue current treatment and monitor for improvement. During an interview on 01/07/2026 at 01:12 p.m. Resident #2 stated he had diarrhea and asked for help. He stated he thought he was receiving medication to alleviate the symptoms but could not remember. He stated that he had been digging in his brief on occasion he had found feces on his hand and under his fingernails. He stated that he believed he had rubbed his face and the soiled hands and feces got into his beard, the sides of his mouth, and maybe into his mouth. He stated he had done it before but was unaware it happens until afterwards. He stated he felt uncomfortable in his brief and would not be aware that he had diarrhea in his brief until after he pulled his hand out. He stated he could not explain why he would put his hand on his face after putting his hand down his brief. He stated he could not recall asking nursing staff for help with his behavior or whether they were aware of his behavior. He stated someone would come and clean him up and changed his brief and sheets afterwards the incidents. He stated he could not stand or walk or get himself to the bathroom on his own to clean himself. During an interview on 01/04/2026 at 05:54 p.m. with ADM and DON both stated that they were not aware of any issue with Resident #2 having dug in his adult brief then having feces on his hands and mouth and he had not shared such information with their staff. DON stated that the resident had been admitted to the skilled hall had not come out of his room since arriving. She stated to her knowledge; the resident had been doing well. DON stated the resident had schizoaffective and bipolar disorder, anxiety, and cerebral infarction. DON stated had they been made aware, depending on the severity or the incident being a one-time occurrence, it would have been care planned for other staff and his facility to be made aware of this behavior. During an interview on 01/04/2026 at 7:05 p.m. Medication Aide (MA) stated that she was also a certified nursing aide (CNA) and on 01/02/2026 sometime between her shift of 2:00 p.m. to 10:00 p.m. (exact time unknown) had entered Resident #2's room to pass him his medications. She stated at that time she observed Resident #2 place his hand in his adult brief and pulled up feces and attempting to place that soiled hand into his mouth. She stated that she immediately intervened by asking the resident What are you doing? You are not about to eat that are you? referring to the resident placing his feces covered hand into his mouth. She stated she immediately left the resident's room to locate his CNA, who was assisting another resident. She stated she came back into the resident's room, washed his hands, changed his brief, and reposited him in bed. She asked the resident again if he was going to put his hands in his mouth, and why he would do that. She stated the resident responded by asking, What are you talking about? She stated the resident acted confused by her questions as if the incident had not taken place. She stated she had not documented or reported the incident to anyone because she thought his behavior had already been reported. She stated that she should have reported the incident to his charge nurse due to infection control, and for the resident's dignity and respect. She stated that she received an in-services training on infection control, and on residents' dignity and respect, and reporting changes in conditions on 01/04/2026. She stated failing to report the incident placed Resident #2 and others at risk of illness and cross contamination. During an interview on 01/06/2026 at 04:42 p.m. LVN A stated she worked for the facility for about a month from 6:00 p.m. to 6:00 a.m. and that she was Resident #2's nurse. She stated she had not been made aware that Resident #2 had any behavioral episodes of the resident with his hands in his brief pulling out feces and placing them into his mouth. She stated this had been the first she had heard. She stated had she seen or heard of that behavior; she would have reported the behavior to the DON, ADM and his MD as a change of condition for an order for a psychiatric evaluation. She stated the risk of resident's behavior going undocumented/unreported would cause for repeated untreated behavior, place the facility at risk for infection control issues, risk for illness, and infection. She stated in addition the behavior places the facility at risk for cross contamination and places the resident's dignity and respect at risk. During a confidential interview at undisclosed time, an anonymous person stated Resident #2 had been known to have feces under his fingernails, on his hands, beard, sides of his mouth, and in his mouth and teeth. The anonymous person stated Resident #2 had feces on his hand, in his fingernails, beard, sides of mouth and in his mouth and teeth. The anonymous person stated a male staff who was not a direct care staff reported to LVN B a charge nurse that Resident #2 was observed with feces on his hand. The anonymous person stated that LVN B entered the residents room observing his condition and stated, Oh, I'm not dealing with that and walked out of the room leaving the resident in his current condition. The anonymous person stated that the lunch trays were being passed at that time and that the male staff washed the residents' hands and had to finally say, This is too far gone, and it's an infection control issue and had to leave the resident to finish his tasks. The anonymous person stated that Resident #2's behavior was recurring and had been happening for a long time where it had been reported but not documented or addressed. The anonymous person stated that the resident was not on any type of isolation or monitoring. During an interview on 01/07/2026 at 11:52 a.m. LVN B stated she had been a unit manager with the facility for about 9 months. She stated that she was somewhat familiar with Resident #2 and had been called to his room the week prior by PTA to look at the resident's fingernails. She stated it looked like the resident had dried up chocolate under his fingernails, hands, and mouth. She stated the resident was drooling and she saw it on his pillow. She stated she called an aide who she could not recall their name to help clean him up the resident, change his brief, and realign him in bed, and ask if he needed to be changed again to press the call light. She stated she asked the resident what was under his nails, and he stated he had not known and then stated, Oh yea that is poop. She stated that she had not suspected that the substance was feces and had she known would have reported to LVN A. She stated then LVN A would have reported the incident to the resident's MD, RP, and for the resident to receive redirections on following infection control protocols. She stated that the resident had to be redirected often because he would forget that he needed his brief changed and would lay in the soiled brief calmly without notifying his care staff. She stated that she had not notified the resident's MD of the incident as she was just pulled off the floor, called into the resident's room to assist and assumed that information was already relayed to the MD. She stated she believed she documented the incident in the progress notes on that data of the incident. During an interview on 01/07/2026 at 12:06 p.m. Physical Therapist Assistant (PTA) stated he had worked for the facility for the last 3 months from 6:00 a.m. to 2:00 p.m. PTA stated on 12/29/2025 during lunchtime he entered Resident #2's room to get him up for therapy services. He stated he observed the resident lying in bed with soiled hands. He stated that he came closer to the resident and could smell the odor of feces then immediately noticed a brown tinge in the resident's mustache, beard and chin. He stated then the resident opened his mouth, and he could smell the odor of feces and could additionally see it on the side of his mouth and in his teeth. He stated he immediately informed LVN B who he felt was a good nurse to leave that information with and LVN B then informed LVN A. He stated he wore gloves and used sanitation wipes to wash the resident's hands and fingernails. He stated he disposed of the wipes in the trash and washed his own hands in the resident's bathroom. He stated Resident #2 told him that he had reached back into his brief, brought his hand around and had not realized that his hands had gotten soiled with feces. He stated that he saw the resident a few times a week for therapy services in the room. He stated he had not felt the resident had mental cognition to inform staff he needed his brief changed. He stated when he returned to the rehab department, he informed the Director of Rehabilitation (DOR) of the resident incident. He stated he had not had an in-service training on infection control since being employed, and felt the facility needed to do better on their infection control practices and monitoring. During an interview on 01/07/2026 at 12:37 p.m. DOR stated she had worked for the facility for 2-years. She stated that DON, ADM, MDS, ADON, and herself had an internal department team meeting on 01/05/2026 to discuss Resident #2's issues with digging in his brief. She stated she had not been made aware of the resident's behavior by PTA for digging in his brief. She stated that the facility had put monitoring in place as an intervention for Resident #2's behavior. She stated that the resident had not been at the facility long and she had previously observed the resident eating in the dining room with no issues. During an interview on 01/07/2026 at 02:59 p.m. Family A stated Resident #2 had received psychiatric services in the past, and saw a psychiatric physician every 3 months for medications for his current diagnosis. She stated that the facility had not informed her of any incidents of the resident outside of a recent fall on 01/05/2025. She was not aware of any past or present abnormal behaviors with the resident other than him losing his will to walk and take care of himself. During an interview on 01/07/2026 at 03:35 p.m. Assistant Director of Nursing (ADON) stated that she was the infection control preventionist (IP) and was informed on 01/04/2026 that Resident #2 had smeared feces, but on 01/07/2026 learned he had placed feces in his mouth and beard. She stated LVN B had told her that Resident #2 had dug in his soiled brief and had BM on his hand. She stated LVN B made him clean his nails and face. She stated on 01/04/2026 the staff were educated on redirecting the resident the best they could and on that same date Resident #2's care plan was updated to reflect that the resident smears feces. She stated knowing the resident's behavior had changed, his MD would be contacted for a psychiatry service evaluation referral, progress notes updated reflecting the incident, the RP contacted and asked whether they were aware of this behavior to understand if it had gone on in the past. She stated that staff would increase rounds to monitor Resident #2 for increased behaviors and check his brief more frequently. She stated it would have been her expectation that staff report such incidents to herself, the DON, and the resident's nurse. She stated that resident's care plan should note the incident. She stated the facility should ensure the resident followed the infection control protocols and ensure Resident #2 was not at risk for illness and disease. She stated that the facility had in-service training on infection control monthly and as needed. During an interview on 01/07/2026 at 03:45 p.m. MDS nurse stated that she had been made aware on 01/04/2026 that Resident #2 had been smearing his feces and she care planned that behavior that same date. She stated had she known he had feces in and around his mouth she would have called an IDT care conference meeting with all the department head managers to make the physician, and family aware and educate Resident #2 on the importance of infection control preventions method. She stated that an IDT meeting will be conducted and staff in-serviced on infection control and reporting a residents change in condition. Record review of policy titled Policies and Procedures Infection Control Program with revised date of 06/2024 reflected: The Facility will establish a comprehensive infection control program encompassing essential elements to safeguard the health and safety of residents, staff, and visitors. The Facility is dedicated to maintaining a safe and healthy environment by implementing an effective infection control program that adheres to state and federal regulations and follows evidence-based practices recommended by the Center of Disease Control (CDC).Program Objectives The program's objectives encompass key infection control ideologies: prevention, identification, reporting, investigation, and control of infections and communicable diseases among residents, employees, and visitors. The Facility promotes awareness and adherence to infection control practices through the Infection Control Committee. The Facility will continually monitor and evaluate the effectiveness of infection control practices through the Quality Assurance and Performance Improvement (QAPI) process.Infection Control Committee The Infection Control Committee is tasked with ensuring compliance with policies and procedures, reviewing data and trends related to infections, conducting training and education sessions, performing audits to assess adherence to standards, and continuously monitoring and evaluating the effectiveness of infection control measures. The committee includes the Infection Preventionist, Medical Director, Administrator, Nursing Leadership including the Director of Nursing, Maintenance, Housekeeping, and Dietary. The committee meets monthly through the Quality Assurance Process. The committee plays a pivotal role in promoting a safe and healthy environment for residents, staff, and visitors by overseeing all aspects of infection prevention and control within the facility.Infection PreventionistThe Facility will designate an Infection Preventionist.FunctionsSurveillanceCollect, analyze, and provide data trends, to include line listings of infections within the facility.Conduct regular surveillance of infections within the facility.Use standardized definitions and criteria for identifying infections.Maintain records of infection rates and trends.ReportingFollowing reporting guidelines for notifiable conditions.Provide regular reports to the Infection Control Committee and facility administration.Education/TrainingThe Infection Preventionist will provide initial and ongoing infection control training for all staff, including competency assessments where indicated.The Infection Preventionist will use evidence-based practices to educate all staff members within their respective departments.Quality Assurance Performance ImprovementInfection prevention and control is a key component of the facility's Quality Assessment and Performance Improvement (QAPI) program, with regular reports submitted to the QAPI committee. Infection prevention and control rounds and audits are conducted to evaluate the quality of care provided, and improvement actions are implemented as needed.

Based on observation, interview and record review, the facility failed to report an allegation of abuse to the state survey agency within 5-working days of the incident for 1 (Residence #1) of 3 residents reviewed for abuse. On 01/01/2026 Certified Nursing Aide (CNA) A failed to report verbal abuse to abuse coordinated immediately or within 2-hours that CNA B had cursed and threatened Resident #1 on 12/31/2025. These deficient practices could place residents at risk for abuse, neglect, exploitation, and/or mistreatment. Findings included:Record review of Resident #1's Facesheet generated on 01/04/2026 at 10:27 a.m. reflected an [AGE] year-old who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include vascular dementia (problems with blood flow to the brain leading to changes in memory, thinking, and behavior), severe, with anxiety (feeling of worry, nervousness, or unease), dysphagia (difficulty swallowing), oropharyngeal phase (challenges transferring food from the mouth to the throat), hypertension (the force of blood against the artery walls is consistently too high), hyperlipidemia (high levels of fat in the blood, increasing the risk of heart attack or stroke), cognitive communication deficit (condition that affects an individual's ability to communicate effectively due to impairments in cognitive processes such as attention, memory, reasoning, and problem-solving), depression (persistent feelings of sadness, loss of interest, and range of emotional and physical problems), anxiety disorder (excessive and persistent worry and fear), post-traumatic stress disorder (a mental health condition that's caused by extremely stressful or terrifying events), chronic, ataxic gait (lack of coordination and balance), other lack of coordination, psychotic disorder (severe mental health condition characterized by a disconnection from reality, which manifests as hallucinations) with delusions due to known physiological condition, and restlessness and agitation. Record review of Resident #1's Minimum Data Set (MDS) dated [DATE] reflected the resident's brief interview for mental status (BIMS) score was of 03 out of 15. A score of 0 to 7 suggests severe cognitive impairment. A score of 15 indicates intact cognitive function. Record review of Resident #1's Care plan reflected:Focus: Resident #1 had episodes of behaviors and was at risk for further increased episodes and injury:07/29/2024 Cursing and yelling at roommate, he does not want roommate, thinks it is his room only08/14/2024 Walked up to female resident and hit her in the face.08/23/2024 Hit another resident on rt shoulder 09/29/2024 Hit another resident with open hand to back of head.10/2/2024 Hit another resident in forearm 08/26/2024 Walking in secured unit cursing, attempting to hit staff.10/30/2024 Resident went into another resident's room, sat on her bed and pulled her hair.01/2/2025 Pushed another resident on the shoulder.04/14/2025 Resident will sometimes get on floor with his blankets instead of getting in bed to sleep.06/12/2025 Yelling and attempting to hit at another resident. No contact occurred.09/16/2025 Swinged fist at nurse on unit. 10/16/2025 Pushed another resident's breakfast tray. Attempted to redirect.Date Initiated: 07/16/2024.Goal: Resident #1 will decrease behavioral episodes through behavioral monitoring and interventions through target date of 12/18/2025. Date initiated/revisions: 07/02/2024.Interventions/Tasks: 01/02/2025 Medication evaluation by psych services, date initiated on 01/03/2025.01/02/2025 Separate residents, date initiated on 01/03/2025.10/03/2024 Sent to Veterans Administration (VA) emergency room (ER) for evaluation, returned same day. Psych services notified, labs ordered, VA case manager notified, Ombudsman notified, date initiated on 10/03/2024.10/30/2024 Attempt to move to quieter area, distract with conversation, date initiated on 10/31/2024.Focus: Resident #1 requires a secure unit, date initiated on 07/16/2024.Goal:Resident's safety would maintain through appropriate supervision and a structured/supportive environment through the review date of 12/18/2025, date initiated on 07/16/2024.Interventions/Tasks:Administer medications as ordered, date initiated: 07/16/2024.Behavior Control: utilize techniques such as redirection, distraction, and calming, date initiated on 07/16/2024.Encourage the resident to participate in ADL care as indicated date initiated on 07/16/2024.Monitor and encourage adequate fluid intake throughout the day, date initiated on 12/01/2025Monitor for changes in the resident's routine and report to the Physician as needed, date initiated on 07/16/2024.Plan and facilitate activities that are meaningful and appropriate for the resident's cognitive and physical abilities, date initiated 12/01/2025.Promote a consistent daily routine for structure and predictability in the resident, date initiated on 07/16/2024.Focus:Resident #1 had impaired cognition and was at risk for further decline and injury r/t neurocognitive deficits.Medication to slow disease process, date initiated/revision on 08/16/2024.Goal:Resident #1 will be met and dignity maintained over the next 90 days/target date of 12/18/2025, date initiated/revised on 08/16/2024. Revision on: 08/16/2024.Interventions/Tasks:Allow time for tasks and responses, date initiated: 08/16/2024.Explain all procedures using terms gestures the resident can understand date initiated 08/16/2024.Involve in care to maintain or increase level of independence, date initiated: 08/16/2024.Praise for tasks the resident completes, date Initiated: 08/16/2024.Repeat information as needed, date initiated 08/16/2024.Focus: Resident received anticoagulant therapy and was at risk for increased bleeding and bruising et cetera (etc.), date initiated 08/16/2024.Goal:Resident would be free of complications of increased bleeding, bruising etc. over the next 90 daysInterventions/Tasks:Encourage resident to be as active as possible Date Initiated: 08/16/2024. During an observation on 01/04/2026 at 03:50 p.m. Resident #1 sat on a couch watching television in the common area of the security unit with his arms crossed. Resident #1 did not respond to words or gestures when spoken to. During an observation on 01/04/2026 at 05:43 p.m. Resident #1 was lying on his bed facing the door. Between Resident #1's wrist and forearm, resident's arm had red, white, blue and black discoloration. Resident #1 did not respond to questions asked with neither words nor gestures. During an interview on 01/04/2026 at 05:14 p.m. CNA E stated that she had worked for the facility for 2 months on a 2 p.m. to 10 p.m. rotating shift on the secured unit. She stated that she had been responsible for Resident #1's care when she worked her shifts. She stated that the resident was easily provoked when presented with aggression and she had witnessed Resident #1 be physically aggressive towards another resident after the other resident bulled him. She stated that Resident #1 could be redirected, and he would walk away mumbling. During an interview on 01/04/2026 at 05:54 p.m. with Director of Nursing (DON) and Administrator (ADM) both stated in the course of investigating a reported incident on 01/04/2026, CNA B reported to them that on 01/01/2026 between her 10 p.m. to 01/02/2026 6 a.m. shift that CNA A came on to the secure unit and told her that while working the secure unit on 12/30/2025 and/or 12/31/2025 that CNA A had an encounter with Resident #1 where he had come around the nurse's station and tried to hit CNA A, and CNA A redirected Resident #1 by telling the resident, Mother fucker, you better not hit me or I'm going to show you. DON stated that both CNA B and CNA A were both suspended pending an investigation as of 01/04/2026. DON stated that CNA B was suspended for failure to report the allegation of verbal abuse timely and CNA A was suspended for verbal abuse. DON stated both CNAs received one-on-one (1:1) in-service training with the DON. DON stated that Resident #1 had been known to flare his arms uncontrollably to protect himself when he felt verbally or physically threatened. DON stated that he was also very sensitive to loud noises. DON stated that Resident #1 had been diagnosed with vascular dementia with anxiety, restlessness and agitation, post-traumatic stress disorder (PTSD), physical disorder with delusions, anxiety, and depression and was receiving the following medications: Risperidone, Divalproex Sodium, Memantine, and Trazodone. DON stated that Resident #1's last psychiatric services assessment was on 11/28/2025 and there were no changes to his medications at that time. DON stated that Resident #1's aggressive behaviors had improved substantially over time. DON stated simply giving the resident a cookie quickly settled him down. ADM stated that CNA A's employment status was pending termination due to the verbal abuse. ADM stated that CNA B was suspended for failure to report the allegation of verbal abuse immediately upon learning of the allegation and failure to report the change of condition to the nurse immediately upon observing Resident #1's arm discoloration. ADM stated that the facility conducted safety surveys in the secured unit with no witness to the allegations, and at that time Resident #1 seemed like his normal self. ADM stated they reported the incident to the local police authorities, resident's medical doctor (MD) and Family A. ADM stated that she was the facility's abuse coordinator. During an interview on 01/04/2026 at 06:43 p.m. Registered Nurse (RN) A stated she worked for the facility for 3-years. She stated Resident #1 was easily bothered by loud noises which caused him to become extremely agitated and exit seeking. She stated that he had PTSD from his war years in the Vietnam War. She stated he used to tell her stories about how he had been a tunnel rat (courageous soldiers in the Vietnam War, who crawled into enemy tunnel systems to clear them of troops, booby traps, and intelligence, armed with little more than a pistol, flashlight, and knife, facing extreme claustrophobia, deadly traps, and close-quarters combat in the dark, making it one of the war's most terrifying roles). She stated that keeping his space quiet kept the resident calm. She started her 01/03/2026, shift at 6 a.m. as the nurse for the secure unit. She stated while rounding/checking on residents found at 06:30 a.m. that Resident #1 had bruising on his right wrist up his forearm with a paler white in between the discoloration. She asked the resident what happened to his wrist, but he had not provided her with an explanation. She stated she had not believed the resident was aware of how the bruise had occurred. She stated that she immediately reported the incident to DON and resident's MD. She stated that she had not received any information on how the bruising could have come about. She stated that she was familiar with CNA A as being the CNA that last worked the overnight shift in the secure unit from 10 p.m. to 6 a.m. on 12/31/2025 into 01/01/2026. She stated because they worked different shifts, she was not familiar with CNA A's work ethics or personality. During an interview on 01/04/2026 at 07:13 p.m. RN B stated she worked for the facility for 2-years off and on as the nurse for the secure unit and the front half of Hall-1 from 6 p.m. to 6 a.m. She stated she last came on shift on 01/03/2026 and was informed by RN A that Resident #1 had a reportable incident and was asked had anything occurred on the unit that could have caused the bruising. She stated she was not aware after being off on 01/01/2026 and 01/02/2026. She stated she had last worked on 12/31/2025 into 01/01/2026. She stated as a result of the celebration of the 2026 new year fireworks and gunshots were going off throughout the shift in the facility's neighborhood making the residents on the secure unit extremely agitated and restless, and stated that Resident #1 was no exception. She stated Resident #1 was nonverbal and had a diagnosis of dementia and on 12/31/2025 he was having a bad evening pacing back and forth exit seeking. She stated she passed him cookies and water both shifts to try and calm his agitation. She stated that CNA A worked from 6 p.m. to 6 a.m. both 12/30/2025 and 12/31/2025 and the facility was short staffed, and CNA A had to cover half the residents outside of the secure unit in addition. She stated that CNA A had a loud and assertive personality and Resident #1 had not been fond of CNA A who was too loud for him. She stated on 12/31/2025, CNA A reported to her that Resident #1 would not go to sleep and continued to pace amongst the other residents. She stated that CNA A had expressed on many occasions that she was not happy working the secure unit. She stated that it takes a certain type of individuals to work with dementia patients and did not believe CNA A was one of them. She also stated that she had to redirect CNA A on both the 12/30/2025 and 12/31/2025 shifts to not leave the unit without letting her know to cover the residents. She stated that the residents in the secure unit have PRN medications that can be given if they exhibit behaviors of agitation. She stated that CNA A had not asked for any of the residents to receive PRN medication to calm their aggression or restlessness. During an interview on 01/06/2026 at 11:36 a.m. CNA A stated that she had worked for the facility since 2022 on a rotating 10 p.m. to 6 a.m. shift. She stated she last worked 01/02/2026 and 01/03/2026 on Hall-3 which was her normal and preferred hall to work. She stated she last worked the secure unit and half of Hall-3 on 12/30/2025 and 12/31/2025. She stated on that shift she was responsible for caring for a total of 30-residents as they were short-staffed those evenings. She stated those were a lot of residents to care for by herself, especially because in celebration of the 2026 new year, fireworks and gunshots were going off all throughout the shifts in the facility's neighborhood making the residents on the secure unit extremely agitated and restless. She stated that she had to remain behind the nurse's station most of the evening because every resident was on the floor pacing and searching for an exit. She stated that Resident #1 was no exception and felt like she was trying to attack him as he would come up to her and bang on the desk. She stated she felt safe because the desk kept enough space between her and the residents. She stated in addition the residents were going into each other's rooms and the common areas and picking up items they would not normally touch, hitting on the exit door, and she had to constantly redirect them from running and bumping into each other, and swing their arms towards her and the computer where she was charting. She stated that she informed RN B of the residents' behaviors and RN B only advised her to keep moving and keep redirecting them. She stated at one point she had to take the computer back to RN B to keep the residents from breaking. She stated she had to leave the secure unit several times to check on, reposition, and change the residents on Hall-3. She stated that she would alert RN B that she was leaving the hall but could not say if RN B stayed in the hall while she was gone. She stated when she returned to shift on 01/02/2026 she worked on Hall-3 and CNA B was working the secure unit. She stated on that shift she told CNA B about how crazy 12/31/2025's shift was as all the residents on the secure unit were awake and exit seeking through the whole shift and how it had never been that busy of an evening. She stated while she was sharing the story with CNA B, CNA stated cuss words may have been used to describe the events of the evening but not used to cuss or threatened to hurt Resident #1 if he hit her or any of the residents. She stated at no time had Resident #1 attempted to hit her or flare his arms near her by accident or on purpose where she would have had to protect herself, nor was she aware if he had hit himself, others, or others hit him where he could have bruised his wrists. She stated she was familiar with the aspects of abuse and named: financial, verbal, physical, mental, and sexual as forms of abuse. She stated that she had an in-service training on abuse, neglect, and exploitation (ANE) almost once every month. She stated she received a call on 01/04/2026 just before her shift that she was being suspended pending an ANE allegation and on 01/06/2026 received another call from the ADM that she had been terminated related to allegations of ANE. She stated that she had never had a write up or been fired from a job and had never been accused of ANE. During an interview on 01/06/2026 at 12:14 p.m. CNA B stated she worked for the facility since 10/20/2023 and worked the 10 p.m. to 6 a.m. shift on the secure unit. She stated she had been off shift last working before 12/25/2025. She stated she returned to work on 01/02/2026 at 10 p.m. and while on shift CNA A told her that on 12/31/2025 the shift CNA worked while on the secure unit was crazy. CNA B stated CNA A stated Resident #1 was upset and came around the desk raised his hand up and tried to hit CNA A. CNA B stated CNA A told Resident #1, Mother Fucker, you better not hit me. She stated Resident #1 had not been known to be aggressive, unless he was irritable or provoked to act aggressive. She stated on 01/02/2026 around 11 a.m. she received a text message from DON asking her about any incident that occurred with Resident #1. She stated she then texted DON back sharing what CNA A had cussed at and threatened Resident #1 on shift 12/31/2025. She stated that she and CNA A were suspended and taken off the schedule pending an investigation. She stated that she should have reported what CNA A had cussed and threatened Resident #1 immediately and stated she was not sure why she had not. She stated that she normally reported every little thing. She stated that forms of ANE were physical, emotional, verbal, and, financial and she received in-service training on ANE all the time. She stated she was suspended for failure to report and document the verbal abuse. She stated she had never been written up or had any disciplinary action. During an interview on 01/06/2026 at 01:05 p.m. MD stated that he was Resident #1's physician. He stated that the resident had sensitivity to noise, yelling, and commotion. He stated those factors triggered the resident's PTSD causing the resident to feel threated and he would become aggressive and lash out verbally aggressive towards others. He stated the resident was under the care of a physiatrist who was managing the resident's behaviors with Risperidone, Divalproex Sodium, Memantine, and Trazodone. He stated that the resident was redirectable, but if provoked as proven on event from 12/21/2025 when another resident bullied him, and he physically lash out. He stated the facility informed him that Resident #1 had bruising to the right wrist on 01/04/2026. He stated that he had prescribed Resident #1 aspirin which could contribute to easy bruising. He stated the facility was unable to determine how the resident obtained the bruising but if a staff member had aggressively approached the resident, he had the tendency to swing his arms in a protective manner and could have hit his arm or wrists on something. He stated fireworks and gunshots sounds would trigger that resident's fight and flight response which could result in aggressive behavior. During an interview on 01/06/2026 at 01:28 p.m. Resident #1's Family A stated that she had been informed that the resident had bruising on his wrist, but that the facility had not been able to determine what had been the cause. She stated that the resident had been known to lose his balance often causing many injuries over the years. She stated that if anyone displayed dominant over the resident it would trigger the resident's PTSD from his days as a Vietnam soldier. She stated the resident would begin to fear he was back in battle again. She stated that the resident was not on blood thinners and had been known to easily bruise. Record review of Resident #1's Progress Notes dated 01/03/2026 at 07:00 a.m. completed by RN A reflected: Observed while making rounds on secure unit, Resident #1 in his room lying on his left side with his right arm lying next to his face, no blanket on resident. Observed a purple area on the top of resident's hand to the wrist then a white area and at the wrist to forearm a purple area. No open area, no edema, no pain, and Resident #1 stated he did know how discoloration occurred. Injury Type: bruising to back of right hand. Record review of Resident #1's Change of Condition Communication dated 01/03/2026 at 07:00 a.m. completed by RN A reflected Resident had a change in condition to skin on his right arm. What occurred: While making rounds observed resident in secure and was lying on his left side facing the door in his bed with his right arm lying next to his face. Observed the right arm had a purple color from the top of the hand to the wrist then a white area and then a purple color on the forearm. Asked resident how he got discoloration, resident stated he did not know. Asked if the area was painful resident stated no. RP notified at 07:15 a.m. MD notified at 09:30 a.m. and x-rays performed. Record review of Resident #1's Skin assessment dated [DATE] at 07:16 a.m. completed by RN A reflected Resident #1's skin was intact, right hand to forearm was purple in color. Area on top of hand by the wrist was white in color and below that, a purple area on forearm below the wrist. No open area and no edema to skin area. Record review of Resident #1's Pain assessment dated [DATE] at 07:16 a.m. completed by RN A reflected Resident #1 was checked for non-verbal sounds for example. (e.g.), crying, whining, gasping, moaning, or groaning), vocal complaints of pain (e.g., that hurts, ouch, stop), and facial expressions (e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw). Resident stated he does not have pain. Record review of Resident #1's radiography (x-ray) dated 01/03/2026 to right forearm, lateral views of the right forearm demonstrate a diffuse osteoporosis (loss of bone density). There is no dislocation or fracture. No bony erosion or destruction is present. The soft tissues are unremarkable. There is no radiopaque foreign body. Impression: The bones are osteoporotic. There is no dislocation or fracture. Record review of Resident #1's Orders reflected:- RisperDAL Oral Tablet 1 milligrams (mg) (Risperidone) to be given 1.5 tablet by mouth at bedtime related (r/t) to psychosis, start date 11/05/2025.- Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) to be given 2 capsule by mouth 3 times (x) a day for behavior, start date 10/15/2025.- Memantine HCl tablet 10 mg to be give 10 mg by mouth 2x a day for neurocognition, start date 07/10/2025. - Donepezil HCl Oral Tablet 10 MG (Donepezil Hydrochloride) Give 1 tablet by mouth at bedtime for neurocognitive, start date 07/10/2025.- TraZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 25 mg by mouth every 12 hours as needed (prn) for major depressive disorder, start date 10/21/2025. Record review of text messages from DON's phone to CNA B on 01/03/2026 reflected CNA A worked the secure unit on 01/01/2026 from 10:00 p.m. to 6:00 a.m. and CNA A came onto the secure unit during that shift and explained that during CNA A's shift 12/30/2025 and 12/31/2025 from 10 p.m. to 6:00 a.m., CNA A had an encounter with Resident #1 trying to hit CNA A when CNA A was behind the desk. CNA B further explained that CNA A had to redirect Resident #1 back to the other side of the desk and told Resident #1 he better not hit CNA A. CNA B stated CNA A told Resident #1, Mother fucker you better not hit me or I'm gonna show you. Record review of text messages from DON's phone to CNA A on 01/03/2026 reflected CNA A was not aware of any bruising on Resident #1 on 12/30/2025 and 12/31/2025. Record review of CNA B's 01/03/2026 statement to the facility reflected that on she worked on the secure unit 01/01/2026. On 01/02/2026 she noticed bruising to Resident #1's right forearm while providing care. She stated she assumed the bruising was old and therefore had not reported the bruising. Record review of CNA A's criminal background check reflected the facility last performed a check on 10/03/2025 finding no results found. Record review of CNA B's criminal background check reflected the facility last performed a check on 07/18/2025 finding no results found.

Based on interview, and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Based on interview, and record review, the facility failed to notify the resident's physician, as applicable, promptly after a significant change in the mental or physical condition of a resident who had mental illness or intellectual disability for 1 of 3 residents (Residents #1) reviewed for Significant Change Notification. The facility failed to notify the medical doctor (MD) after Resident #2 was found with feces in/on his mouth. The facility failed to document Resident #2 having feces in/on his mouth. This failure could place residents requiring psychiatric services at risk of not having their special needs assessed and met by the facility.Findings include: Record review of Resident #2's Facesheet generated on 01/04/2026 reflected a [AGE] year old male who admitted to the facility on [DATE] as his own responsible party (RP) with medical diagnoses including gastro-esophageal reflux disease (a condition where the stomach acid frequently flows back into the esophagus (canal that connects the throat to the stomach), irritating its lining, causing symptoms like heartburn, regurgitation (food/fluid coming up), schizoaffective disorder (a mood disorder featuring periods of hallucinations, delusions, and disorganized thinking) depressive type, cognitive communication deficit (difficulty speaking, listening, reading, or writing due to impaired thinking skills like memory, attention, problem-solving, and organization), and bipolar disorder (a serious mental illness causing extreme shifts in mood, energy, and activity levels, ranging from manic highs (euphoria, irritability, high energy) to depressive lows (sadness, hopelessness, low energy). Record review of Resident #2's Minimum Data Set (MDS) dated [DATE] reflected the resident's Brief Interview for Mental Status (BIMS) was an 11 out of 15 reflecting Resident #2 had moderate cognition impairment. (A score of 13-15 would indicate intact cognition.) He received a Preadmission Screening and Resident Review (PASRR: in-depth assessment reviews records, interviews individuals/families, and involves mental health/intellectual development professionals to create personalized placement and treatment plans) positive level II (suspicion of serious mental illness). He required assistance with toileting and was incontinent for both bladder and bowel. Record review of Resident #2's Care Plan reflected:Focus:Resident #2 had a PASRR positive status related (r/t) to signs and symptoms of severe mental illness on admission, revision date of 12/29/2025. (The Care Plan had not reflected focused behaviors r/t to digging in his brief, eating or smearing feces.)Focus:Resident #2 was at risk for further increased episodes and injury behaviors of smearing his feces.Goal: Through behavioral monitoring and interventions, Resident #2 will have decreased behaviors and episodes, dated 01/04/2026.Interventions/Tasks Encourage:Resident #2 will be explained procedures by using terms/gestures the resident can understand and encouraged to attend social activities of preference, report progression/declines to MD for psychiatric consultants as ordered in resident's chart. Record review of Resident #2's Progress Note dated 01/05/2026 at 08:45 p.m. reflected Nurse Practitioner (NP) performed an evaluation with Resident #2 with a chief complaint of diarrhea. Record review of Resident #2's Progress Note dated 01/05/2026 at 08:53 p.m. reflected MD ordered Resident #2 receiving monitoring for signs of dehydration and/or electrolyte imbalance, after reporting loose stools approximately once daily. Labs were ordered on 01/05/2026 to include a comprehensive panel to assess electrolyte status, to continue current treatment and monitor for improvement. During an interview on 01/07/2026 at 01:12 p.m. Resident #2 stated he had been experiencing repeated days of diarrhea and on occasion dug in his soiled brief in the back due to discomfort. He stated afterwards that his hands and fingernails were found to be soiled with feces, and he had rubbed his face, beard, sides of his mouth and maybe placed his hands in his mouth with his soiled hands. He stated that behavior had been an ongoing habit, and he was unaware when his hands were soiled with feces until after he had already but his hands in his mouth. He said he could not recall care staff being called to assist him with his soiled hands or brief but stated that he would be cleaned by the staff once they discovered him soiled. During an interview on 01/04/2025 at 05:54 p.m. with Administrator (ADM) and Director of Nursing (DON) both stated that they were not aware of any issues reported to Resident #2's MD for feces on/in his mouth from digging in his soiled brief. DON stated that the resident had schizoaffective, anxiety, and bipolar disorders and from her knowledge had been doing well at the facility. DON stated that now that they had been made aware of the resident's behavior, they needed to determine whether the behavior was a one-time occurrence or repeated behavior. She stated that if the behavior was repeated, his care plan should reflect the behavior to make other staff aware. During an interview on 01/04/2026 at 7:05 p.m. Medication Aide (MA) stated that on 01/02/2026 sometime between her shift of 2:00 p.m. to 10:00 p.m. (exact time unknown) while passing medication to Resident #2's she observed Resident #2 place his hand in his adult brief and pulled up feces. She stated then she observed Resident #2 attempting to place that soiled hand into his mouth. She stated that she immediately intervened and asked the resident What are you doing? You are not about to eat that are you? referring to the resident placing his feces into his mouth. She stated he stopped and then she left the room to locate his CNA, but she was assisting another resident, so she returned to the resident's room and washed his hands and changed his brief. She asked the resident again about placing his soiled hands in his mouth, and the resident asked her what was talking about? She stated the resident seemed confused by her questions as if the incident had not taken place. She stated she had not documented or reported the incident to anyone because she thought his behavior had already been reported and care planned. She stated that she should have reported the incident to LVN A who was his charge nurse due to infection control issues and maintaining the resident's dignity and respect. She stated that she received a training in-service on reporting changes in conditions, residents' dignity and respect, and infection control on 01/04/2026. She stated failing to report Resident #2's behavior could continue the behavior and place the resident and others at risk of illness and cross contamination. During an interview on 01/06/2026 at 04:42 p.m. LVN A stated she was Resident #2's nurse and worked for the facility for about a month on the 6:00 p.m. to 6:00 a.m. shift. She stated she had not been made aware of behaviors Resident #2 was exhibiting relating to him pulling feces out of his brief and placing his hand into his mouth. She stated had she been made aware, she would have reported the behavior to the DON, ADM and his MD as a change of condition and would have expected his MD to order a psychiatric evaluation. She stated the incident going undocumented and unreported placed the resident at risk for repeated behavior, illness, and infection, place the facility at risk for infection control and cross contamination issues, and further place the resident at risk for loss of dignity and respected. During a confidential interview at undisclosed time, an anonymous person stated Resident #2 had been known to have feces under his fingernails, on his hands, beard, sides of his mouth, and in his mouth and teeth. The anonymous person stated the incidents occurred sometime during the New Year's Day holiday week around lunch time meal pass. The anonymous person stated she could not provide specific dates/times. The anonymous person stated an unknown male staff reported to LVN B that Resident #2 was observed with feces in his mouth and in his beard, and on his hands. The anonymous person stated LVN B entered the resident's room and upon seeing the resident's condition said, Oh, I'm not dealing with that and walked out of the room. The anonymous person stated the incident was not further reported leaving the non-care staff to clean the resident's hands, but eventually, that male staff said, This is too far gone, and it's an infection control issue and had to leave the resident to finish his tasks. The anonymous person stated that Resident #2's behavior had been a recurring event that had gone on undocumented and without any type of isolation or monitoring. During an interview on 01/07/2026 at 11:52 a.m. LVN B stated that about a week ago Physical Therapist Assistant PTA asked her to observe Resident #2's fingernails for what she thought was chocolate dried under his fingernails. She stated upon observing the resident she again stated he had what appeared to be chocolate under his nails, and on his hand, and on and around his mouth. She stated the resident was drooling and saw some of the same chocolate on his pillow. She stated she called an aide whose name could not be recalled to help clean up the resident and change his brief. She stated she educated the resident about pressing his call light when he needed changing and asked the resident what was under his fingernails. She stated at first the resident responded that he had not known and then stated to her, Oh yea that is poop. She stated that she had not suspected that the substance was feces and had not sensed an odor of feces when cleaning up the resident. She stated had she known that the resident had feces on his hand or face she would have reported to LVN A who was the resident's nurse. She stated that incident would be considered a change in condition and required immediate reporting to the resident's MD and RP. She stated interventions would then be put in place for Resident #2 to be redirected following the infection control policy. She stated that the resident had to be redirected often about notifying staff when he had a soiled brief so he could be changed. She stated she believed she documented the incident in progress notes but could not recall the date or time. on that date but stated that she had not reported the incident to the resident's MD because she was pulled into his room to assist and was sure if that was behavior that required reporting, LVN A would have already had reported. During an interview on 01/07/2026 at 12:06 p.m. PTA stated on or about 12/29/2025 during lunchtime he entered Resident #2's room for therapy services and observed the resident in bed with what appeared to be feces on his hand. He stated that he came closer and could smell the odor of feces from the resident and then noticed a brown tinge in the resident's mustache, beard and chin. He stated then the resident began speaking and he saw more feces in the resident's mouth and teeth and the odor of feces increased. He stated he immediately searched for a nurse finding LVN B who he felt was a reliable nurse to share his finding. He stated LVN B observed the resident and left the room stating she was reporting the incident to LVN A. He stated no one returned to clean the resident and lunch trays were being passed so he put on gloves and used sanitation wipes to clean resident's hands and fingernails. He stated while cleaning, Resident #2 told him that he had reached back into his brief, brought his hand around and had not realized that his hands had gotten soiled with feces. He stated he disposed of the wipes in the resident's bathroom trashcan, washed his hands, and left the resident returning to the rehab department. He stated he informed the Director of Rehabilitation (DOR) of the incident. He stated he had not had an in-service training on infection control since being employed, and felt the facility needed to do better on their infection control monitoring and practices. He stated he had not felt the resident had the mental cognition to inform staff when he soiled his briefs and saw the resident a few times a week for therapy services in the resident's room. He stated that the resident was not compliant with therapy services, and he had to continuously motivate the resident to get him out of bed. He stated that OTA and himself assisted with feeding residents during meals and stated that this was not the first incident where the resident was found with feces on his hand. During an interview on 01/07/2026 at 12:37 p.m. DOR stated that she had not been made aware of Resident #2 digging in his soiled brief by PTA. She stated on 01/05/2026 the facility had an interdisciplinary team (IDT) meeting which consisted of DON, ADM, MDS, and herself to discuss Resident #2's issue of digging in his brief. She stated that the facility had set additional monitoring in place as an intervention for Resident #2's behavior. She stated that the resident had not been at the facility long and she had previously observed the resident eating in the dining room with no issues. During an interview on 01/07/2026 at 02:59 p.m. Family A stated that the facility had not informed her of any incidents relating to Resident #2 outside of a recent fall on 01/05/2026. She stated she was not aware of any past or present abnormal behaviors with the resident other than losing his will to walk and take care of himself. She stated that the resident had received psychiatric services in the past and saw a psychiatric physician every 3 months for medications to treat some current diagnosis. During an interview on 01/07/2026 at 03:35 p.m. Assistant Director of Nursing (ADON) stated that on 01/04/2026 ADM and DON informed her that that Resident #2 had smeared his feces, not knowing until 01/07/2026 at 03:35 p.m. feces was in/on his mouth and beard. She stated LVN B had apparently told LVN A that the resident had placed his hand in his mouth after digging in his brief with bowel movement. She stated when LVN B confronted the resident about the behavior, he denied the event. She stated all she knew was LVN B made him clean his nails and face and then MDS care planned that he had smeared feces. She stated as the infection control preventionist (IP) she was informed and began in-service training on 01/04/2026 with the staff on infection control to educate on redirecting the resident the best they could. She stated knowing that occurrence makes the incident a change in condition and required his MD to be notified. She would expect the MD would refer the resident for a psychiatry evaluation. She stated that progress notes would be updated and reflect the behavior, and the resident's RP would be made known and asked if that was a previously known behavior to understand if it had gone on in the past. She stated that interventions were put in place to increase rounds to monitor resident for increased behaviors and assure his brief was changed more frequently to avoid the behavior. She stated it would have been her expectation that staff followed infection control procedures by reporting and documenting the incidents. She stated the risk of not reporting placed Resident #2 and other residents at risk for illness and disease. She stated that the facility had in-service training on infection control monthly and as needed. During an interview on 01/07/2026 at 03:45 p.m. MDS stated on 01/04/2026 she had been made aware that Resident #2 had smeared his feces and updated his care plan to reflect that behavior on 01/04/2026. She stated she had not known that resident had feces in and around his mouth she would have called an IDT care conference meeting with all the department head managers to discuss the behavior and make both the physician and family aware. She stated that Resident #2 would receive education on the importance of infection control, and the IDT will be conducted an all-staff in-service on reporting a residents change in condition infection control. Record review of policy titled Nursing Policies and Procedures with revised date of 06/2019 reflected: Subject: Change in Condition Communication: Policy:To improve communication between physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition, and provide guidance for the notification of patients/residents and their responsible party regarding changes in condition.Procedures:Complete assessment of the patient/resident which may include but is not limited to: A. Patient/resident name, age, primary diagnosis.Notify the physician of the change in medical condition. (The physician notification grid may be used as a reference tool regarding acceptable notification timeframes.} The nurse will document all assessments and changes in the patient's/resident's condition in the medical record.If the physician does not respond within an acceptable time frame, the Medical Director and Director of Nursing will be notified. The Medical Director will provide medical orders as necessary to treat the patient's/resident's condition.The patient/resident and patient's/resident's family member/legal representative will be notified of any changes in medical condition or treatment plan as indicated by Health Insurance Portability and Accountability (HIPAA) directives. Record review policy titled Policies and Procedures Standards of Care and revised date of 10/2023 reflected:PolicyThe purpose of this policy is to establish and maintain acceptable standards of care for all residents, ensuring their safety, well-being, and dignity are maintained.Procedure1. Health and Safety Standardsa. All care provided will comply with current guidelines, best practices, and Federal/State regulationsb. Infection control protocols will be strictly followed to prevent the spread of infectious diseasesc. Safety measures will be in place to prevent accidents and injuries, including fall prevention strategies and regular safety inspections2. Staff Training and Competencya. All staff will receive ongoing training to ensure they are knowledgeable and competent in their rolesb. Training will include, but is not limited to clinical skills, emergency procedures, communication skills, and resident rightsc. Staff performance will be regularly evaluated, and additional training will be provided as needed3. Quality Improvementa. A continuous quality improvement program will be in place to monitor and enhance quality of careb. Resident and family feedback will be sought and used to improve services and address any concernsc. Incident reports and care outcomes will be analyzed to identify trends and implement corrective action plans as needed ResponsibilityAll staff members are responsible for adhering to this policy and for providing care that meets these standards. The Administrator will oversee the implementation and compliance with this policy.

Based on interviews, and record review, the facility failed to ensure each resident was free from abuse for 1 of 3 residents (Resident #1) reviewed for abuse in that: The facility failed to ensure each resident was free from verbal abuse when CNA A cussed at and threatened Resident #1 on 12/31/2025. These failures placed residents, who resided in the facility, at risk of abuse, and mental anguish and fearfulness.Findings includedRecord review of Resident #1's Facesheet generated on 01/04/2026 at 10:27 a.m. reflected an [AGE] year-old who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include vascular dementia (problems with blood flow to the brain leading to changes in memory, thinking, and behavior), severe, with anxiety (feeling of worry, nervousness, or unease), cognitive communication deficit (condition that affects an individual's ability to communicate effectively due to impairments in cognitive processes such as attention, memory, reasoning, and problem-solving), anxiety disorder (excessive and persistent worry and fear), restlessness and agitation, post-traumatic stress disorder (a mental health condition that's caused by extremely stressful or terrifying events), chronic, ataxic gait (lack of coordination and balance), other lack of coordination, depression (persistent feelings of sadness, loss of interest, and range of emotional and physical problems), and psychotic disorder (severe mental health condition characterized by a disconnection from reality, which manifests as hallucinations) with delusions due to known physiological condition. Record review of Resident #1's Minimum Data Set (MDS) dated [DATE] reflected the resident's brief interview for mental status (BIMS) score was of 03 out of 15. A score of 0 to 7 suggests severe cognitive impairment. A score of 15 indicates intact cognitive function. Record review of Resident #1's Care plan reflected:Focus: Resident #1 had episodes of behaviors and was at risk for further increased episodes and injury:07/29/2024 Cursing and yelling at roommate, as resident does not want a roommate, and feels he should have a room to himself.08/14/2024 Walked up to female resident and hitting her in the face.08/23/2024 Hit another resident on their right shoulder.08/26/2024 Walking in secured unit cursing and attempted to hit staff.09/29/2024 Hit another resident with open hand to back of head.10/2/2024 Hit another resident in forearm.10/30/2024 Resident went into another resident's room, sat on her bed and pulled her hair.01/2/2025 Pushed another resident on the shoulder.04/14/2025 Resident will sometimes get on floor with his blankets instead of getting in bed to sleep.06/12/2025 Yelling and attempting to hit at another resident. No contact occurred.09/16/2025 Swinged fist at nurse on unit.10/16/2025 Pushed another resident's breakfast tray. Attempted to redirect.Goal: Resident #1 will decrease behavioral episodes through behavioral monitoring and interventions through target date of 12/18/2025. Date initiated/revisions: 07/02/2024.Interventions/Tasks: 01/02/2025 Medication evaluation by psychiatric services, date initiated on 01/03/2025.01/02/2025 Separate residents, date initiated on 01/03/2025.10/03/2024 Sent to Veterans Administration (VA) emergency room (ER) for evaluation, returned same day. Psych services notified, labs ordered, VA case manager notified, Ombudsman notified, date initiated on 10/03/2024.10/30/2024 Attempt to move to quieter area, distract with conversation, date initiated on 10/31/2024.Focus: Resident #1 requires a secure unit, date initiated on 07/16/2024.Goal:Resident's safety would maintain through appropriate supervision and a structured/supportive environment through the review date of 12/18/2025, date initiated on 07/16/2024.Interventions/Tasks:Administer medications as ordered, date initiated: 07/16/2024.Behavior Control: utilize techniques such as redirection, distraction, and calming, date initiated on 07/16/2024.Encourage the resident's participate in ADL care as indicated date initiated on 07/16/2024.Monitor and encourage adequate fluid intake throughout the day, date initiated on 12/01/2025Monitor for changes in the resident's routine and report to the Physician as needed, date initiated on 07/16/2024.Plan and facilitate activities that are meaningful and appropriate for the resident's cognitive and physical abilities, date initiated 12/01/2025.Promote a consistent daily routine for structure and predictability in the resident, date initiated on 07/16/2024.Focus:Resident #1 had impaired cognition and was at risk for further decline and injury r/t neurocognitive deficits.Medication to slow disease process, date initiated/revision on 08/16/2024.Goal:Resident #1 will be met and dignity maintained over the next 90 days/target date of 12/18/2025, date initiated/revised on 08/16/2024. Revision on: 08/16/2024.Interventions/Tasks:Allow time for tasks and responses, date initiated 08/16/2024.Explain all procedures using terms gestures the resident can understand, date initiated 08/16/2024.Involve in care to maintain or increase level of independence, date initiated: 08/16/2024.Praise for tasks the resident completes, date Initiated: 08/16/2024.Repeat information as needed, date initiated 08/16/2024.Focus:Resident received anticoagulant therapy and was at risk for increased bleeding and bruising et cetera (etc.), date initiated 08/16/2024.Goal:Resident would be free of complications of increased bleeding, bruising etc. over the next 90 daysInterventions/Tasks:Encourage resident to be as active as possible Date Initiated: 08/16/2024. During an observation on 01/04/2026 at 03:50 p.m. Resident #1 in secure unit, sitting calmly in common area watching television. Resident's arms crossed, no visible bruising noted. Resident #1 did not respond to words or gestures when spoken to. During an observation on 01/04/2026 at 05:43 p.m. Resident #1 lay in his bed awake facing the door. Observed Resident #1's wrist and forearm, resident's arm red, white, blue and black in color. Resident #1 did not respond to questions asked with neither words nor gestures. During an interview on 01/04/2026 at 05:14 p.m. CNA E stated that she had been employed with the facility for 2 months and worked a 2 p.m. to 10 p.m. rotating shift on the secured unit. She stated that Resident #1's was easily provoked when presented with verbal aggression and hostility. She stated she had witnessed Resident #1's physical aggressive towards a female resident just a few days prior after the female resident bulled him. She stated that Resident #1 was redirected, and he would respond by walk away mumbling. She stated she came on shift on 01/04/2026 and learned Resident #1 had bruising to his wrist but was unaware of how the bruising occurred. During an interview on 01/04/2026 at 05:54 p.m. with Director of Nursing (DON) and Administrator (ADM) both stated that at 01/03/2026 at 06:30 a.m. Registered Nurse (RN) A reported that Resident #1 had bruising to his right wrist. DON stated on 01/03/2026 course of investigating CNA B reported that on 01/01/2026 between her 10 p.m. to 01/02/2026 6 a.m. shift that CNA A came on to the secure unit and told her that while working the secure unit on 12/31/2025 that CNA A had an encounter with Resident #1 where he had come around the nurse's station and tried to hit CNA A. DON stated that CNA A redirected Resident #1 by telling the resident, Mother fucker, you better not hit me or I'm going to show you. DON stated that both CNA B and CNA A were suspended pending an investigation as of 01/04/2026. DON stated that CNA B had also observed bruising to the resident's right wrist on 01/02/2026 and failed to report the bruising to a charge nurse. DON stated that CNA B was suspended for failure to report the allegation of verbal abuse timely and CNA A was suspended for verbal abuse with termination pending. DON stated she provided both CNAs with one-on-one (1:1) in-service training. DON stated that Resident #1 had been known to flare his arms uncontrollably to protect himself when he felt verbally or physically threatened and he was very sensitive to loud noises. DON stated that Resident #1 had been diagnosed with vascular dementia with anxiety, post-traumatic stress disorder (PTSD), restlessness and agitation, physical disorder with delusions, depression, and anxiety. DON stated that Resident #1 received the following medications: Risperidone, Divalproex Sodium, Memantine, and Trazodone. DON stated that Resident #1's last had psychiatric services assessment on 11/28/2025 with no changes to his medications. DON stated that Resident #1's had aggressive behaviors that had improved substantially over time. DON started giving the resident a cookie quickly settled him down. ADM stated that CNA A's employment status was pending termination because of the allegation of verbal abuse. ADM stated that CNA B was suspended for failure reporting the allegation of verbal abuse and bruising to Resident #1's right wrist immediately upon learning of both events. ADM stated that the facility conducted safety surveys in the secure unit finding no witnesses nor other victims. ADM stated Resident #1 seemed like his normal self as of 01/04/2026 and had not expressed any pain. ADM stated that the resident does not have the mental capacity to provide a statement and had not expressed any pain or discomfort. ADM stated the incident was reported to the local law enforcement agency, the resident's medical doctor (MD) and Family A. ADM stated that she was the facility's abuse coordinator and that all allegations of abuse were to be reported to her immediately.During an interview on 01/04/2026 at 06:43 p.m. Registered Nurse (RN) A stated she worked for the facility for 3-years. She started her 01/03/2026, shift at 6 a.m. as the nurse for the secure unit. She stated while rounding/checking on residents found at 06:30 a.m. that Resident #1 had bruising on his right wrist up his forearm with a paler white in between the discoloration. She asked the resident what happened to his wrist, but he had not provided her with an explanation. She stated she had not believed the resident was aware of how the bruise had occurred. She stated that she immediately reported the incident to DON and resident's MD and began her skin and pain assessments. She stated Resident #1 was easily bothered by loud noises which caused him to become extremely agitated and exit seeking. She stated that he had PTSD from his war years in the Vietnam War. She stated he used to tell her stories about how he had been a tunnel rat (courageous soldiers in the Vietnam War, who crawled into enemy tunnel systems to clear them of troops, booby traps, and intelligence, armed with little more than a pistol, flashlight, and knife, facing extreme claustrophobia, deadly traps, and close-quarters combat in the dark, making it one of the war's most terrifying roles). She stated that keeping his space quiet kept the resident calm. She stated that she was familiar with CNA A as being the CNA that last worked the overnight shift in the secure unit from 10 p.m. to 6 a.m. on 12/31/2025 into 01/01/2026. She stated because they worked different shifts, she was not familiar with CNA A's work ethics or personality.During an interview on 01/04/2026 at 07:13 p.m. RN B stated she worked for the facility for 2-years. She stated she primarily worked the secure unit and the front half of Hall-1 from 6 p.m. to 6 a.m. She stated she last came on shift on 01/03/2026 and was informed by RN A that Resident #1 had a reportable incident, bruising to his right wrist. She stated she was not aware after being off on 01/01/2026 and 01/02/2026, last working 12/30/2025 and 12/31/2025 and had not received any reports of bruising to the Resident #1's wrist. She stated on 12/31/2025, New Year's Eve fireworks and gunshots were going off throughout the shift in the facility's neighborhood and the residents on the secure unit were extremely agitated and restless including Resident #1. She stated Resident #1 was nonverbal and had a diagnosis of dementia and on 12/31/2025 he was exit seeking and paced back and forth. She stated she passed him cookies and water both shifts to try and calm his agitation, with no avail. She stated that CNA A worked from 6 p.m. to 6 a.m. both 12/30/2025 and 12/31/2025. She stated the facility was short staffed both those shifts, and CNA A had to cover half the residents outside of the secure unit in addition to the secure unit residents. She stated that CNA A had a loud and assertive personality and Resident #1 had not been fond of CNA A who was too loud for him. She stated on 12/31/2025, CNA A reported to her that Resident #1 would not go to sleep and continued to pace amongst the other residents. She stated that CNA A had expressed on many occasions that she was not happy working the secure unit. She stated that it takes a certain type of individuals to work with dementia patients and did not believe CNA A was one of them. She also stated that she had to redirect CNA A on both the 12/30/2025 and 12/31/2025 shifts to not leave the unit without letting her know to cover the residents. She stated that the residents in the secure unit have PRN medications that can be given if they exhibit behaviors of agitation. She stated that CNA A had not asked for any of the residents to receive PRN medication to calm their aggression or restlessness. During an interview on 01/06/2026 at 11:36 a.m. CNA A stated that she had worked for the facility since 2022 on a rotating 10 p.m. to 6 a.m. shift. She stated she last worked the secure unit and half of Hall-3 on 12/30/2025 and 12/31/2025 and on 01/02/2026 and 01/03/2026 on Hall-3 which was her preferred hall to work. She stated on 12/30/2025 and 12/31/2025 the facility was short staffed, and she was responsible for caring for a total of 30-residents. She stated because of the New Years Eve holiday, fireworks and gunshots were going off throughout the shifts in the facility's neighborhood making the residents on the secure unit extremely agitated, restless, and exit seeking. She stated that she had to remain behind the nurse's station most of the evening because every resident on the secure unit was pacing and searching for an exit. She stated that Resident #1 felt like she was trying to attack him and he came up to her and banged on the nurse's station desk. She stated she felt safe because the desk kept enough space between her and the residents. She stated in addition the residents were going into each other's rooms and the common areas and picking up items they would not normally touch, hitting on the exit door, and she had to constantly redirect them from running and bumping into each other, and swing their arms towards her and the computer where she was charting. She stated that she informed RN B of the residents' behaviors and RN B only advised her to keep moving and keep redirecting them. She stated at one point she had to take the computer back to RN B to keep the residents from breaking. She stated she left the secure unit several times to check on residents on Hall-3 and stated she alerted RN B to cover the hall when she left. She stated she returned to shift on 01/02/2026 worked on Hall-3 and CNA B worked the secure unit. She stated she told CNA B about how crazy 12/31/2025's shift was with all the resident in the secure unit were exit seeking the entire shift. She stated while she was sharing the story with CNA B, CNA stated cuss words may have been used to describe the events of the evening but not used to cuss or threatened to hurt Resident #1 if he hit her or any of the residents. She stated at no time had Resident #1 attempted to hit her or flare his arms near her by accident or on purpose where she would have had to protect herself, nor was she aware if he had hit himself, others, or others hit him where he could have bruised his wrists. She stated she was familiar with the aspects of abuse and named: financial, verbal, physical, mental, and sexual as forms of abuse. She stated that she had an in-service training on abuse, neglect, and exploitation (ANE) almost once every month. She stated she received a call on 01/04/2026 just before her shift that she was being suspended pending an ANE allegation and on 01/06/2026 received another call from the ADM that she had been terminated related to allegations of ANE. She stated that she had never had a write up or been fired from a job and had never been accused of ANE. During an interview on 01/06/2026 at 12:14 p.m. CNA B stated she worked for the facility since 10/20/2023 and worked the 10 p.m. to 6 a.m. shift on the secure unit. She stated she had been off shift last working before 12/25/2025. She stated she returned to work on 01/02/2026 at 10 p.m. and while on shift CNA A told her that on 12/31/2025 the shift CNA worked while on the secure unit was crazy. CNA B stated CNA A stated Resident #1 was upset and came around the desk raised his hand up and tried to hit CNA A. CNA B stated CNA A told Resident #1, Mother Fucker, you better not hit me. She stated on 01/02/2026 around 11 a.m. she received a text message from DON asking her about any incident that occurred with Resident #1. She stated she replied that CNA A had cussed and threatened Resident #1 on the 12/31/2025 overnight shift. She stated that she and CNA A were suspended pending an investigation for failure to report and document the verbal abuse. She stated she had never been written up or had any disciplinary action. She stated that she should have reported what CNA A had cussed and threatened Resident #1 immediately upon learning. She stated she was unsure why she had not because she normally reported everything. She stated Resident #1 had not been known to be aggressive, unless he was irritable or provoked to act aggressive. She stated that forms of ANE were emotional, physical, verbal, and, financial and she received in-service training on ANE often. During an interview on 01/06/2026 at 01:05 p.m. MD stated that he was Resident #1's physician and the facility informed him that Resident #1 had bruising to the right wrist on 01/04/2026. He stated that the resident had sensitivity to noises such as loud commotions and yelling. He stated those factors would trigger Resident #1 who had a diagnosis of PTSD and could cause the resident to become aggressive and lash out. He stated the resident was under the care of a physiatrist who was managing the resident's behaviors with Risperidone, Trazodone, Divalproex Sodium, and Memantine. He stated that the resident was redirectable, but if provoked he would physically lash out. He stated that he had prescribed Resident #1 aspirin which could contribute to easy bruising. He stated the facility was unable to determine how the resident obtained the bruising but if a staff member had aggressively approached the resident, he had the tendency to swing his arms in a protective manner and could have hit his arm or wrists on something. He stated fireworks and gunshots sounds would trigger that resident's fight and flight response which could result in aggressive behavior. During an interview on 01/06/2026 at 01:28 p.m. Resident #1's Family A stated that she had been informed by the facility of the bruising on the resident's wrist. She stated that the facility had not been able to determine the cause of the bruise. She stated that the resident was not on blood thinners and had been known to easily bruise. She stated that the resident had many injuries over the years due to his poor balance and gait. She stated the resident was diagnosed with PTSD resulting from his days as a Vietnam soldier. She stated that if anyone displayed dominance over the resident it would trigger the fear of being in battle again. Record review of Resident #1's Progress Notes dated 01/03/2026 at 07:00 a.m. completed by RN A reflected: Observed purple area on the top of resident's hand to the wrist then a white area and at the wrist to forearm a purple area. No open area, no edema, no pain, and Resident #1 stated he did know how discoloration occurred. Injury Type: bruising to back of right hand. Record review of Resident #1's Change of Condition Communication dated 01/03/2026 at 07:00 a.m. completed by RN A reflected Resident #1's change in condition regarding his skin on his right arm. While making rounds RN A observed resident in secure unit while in bed facing the door. Right arm lying next to his face and observed the right arm had a purple color from the top of the hand to the wrist then a white area and then a purple color on the forearm. Resident asked how he got discoloration, but resident was unaware and noted not having any pain. Resident's MD and RP notified and x-rays ordered and performed. Record review of Resident #1's Skin assessment dated [DATE] at 07:16 a.m. completed by RN A reflected Resident #1's skin was intact, right hand to forearm was purple in color. Area on top of hand by the wrist was white in color and below that, a purple area on forearm below the wrist with no open area or edema to skin area. Record review of Resident #1's Pain assessment dated [DATE] at 07:16 a.m. completed by RN A reflected Resident #1 was checked for non-verbal sounds for example. (e.g.), crying, whining, gasping, moaning, or groaning), vocal complaints of pain (e.g., that hurts, ouch, stop), and facial expressions (e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw). Resident stated he does not have pain. Record review of Resident #1's radiography (x-ray) dated 01/03/2026 to right forearm, lateral views of the right forearm demonstrate a diffuse osteoporosis (loss of bone density). There is no dislocation or fracture. No bony erosion or destruction is present. The soft tissues are unremarkable. There is no radiopaque foreign body. Impression: The bones are osteoporotic. There is no dislocation or fracture. Record review of Resident #1's Orders reflected:- RisperDAL Oral Tablet 1 milligrams (mg) (Risperidone) to be given 1.5 tablet by mouth at bedtime related (r/t) to psychosis, start date 11/05/2025.- Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) to be given 2 capsule by mouth 3 times (x) a day for behavior, start date 10/15/2025.- Memantine HCl tablet 10 mg to be give 10 mg by mouth 2x a day for neurocognition, start date 07/10/2025. - Donepezil HCl Oral Tablet 10 MG (Donepezil Hydrochloride) Give 1 tablet by mouth at bedtime for neurocognitive, start date 07/10/2025.- TraZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 25 mg by mouth every 12 hours as needed (prn) for major depressive disorder, start date 10/21/2025. Record review of text messages from DON's phone to CNA B on 01/03/2026 reflected CNA A worked the secure unit on 01/01/2026 from 10:00 p.m. to 6:00 a.m. and CNA A came onto the secure unit during that shift and explained that during CNA A's shift 12/30/2025 and 12/31/2025 from 10 p.m. to 6:00 a.m., CNA A had an encounter with Resident #1 trying to hit CNA A when CNA A was behind the desk. CNA B further explained that CNA A had to redirect Resident #1 back to the other side of the desk and told Resident #1 he better not hit CNA A. CNA B stated CNA A told Resident #1, Mother fucker you better not hit me or I'm gonna show you. Record review of text messages from DON's phone to CNA A on 01/03/2026 reflected CNA A was not aware of any bruising on Resident #1 on 12/30/2025 and 12/31/2025. Record review of CNA B's 01/03/2026 statement to the facility reflected that on she worked on the secure unit 01/01/2026. On 01/02/2026 she noticed bruising to Resident #1's right forearm while providing care. She stated she assumed the bruising was old and therefore had not reported the bruising. Record review of CNA A's criminal background check reflected the facility last performed a check on 10/03/2025 finding no results found. Record review of CNA B's criminal background check reflected the facility last performed a check on 07/18/2025 finding no results found. Record review of policy titled Nursing Policies and Procedures and revised date 06/2019 Subject: Behavior Management Policy: It is the policy of this facility that the staff will incorporate behavior management techniques to improve the resident's quality of life.Behaviors are a form of communication; behavior management is the attempt to understand that communication and meet the needs of the patient/residentsNot all behaviors are necessarily a problem - a behavior is only a problem if it meets one of these criteriaA. Does the behavior significantly violate the rights of others?B. Does the behavior pose a significant threat to someone's health or safety?C. Does the behavior make it significantly more difficult to meet regulations, such as bathing requirements? If the answer is yes to any of these questions; you will need to develop an intervention.Procedure:Assessment:All behavior management must begin with a comprehensive assessment. Only then can your team develop effective and appropriate intervention. Every resident/patient will have an initial assessment for any mood or behavior need. Staff should be familiar with resident/patients to readily recognize any change in baseline mood and behaviors.The assessment process is ongoing and should change with any new needs identified:1. Elimination of any physiological concerns will be the first consideration; pain, infections, medication side effects sleep deprivation, elimination issues .2. Document and track mood and behaviors and document non-pharmacological attempts to intervene with mood or behavior issues on the behavior monitoring forms as they occur per facility guidelines. Ensure you have identified the target mood or behavior on the behavior monitoring forms not just the diagnosis. All psychotropic medications must be monitored by nursing each shift. A psychotropic is any drug that affects brain activities associated with mental process and behaviors.The following medications must have a behavior monitoring form;A. AntipsychoticB. AntidepressantC. AntianxietyD. Hypnotic3. Review your behavior documentation including Behavior Interventions Monthly Flow record for accuracy and patterns. Time of day, week or month behaviors occurs, what task was being performed, or staff member or another patient/resident involved when behavior occurs.4. Assess needs related to:A. Eliminating hunger or thirstB. Ruling out the need for rest or sleepC. Eliminating pain as a sourceD. Eliminating warmth or cold as a sourceE. Physiological or medical problems (e.g. blood sugar changes, dialysis issue . )F. Attending to toileting needsG. Ensure hygiene needs are metH. Shift change issues-time to go home, new staff.Diagnosis Review:A key element to the assessment process is to review of the resident diagnosis. Knowledge of the epidemiology anticipated can be very helpful in understanding possible root causes of mood and behavior issues.Looking at mental health diagnosis can be helpful and we will review a few; however, do not overlook other diagnosis that can have a profound effect of mood and behavior's such as: COPD, Lupus, and Arthritis (any diagnosis associated with pain), and blindness, deaf or hard of hearing . Record review of policy titled Nursing Policies and Procedures and revised date 06/2019 reflected Subject: Combative Resident, Care and Safety Policy: The Facility has procedures in place to protect the health and safety of residents, staff, visitors and others in the care or proximity of a combative resident.Procedures: 1. Any person who identifies a resident with a change in behavior or an escalation of behavior which may lead to physical combativeness, reports observation to a licensed nurse2. A licensed professional, e.g., nurse, social worker, licensed independent practitioner evaluates the resident and may intervene with behavior de-escalation techniques, if appropriate3. Individuals deemed to be combative or otherwise dangerous to self or others may be placed on close observation, which may include but is not limited to:A. Relocating individual to a less stimulating environmentB. Conducting frequent checks on the individual (e.g., every 10, 15 or 30 minutes)C. Providing a one-on-one staff member for continuous observation and intervention D. Redirecting attention or use of other therapeutic techniques for de-escalation4. Notification of change in condition and escalation of behaviors is made to:A. Physician or licensed independent practitionerB. Family or responsible partyC. Law enforcement, emergency medical services or others as may be necessary or appropriate to ensure the safety and well-being of the combative person or persons inproximity to the situation5. Transfers and Communication:A. Combative or persons exhibiting dangerous behaviors may have treatment and care needs outside the scope of the Facility. In these cases, and to ensure the most appropriate services, the physician may order a transfer to a different level of care.B. Prior to transfer, the licensed nurse or other professional provides handoff communication to:1) Receiving facility or care provider2) Transferring emergency medical services providerC. Handoff communication includes but is not limited to:1) Current evaluation and observations related to behaviors, risks, etc.2) Information related to current medical and mental conditions3) Advance directives4) Other pertinent information

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (Resident #2) reviewed for care plans. The facility failed to ensure a comprehensive care plan for a behavior of resident placing his hand in him soiled brief with bowel movement and placing his hand in his mouth was implemented for Resident #2 This failure placed residents at risk of not receiving care and treatment to meet the resident's physical, mental, and psychosocial needs.Findings include: Record review of Resident #2's Facesheet generated on 01/04/2026 reflected a [AGE] year old male who admitted to the facility on [DATE] as his own responsible party (RP) with medical diagnosis including bipolar disorder (a serious mental illness causing extreme shifts in mood, energy, and activity levels, ranging from manic highs (euphoria, irritability, high energy) to depressive lows (sadness, hopelessness, low energy), schizoaffective disorder (a mood disorder featuring periods of hallucinations, delusions, and disorganized thinking) depressive type, and gastro-esophageal reflux disease (a condition where the stomach acid frequently flows back into the esophagus (canal that connects the throat to the stomach), irritating its lining, causing symptoms like heartburn, regurgitation (food/fluid coming up). Record review of Resident #2's Minimum Data Set (MDS) dated [DATE] reflected the resident's Brief Interview for Mental Status (BIMS) was 11 out of 15 reflecting moderate cognition impairment for the resident. (A score of 13-15 would indicate intact cognition.) Resident received a Preadmission Screening and Resident Review (PASRR: in-depth assessment reviews records, interviews individuals/families, and involves mental health/intellectual development professionals to create personalized placement and treatment plans) positive level II (suspicion of serious mental illness evaluation), for serious mental illness, and was incontinent for both bladder and bowel and required helper assistance with toileting. Record review of Resident #2's Care Plan reflected:Focus:PASRR positive status related (r/t) mental illness and severe signs and symptoms on admission, revision dated 12/29/2025. Resident #2's Care Plan had not reflected any focused behaviors associated with digging in is brief, eating, or smearing his feces.Focus:Resident #2 had increased episodes and injury behaviors of smearing feces.Goal:Resident #2 had behavioral monitoring and interventions in place to decrease episode behaviors, date revised 01/04/2026.Interventions/tasks:Resident #2 had staff explain procedures with use terms/gestures the resident could understand and encourage the resident to attend social activities of preference, and report to MD progression/declines for ordered psychiatric consults as ordered within resident's clinical chart. Record review of Resident #2's Progress Note dated 01/05/2026 at 08:45 p.m. reflected Nurse Practitioner (NP) performed an evaluation r/t to Resident #2 chief complaint of diarrhea. Record review of Resident #2's Progress Note dated 01/05/2026 at 08:53 p.m. reflected MD ordered Resident #2 to receive monitoring for signs of dehydration and/or electrolyte imbalances due to report of loose stools approximately once a day. Ordered labs on 01/05/2026 to include a comprehensive panel of assess electrolyte status and continue current treatment/monitoring for improvement. During an interview on 01/07/2026 at 01:12 p.m. Resident #2 stated he had been experiencing repeated days of diarrhea and on occasion reached to the back of his brief to rub due to discomfort. He stated afterwards he had found that his hands and fingernails were soiled with feces, and unbeknown to him would rub his hand on his face and BM would get in his beard, on the sides of his mouth. He stated that behavior had become a repeated pattern. He stated he could not remember if care staff assist him with his soiled hands or brief but stated that he believed they had as his hands would be cleaned. During an interview on 01/04/2026 at 05:54 p.m. with Administrator (ADM) and Director of Nursing (DON) both agreed that no issues had been reported relating to Resident #2 having dug into his soiled brief and putting feces on/in his mouth. DON stated had they been made aware of the resident's behavior being more than a one-time occurrence, the behavior should have been care planned and progress notes made noting the behavior. DON stated that the resident had diagnosis of schizoaffective, anxiety, and bipolar disorders and from her knowledge had transitioned within the facility well. During an interview on 01/04/2026 at 7:05 p.m. Medication Aide (MA) stated that on 01/02/2026 sometime during her 02:00 p.m. to 10:00 p.m. (exact time unknown) shift she observed Resident #2 place a hand in his adult brief and pulled out feces and would have placed that soiled hand into his mouth had she not immediately intervened. She stated she asked the resident what he was doing and whether he was about to eat his feces. She stated the resident stopped, and she quickly left the room to locate his certified nursing aide (CNA), only to find that CNA was assisting another resident. She stated that she returned to the resident and washed his hands and changed his brief as she was also a CNA asking him again was he going to place his soiled hand in his mouth. She stated the resident asked what she was talking about and seemed confused by her questions. She stated that she should have reported the incident to LVN A who was his charge nurse due to infection control issue and maintaining the resident's dignity and respect but had not. She stated she thought his behavior had already been care planned. She stated failing to report the resident's behavior placed him at risk of repeated undocumented behaviors, illness, and put the facility at risk for cross contamination. She stated on 01/04/2026 she received a training in-service on reporting changes in conditions, residents' dignity and respect, and infection control. During an interview on 01/06/2026 at 04:42 p.m. LVN A stated she was Resident #2's nurse and had not been made aware of behaviors relating to him pulling feces out of his brief and placing his hand into his mouth. She stated had she been made aware, the behavior would have been reported immediately to the DON, ADM and his MD. She stated that his behavior fell under a change of condition and by reporting to his MD would expect a psychiatric evaluation order to be put in place and the resident's care plan updated. She stated the incident going undocumented and unreported placed the resident at risk for repeated behaviors and receptive to illness, and infection. She stated it further placed the facility at risk for infection control and cross contamination issues. During a confidential interview at undisclosed time, an anonymous person stated Resident #2 had been known to have feces under his fingernails, on his hands, beard, sides of his mouth, and in his mouth and teeth. The anonymous person stated the incidents occurred sometime during the New Year's Day holiday week during lunch time meal pass. The anonymous person stated she could not provide specific dates/times. The anonymous person stated an unknown male staff reported to LVN B that Resident #2 was observed with feces in his mouth and in his beard, and on his hands. The anonymous person stated LVN B entered the resident's room and upon seeing the resident's condition said, Oh, I'm not dealing with that and walked out the room. The anonymous person stated the incident was not further reported leaving the non-care staff to clean the resident's hands, but eventually, that male staff said, This is too far gone, and it's an infection control issue and had to leave the resident to finish his tasks. The anonymous person stated that Resident #2 behavior had been a recurring event that has continued to go on undocumented and further addressed without any type of isolation or monitoring. During an interview on 01/07/2026 at 11:52 a.m. LVN B stated that about a week ago Physical Therapist Assistant PTA had come and asked her to observe the fingernails of Resident #2. She stated upon observation Resident #2's appeared to have dried chocolate under his fingernails, on his hand, and on and around his mouth. She stated the resident was drooling and saw some of the same chocolate on his pillow. She stated she called an aide who she could not recall their name to help clean up the resident, change his brief, and repositing him in his bed. She stated she educated the resident about pressing his call light when he needed changing and asked the resident what was under his fingernails. She stated at first the resident responded that he had not known and then stated to her, Oh yea that is poop. She stated that she had not suspected that the substance was feces and had not sensed an odor of feces when cleaning up the resident. She stated had she known that the resident had feces on his hand or face she would have reported to LVN A who was the resident's nurse. She stated that incident would be considered a change in condition and required immediate reporting to the resident's MD and RP. She stated interventions would then be put in place for Resident #2 to be redirected to follow the infection control policy. She stated that the resident had to be redirected often about notifying staff when he had a soiled brief so he could be changed. She stated she believed she documented the incident in progress notes on that date but stated that she had not reported the incident to the resident's MD because she was pulled into assistance and was sure if that was behavior that required reporting LVN A would have already been reported. During an interview on 01/07/2026 at 12:06 p.m. PTA stated on or about 12/29/2025 he entered Resident #2's room for therapy services and observed the resident in bed with what appeared to be feces on his hand. He stated that he came closer and could smell the foul odor of feces from the resident and then noticed a tinge of brown in the resident's mustache and beard and on the resident's chin. He stated then the resident began speaking and the smell of feces increased and he could see feces in the resident's mouth and on his teeth. He stated he immediately searched for a nurse finding LVN B who he felt was a reliable nurse to share his finding. He stated LVN B observed the resident and left the room stating she was reporting the incident to LVN A. He stated none returned to clean the resident and lunch trays were being passed so he put on gloves and used sanitation wipes to clean resident's hands and fingernails. He stated while cleaning, Resident #2 told him that he had reached back into his brief, brought his hand around and had not realized that his hands had gotten soiled with feces. He stated he disposed of the wipes in the resident's bathroom trashcan, washed his hands, and left the resident returning to the rehab department. He stated he informed the Director of Rehabilitation (DOR) of the incident. He stated he had not had an in-service training on infection control since being employed, and felt the facility needed to do better on their infection control monitoring and practices. He stated he had not felt the resident had the mental cognition to inform staff when he soiled his briefs and saw the resident a few times a week for therapy services in the resident's room. He stated that the resident was not compliant with therapy services, and he had to continuously motivate the resident to get him out of bed. He stated that OTA and himself assisted with feeding residents during meals and stated that this was not the first incident where the resident was found with feces on his hand. During an interview on 01/07/2026 at 12:37 p.m. DOR stated that she had not been made aware of Resident #2 digging in his soiled brief by PTA. She stated on 01/05/2026 the facility had an interdisciplinary team (IDT) meeting which consisted of DON, ADM, MDS, and herself to discuss Resident #2 issue digging in his brief. She stated that the facility had set additional monitoring in place as an intervention for Resident #2's behavior. She stated that the resident had not been at the facility long and she had previously observed the resident eating in the dining room with no issues. During an interview on 01/07/2026 at 02:59 p.m. Family A stated that the facility had not made her aware of any past or present abnormal behaviors of Resident #2's. She stated that the resident had received psychiatric services from a psychiatric physician every 3 months for medications refills to treat some current diagnosis. During an interview on 01/07/2026 at 03:35 p.m. Assistant Director of Nursing (ADON) stated that on 01/04/2026 ADM and DON informed her that that Resident #2 had smeared feces, but on 01/07/2026 at 03:35 p.m. the feces had been in/on his mouth and beard. She stated LVN B had apparently told LVN A that the resident had placed his hand in his mouth after digging in in brief finding feces on his hand, then told LVN B he had not dug in his brief. She stated all she knew was LVN B made him clean his nails and face and then MDS care planned that he had smeared feces. She stated as the infection control preventionist (IP) she was informed and began in-service training on 01/04/2026 with the staff on infection control to educate on redirect the resident the best they could. She stated knowing that occurrence makes the incident a change in condition and required his MD to be notified. She would expect the MD would refer to the resident for a psychiatry evaluation. She stated that progress notes would be updated and reflect the incident, and the RP contacted and asked whether he/she had been of that behavior to understand if it had gone on in the past. She stated that interventions were put in place to increase rounds to monitor resident for increased behaviors and assure his brief was changed more frequently to avoid the behavior. She stated it would have been her expectation that staff followed infection control procedures by reporting and documenting the incidents. She stated the risk of not reporting placed Resident #2 and other residents at risk for illness and disease. She stated that the facility had in-service training on infection control monthly and as needed. During an interview on 01/07/2025 at 03:45 p.m. MDS stated on 01/04/2026 she had been made aware that Resident #2 had smeared his feces and updated his care plan to reflect that behavior on 01/04/2026. She stated she had not known that resident had feces in and around his mouth she would have called an IDT care conference meeting with all the department head managers to discuss the behavior and make both the physician and family aware. She stated that Resident #2 would receive education on the importance of infection control, and the IDT will be conducted an all-staff in-service on reporting a residents change in condition infection control. Record review of policy titled Policies and Procedures Baseline Care Plan with a revised date of 06/2024 reflected PolicyThe Facility will implement a Baseline Care Plan to ensure continuity of care and communication, prevent adverse events, and inform the resident and/or responsible party of the initial care and services.Procedure A Baseline Care Plan will be developed within 48 hours of admission. A Comprehensive Care Plan may be developed in place of the baseline care plan if the comprehensive plan is developed within 48 hours of admission and meets the Comprehensive Care Plan requirements. At minimum, the Baseline Care plan will address:o Initial goals based on admission orderso Physician orderso Dietary orderso Therapy serviceso Social serviceso PASRR recommendation, if applicable Baseline Care Plan Summaryo The Facility will provide a Baseline Care Plan Summary (Baseline Care Plan itself) to the resident and/or responsible party.o The timeline of delivery will be by the completion of the Comprehensive Care Plan.o The Medical Record will reflect evidence that the Baseline Care Plan Summary was provided to the resident and/or responsible party. Updates to Plan of Careo Updates to the Resident's plan of care after the completion of the Baseline Care Plan will be made in the Comprehensive Care Plan.

Based on interview and record review, the facility failed to maintain medical records on each resident that are accurately documented for 1 (Resident #1) of 9 residents reviewed for resident records.Resident #1's Medication Administration Record showed medications were administered on 11/6/25 and 11/8/25 after Resident #1 left the faciity on [DATE]. The failure could place residents at risk of an inaccurate medical record.Findings include:Record review of Resident #1's face sheet dated 11/17/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Unspecified Sequelae of Cerebral Infarction (Stroke).Record review of Resident #1's admission MDS dated [DATE], section C revealed a BIMS score of 13 that indicated cognition was intact. Section N revealed Resident #1 was taking an antidepressant and an anticoagulant. Record review of Resident #1's nursing progress note dated 11/3/25 at 6:26 p.m. written by LVN A revealed Resident Out of facility with family. Record review of Resident #1's nursing progress notes 10/23/2025 to 11/10/2025 revealed no notes regarding Resident #1 returning to the facility after leaving on 11/3/25. Record review of Resident #1's physician orders revealed orders for Cholecalciferol 1000 units, Isoniazid 300 mg, Aspirin 81 mg, Cyanocobalamin 1000 mcg, Ezetimibe 10 mg, Isoniazid 300 mg, Metoprolol Succinate ER 50 mg, Pyridoxine 50 mg, Brimonidine Tartrate, Polyethylene Glycol 3350 Oral Powder 1 scoop, Sennosides 8.6 mg, Polyethylene Glycol 3350 Oral Powder, Sennosides 8.6 mg, Latanoprost Ophthalmic Solution 0.005%, Pravastatin 20 mg and Trazodone 50 mg 0.5 tablet. Record review of Resident #1's November 2025 MAR revealed the following:MA A documented the following medications were administered: 11/06/25 at 8:00a.m.*Cholecalciferol 1000 units 11/06/25 at 9:00 a.m.*Aspirin 81 mg *Cyanocobalamin 1000 mcg, *Ezetimibe 10 mg *Isoniazid 300 mg *Metoprolol Succinate ER 50 mg, *Pyridoxine 50 mg, *Polyethylene Glycol 3350 Oral Powder, *Sennosides 8.6 mg*Brimonidine Tartrate11/06/25 at 1:00p.m.*Brimonidine Tartrate. MA B documented the following medications that were administered: 11/08/25 at 8:00a.m.*Aspirin 81, *Cyanocobalamin 1000 mcg, *Ezetimibe 10 mg, Isoniazid 300 mg, *Metoprolol Succinate ER 50 mg, *Pyridoxine 50 mg, *Brimonidine Tartrate *Polyethylene Glycol 3350 Oral Powder*Sennosides 8.6 mg11/08/25 at 1:00p.m.*Brimonidine Tartrate11/08/25 at 5:00p.m.*Brimonidine Tartrate*Polyethylene Glycol 3350 Oral Powder *Sennosides 8.6 mg 11/08/05 at 6p.m.*Latanoprost Ophthalmic Solution 0.005% was administered 11/08/25 at 8:00p.m.* Pravastatin *Trazodone 50 mg 0.5 tabletDuring interview on 11/12/25 at 10:46 a.m., Resident #1's family member said Resident #1 was picked up from the facility on 11/3/25 and did not return to the facility. During interview on 11/13/25 at 2:24 p.m., LVN B said Resident #1 left the faciity on a pass with a family member on 11/3/25 around shift change which was 6 p.m. and did not return to the facility. During interview on 11/17/25 at 9:46 a.m., MA A said they would not know if a resident was not at the facility until they asked the nurse and that residents were never taken out of the electronic medical system. MA A said they could not remember if Resident #1 was at the facility on 11/6/25 when they documented that medications were given. During interview on 11/17/25 at 9:56 a.m., MA B said they documented after medications were given to a resident in the electronic medical record after each individual resident. MA B said it would be on the resident's MAR if the resident was out on leave. MA B said they thought Resident #1's family had taken him out on the weekend but could not remember what day. During interview on 11/17/25 at 11:36 a.m., the DON said staff were supposed to chart immediately after administration of medications and go to the laptop to document that the medication was given. The DON said the expectation regarding medication administration was for the staff to lay eyes on the resident, follow the rights of medication and were giving medications at the right time to the right person. The DON said she interviewed residents to make sure they were getting the care they were supposed to and observed staff to make sure they were doing what they were supposed to.During interview on 11/17/25 at 11:56 p.m., the Administrator said that every resident could be affected if staff members were documenting that medications were given but the resident was not present at the facility, and they would question if medications were being given or being given to the right person or right time. During interview on 11/17/25 at 1:28 p.m., the Unit Manager said that once Resident #1 left they did not return to the facility. The Unit Manager said the expectation is that staff chart medications were given right after they were given. Record review of the facility's policy Medication Administration and Management revised 6/2019 revealed The authorized licensed and or certified/permitted medication aide or by state regulatory guidelines staff member documents that the medication is given in the correct slot of MAR, before going to the next patient/resident. and If the resident is not in the room, flag the MAR and follow the guidelines when the patient/resident is located.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 (Resident #1 and Resident #2) of 3 residents reviewed for catheter care.The facility failed to ensure Resident #1 and #2 received urinary catheter changes as ordered every month. This failure caused Resident #1 emotional distress and Resident #2 experienced a urinary tract infection. Resident #1 reported anxiety regarding the urinary catheter not being changed and Resident #2 was prescribed oral antibiotics on 10/13/25 for urinary tract infection. This failure could place other residents with catheters at risk of infection or emotional distress.Findings included:Record review of Resident #1's face sheet, dated 10/9/25, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including paraplegia (paralysis of the lower body) and neuromuscular dysfunction of the bladder (condition where nurse damage affects bladder control). Record review of Resident #1's quarterly MDS, dated [DATE], section C, revealed a BIMS score of 10 that indicated moderate cognitive impairment and section H revealed an indwelling catheter. Record review of Resident #1's Clinical Physician Orders, dated 10/13/25, revealed a physician's order for indwelling urinary catheter with instructions to change as needed for blockage and/or leaking with a start date of 2/3/25. Record review of Resident #1's care plan, dated 10/13/25, revealed focus of Resident #1 having a catheter and intervention to change catheter, tubing, and bag per order. Record review also revealed focus dated 1/20/25 that Resident #1 refused catheter changes.Record review of Resident #1's August 2025 TAR did not reveal any documentation regarding catheter change. Record review of Resident #1's September 2025 TAR did not reveal any documentation regarding catheter change. Record review of Resident #1's October 2025 TAR did not reveal any documentation regarding catheter change. Record review of Resident #1's progress notes did not reveal any documentation regarding Resident #1 refusing or requesting a catheter change. Record review of Resident #2's face sheet, dated 10/9/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including retention of urine, unspecified and other obstructive and reflux uropathy (condition where urine flows backward from the bladder into the ureters and kidneys). Record review of Resident #2's quarterly MDS, dated [DATE], section C, revealed a BIMS score of 11 that indicated moderate cognitive impairment. Section H revealed indwelling catheter. Record review of Resident #2's Clinical Physician Orders #1, dated 10/13/25 revealed, a physician's order for suprapubic (above the region on the center front wall of the abdomen immediately above the pubic bone) indwelling urinary catheter with instructions to change monthly and as needed with start date of 9/15/25. Record review of Resident #2's September 2025 TAR revealed documentation by LVN B on 9/15/25 for suprapubic indwelling urinary catheter change monthly and as needed. Record review of Resident #2's physician's order notes on 10/13/25 at 12:43 p.m. revealed Macrobid Oral Capsule 100 mg with instructions to give 1 capsule by mouth two times a day for UTI for 10 days. Record review also revealed a physician order note on 10/13/25 at 12:39 p.m. of Levofloxacin Oral Tablet 500 mg with instructions give 1 tablet by mouth one time a day for UTI for 10 days. Record review of Resident #2's Care Plan printed and reviewed on 10/13/25 revealed Resident #2 had frequent UTIs as evidenced by catheter with intervention of Staff to provide catheter care every shift and as needed. During an interview and observation on 10/9/25 at 10:09 a.m., Resident #1 said she had a catheter. Resident #1 said the facility staff did not change the catheter every month and if she told the facility staff then they got mad about it. Resident #1 showed me the date on her urinary catheter bag. Observation revealed 8/28/25 was written on the back on the urinary bag and brown coloring in the urinary bag. Resident #1 said the urinary bag smell ed. Resident #1 said she could not feel anything physically below her waist, but she felt anxious regarding the urinary bag not being changed. Observation on 10/9/25 at 2:16 p.m. revealed written on the back of Resident #2's bag was WED 8/27/25 14.00 HRS INSTALLED. During an interview on 10/9/25 at 3:26 p.m., the Unit Manager said the whole urinary catheter was supposed to be changed every 30 days but depended on the facility's policy. The Unit Manager said that they changed the urinary catheter bags if they were dirty. The Unit Manager said the nurses were responsible for changing the urinary catheters. The Unit Manager said there were admission set orders that gave instructions to how often and when the urinary catheters were supposed to be changed. The Unit Manager said once the order for the urinary catheter was in the residents' orders then it goes on the MAR/TAR. Observation on 10/13/25 at 8:16 a.m. of Resident #2 revealed writing on the back of Resident's #2's urinary catheter bag of WED 8/27/25 14.00 HRS INSTALLED which was the same as observed on Thursday 10/9/25. During interview and observation on 10/13/25 at 8:18 a.m., Resident #1 said staff changed her urinary catheter on 10/11/25. Observation of urinary catheter bag revealed no writing on the back of the urinary catheter bag. Observation revealed urinary catheter bag and tubing were clean with no brown substance in the bag. During an interview on 10/13/25 at 11:46 a.m., LVN A said she normally worked on the hallway where Resident #1 and Resident #2 resided. LVN A said residents' catheters were changed once a month and as needed. LVN A said Resident #2 had an appointment at the end of the month for urology. LVN A said she monitored schedules regarding changing catheters. LVN A said there should be a physician's order in the chart regarding changing the urinary catheter. LVN A said if urology was supposed to change the catheter we would keep in contact with the doctor and see what they did and what their orders were as well. LVN A said if a resident's catheter was supposed to be changed by urology that should be specified in the order. LVNA A said she would have to thumb through the chart and see when Resident #2's catheter was last changed. LVN A said it was documented under the progress notes when a catheter was changed, and she would have to look at the order to see when a catheter was supposed to be changed. LVN A said she would have to check when Resident #1's catheter was last changed because Resident #1 was noncompliant with a lot of her care overall. During interview on 10/13/25 at 1:47 p.m., Resident #1 said three months ago she had an appointment, so she refused to let the staff change her catheter until she returned and denied any other refusals regarding changing the catheter.During interview on 10/13/25 at 1:58 p.m., the ADON said urinary catheters, the whole system, were to be changed every 30 days and as needed. The ADON said as far as she knew it was the responsible of the nurses to change the current residents' urinary catheters per the order of the doctor and there were no residents who the doctor changed the resident's urinary catheter. The ADON said the nurse was supposed to document in the electronic MAR when a catheter was to be changed. The ADON said an effect it could have on the resident if a urinary catheter was not changed every 30 days was the resident could have bacteria buildup and possible UTI. The ADON said they did monthly in-services and competencies regarding catheters. During interview on 10/13/25 at 2:40 p.m., the ADON said there was documentation LVN B changed Resident #2's catheter on 9/15/25. During interview on 10/13/25 at 3:30 p.m., the ADON said Resident #1 was resistive to care and the behavior was care planned. The ADON said Resident #1 told them when she wanted her catheter changed. Record review of facility's policy, Catheter/Suprapubic Catheter, Changing Of, dated 6/2019, revealed changing of a catheter would be done by the appropriate licensed nurse when there was a specific physician order.

Based observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 1 (Resident #1) of 11 residents reviewed for pharmaceutical services.The facility failed to ensure Resident #1 received Acetaminophen-Codeine Tablet 300-30 mg as ordered as evidenced by gaps in administration. This failure could place the residents at risk of not receiving medications as ordered by the physician and unmanaged pain.Findings included: Record review of Resident #1's face sheet, dated 10/9/25, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including paraplegia (paralysis of the lower body).Record review of Resident #1's quarterly MDS, dated [DATE], section C, revealed a BIMS score of 10 that indicated moderate cognitive impairment. Record review of Resident #1's care plan, dated 10/13/25, revealed focus of chronic pain with intervention to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Record review of Resident #1's Clinical Physician Orders, dated 10/13/25, revealed physician's order for Acetaminophen-Codeine Tablet 300-30 mg with start date of 2/24/25. Record Review of Resident #1's May 2025 MAR revealed code 8 documented on 5/27/25 at 8 a.m. and 4 p.m. for Acetaminophen-Codeine Tablet 300-30 mg with instructions to give 1 tablet by mouth every 8 hours for lower back pain. Code 8 per MAR chart code equaled Other/See Progress Notes. Record Review of Resident #1's June 2025 MAR revealed code 8 documented on 6/28/25 at 8 a.m. and 6/29/25 at 12 a.m., 8 a.m. and 4 p.m. for Acetaminophen-Codeine Tablet 300-30 mg with instructions to give 1 tablet by mouth every 8 hours for lower back pain. Code 8 per MAR chart code equaled Other/See Progress Notes. Record Review of Resident #1's August 2025 MAR revealed code 8 documented on 8/31/25 at 8 a.m. for Acetaminophen-Codeine Tablet 300-30 with instructions to give 1 tablet by mouth every 8 hours for lower back pain. Code 8 per MAR chart code equaled Other/See Progress Notes. Record Review of Resident #1's September 2025 MAR revealed code 8 documented on 9/30/25 at midnight for Acetaminophen-Codeine Tablet 300-30 mg with instructions to give 1 tablet by mouth every 8 hours for lower back pain. Code 8 per MAR chart code equaled Other/See Progress Notes. Record Review of Resident #1's October 2025 MAR revealed code 8 documented on 10/1/25 at midnight, 8 a.m. and 4 p.m. for Acetaminophen-Codeine Tablet 300-30 mg with instructions to give 1 tablet by mouth every 8 hours for lower back pain. Code 8 per MAR chart code equaled Other/See Progress Notes. Record Review of Resident #1's progress notes for date range 9/13-10/14/25 did not reveal any further documentation on 9/30-10/1/25 related to administration of Acetaminophen-Codeine Tablet 300-30 mg related to Code 8 Other/See Progress Notes from the MAR. During an interview on 10/9/25 at 10:09 a.m., Resident #1 said the facility was supposed to have her medication on time. Resident #1 said they do not have her medication, and one would say they called the pharmacy, and the other one said she had not called the pharmacy regarding her Tylenol #3 (Acetaminophen-Codeine) for pain. Resident #1 said this happens every month and had been going on since last year and staff blame the pharmacy that the medication was not available. During an interview on 10/13/25 at 11:46 a.m., LVN A said the medication aide administered scheduled narcotics and the nurse administered as needed narcotics.During an interview on 10/13/25 at 12:02 p.m., MA A said she usually worked on the hallway where Resident #1 resided. MA A said she gave Resident #1 Tylenol #3 (Acetaminophen-Codeine) twice a day. MA A said she had to notify the nurse to reorder Tylenol #3 as the CNAs did not reorder narcotics. MA A said sometimes the doctors were slow and they had to get the Tylenol # 3 out of the automated medication dispensing system. MA A said if she had to get the Tylenol #3 out of the Pyxis (automated medication dispensing system) she had to notify the notify the nurse, wait on pharmscript (specialized pharmacy service provider) that takes about 30 to 40 minutes for approval. MA A said this was only if they did not have any Tylenol #3 but normally the nurse was able to get the medication delivered by 12 that night if we ordered them that morning. MA A said regarding documenting 8 on the MAR she probably let the nurse know and the nurse gave the Tylenol #3 but she did not. MA A said she would not have given the Tylenol #3 because the Tylenol #3 would not have been there. MA A said maybe the Tylenol #3 did not come in on time from the pharmacy was why it would not have been available. MA A said she could not remember why she documented an 8 on the MAR for 8/31/25 but if she put an 8 then she would notify the nurse, and they would give out of the Pyxis (automated medication dispensing system). MA A said she would not know where the nurse documented if they administer the Tylenol #3.During interview on 10/13/25 at 11:46 a.m., LVN A said the nurse ordered narcotics. LVN A said to reorder narcotics she had to notify the physician directly. LVN A denied any issues reordering Resident #1's narcotics and said sometimes the pharmacy took a while. LVN A said she might document in the electronic medical record or sometimes in the 24 hour report regarding if narcotics were reordered. During interview on 10/13/25 at 1:47 p.m., Resident #1 said when she did not get her pain medication, she felt terrible, could not sleep at night, her tailbone hurt, and she got a headache. Resident #1 said she had just been administered pain medication today and denied any current problems with pain medication and said she was doing ok regarding pain right now. During interview on 10/13/25 at 1:58 p.m., the ADON said the nurses reordered narcotics when they saw the medication was running out. The ADON said when there was a week's supply, they reach out to the doctor to obtain a script for refill, and they would send the escript to the pharmacy and we wait on the pharmacy to bring the medication to the building. The ADON denied any problems with reordering narcotics. The ADON said if a narcotic was not refilled in time, then there could be unmanaged pain. The ADON said there were certain narcotics in the Pyxis (automated medication dispensing system) and we should be taking care of it so there was no lapse. The ADON said Resident #1 did s not want to be woken up at midnight for pain medication if she was sleeping and was care planned regarding refusal of medications. During interview on 10/13/25 at 2:40 p.m., the ADON said they have the Tylenol #3 (Acetaminophen-Codeine) in the Pyxis (automated medication dispensing system). The ADON said she knows the Tylenol #3 is here but could not give an answer to why the medication was not given but was an opportunity to educate. Record review of facility's policy Administration of Drugs, dated 6/2019, revealed, It is the policy of this facility that medications shall be administered as prescribed by the attending physician.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 out of 21 residents (Resident #1) reviewed for adequate supervision. The facility failed to provide adequate supervision to Resident #1 who had a diagnosis of vascular dementia and eloped from the facility to a tire shop two blocks away from the facility for at least an hour. Resident #1 was severey cognitively impaired, which put her at increased risk of injury. An IJ for Past Non-Compliance was called on 2/20/25 at 3:18pm with the facility Administrator and DON. The noncompliance was identified as Past Non-Compliant. The IJ began on 12/2/24 and ended on 12/5/24. The facility corrected the noncompliance by providing in-servicing and hands-on training regarding elopement for facility staff prior to surveyor entrance. The failures placed residents at risk for elopement which could result in injury, hospitalization , and death. Findings included: Record review of Resident #1's Admission Record dated 2/20/25 revealed she was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses, personality disorder (a mental health condition characterized by patterns or behavior, thoughts and emotions that deviate significantly from cultural expectations and cause distress and or impairment of functioning), and vascular dementia moderate without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (term for brain changes that affect memory, thinking and can affect behavior but can occur without behavioral or mood changes). Record review of Resident #1's MDS (Minimum Data Set) dated August 8, 2024, section A revealed Resident #1 admitted from short-term general hospital. Section C revealed a BIMS (Brief Interview for Mental Status) score of 1 out of 15 indicating significant cognitive impairment. Section E regarding Resident #1 behaviors revealed rejection of care occurred 1 to 3 days. Resident #1 had no wandering behaviors. Section GG regarding Resident #1's Activities of Daily Living (ADL) Assistance revealed the resident needed set-up assistance with eating and oral hygiene, supervision with toilet use, moderate assistance with dressing and personal hygiene and maximum assistance with bathing. Section V regarding (CAAs), Care Area Assessments revealed Resident #1 was reviewed for risks in the following areas: Cognitive loss/Dementia-dated 8/9/24, Communication dated 8/9/24, Urinary incontinence/Indwelling catheter dated 8/9/24, Behavioral symptoms (related to refusals of care) dated 8/9/24, falls dated 8/9/24, Nutritional status dated 8/9/24, pressure ulcers dated 8/9/24 and psychotropic drug use dated 8/9/24. Record review of the facility's daily sign-in sheet dated 12/2/24 revealed staff worked 12-hour shifts from 6 am-6 pm and from 6 pm-6 am. LVN A was working on Resident #1's hall on the day shift and ADON was working on Resident #1's hall on the night shift. Continued review revealed MA A and CNA A were working on Resident #1's hall on the day shift and MA B and CNA B were working on Resident's #1 hall on the night shift. Record review of Resident #1's EMR for assessments on 2/3/25 at 12:22pm revealed no admission elopement risk assessment. Record review of Resident #1's nursing progress notes from 8/2/24 through 12/1/24 revealed staff documented by exception, Resident #1 was ambulatory without an assistive device and had no exit seeking or wandering behaviors prior to the incident on 12/2/24. Record review of facility incident and accident report from 8/2/24 through 2/20/25 at 7:53 pm revealed Resident #1 had an elopement incident on 12/2/24. There were no other elopement incidents or accidents from August 2024 through February 2025. Record review of Resident #1's facility provider investigation report dated 12/2/24 revealed Resident #1 was found by police at a tire shop up the road from the facility and returned to the facility by police and a family member unharmed around 7:50pm. Further record review of report revealed Resident #1 was gone from facility for about 1 hour and had gotten out of the facility through a side door that was no alarmed and was not part of the facility's secured unit. Record review of facility map revealed Resident #1 resided on an L-shaped unit that only had 1 unsecured entry/exit door. Continued record review of report revealed CNA B was the last to see Resident #1 around 6pm and staff did not recognize resident was not inside the facility until ADON received telephone call from Resident #1's family member around 6:30pm. Record review of LVN A's nursing note dated 12/2/25 at 5:46pm revealed the following: received phone call residents family member (sic) that resident was (sic) seen several streets down at tire shop and was obtained by the police and take (sic) to the police station. RP family member to pick her up and bring her to facility charge nurse on floor informed. Record review on 2/5/25 at 3:12pm of the ADON's nursing note dated 12/2/25 at 7:44 pm revealed the following: resident returned to facility and stated that (family member) does not want [Resident #1] to go to the secured unit. Education provided. Record review of Resident #1's MAR dated 12/1/2024-12/31/2024 revealed it was documented that Resident #1 received two 4:00 pm medications from LVN A, three 5:00pm medications from MA B, and received two medications from LVN B at 8:00pm. Telephone interview with MA A on 2/4/25 at 3:30 pm said Resident #1 had never tried to leave the facility prior to the incident and received her dinner and evening medications on 12/2/24 and could not have been missing from the facility very long. MA A said they had been trained on ANE upon hire and at least quarterly and had also been trained on elopement policy and procedures prior to and after the incident with Resident #1 on 12/2/24. MA A said that the facility conducted a code orange on the day Resident #1 went missing and searched the entire facility including bathrooms and closets and the interior and exterior of the facility. MA A said it was determined on 12/2/24 after the elopement search, that there were no other residents missing. MA A said they had been re-trained on ANE and elopement drills after the incident as well and that the facility conducted at least monthly elopement drills on each shift. MA A said that all doors were alarmed after the incident. Interview on 2/5/25 at 1:15 pm the DON said Resident #1 should have had an admission elopement assessment. The DON said she was working at the facility and helped complete the investigation involving Resident #1's elopement. The DON said it was determined through investigation that Resident #1 got out of a side facility door, and it was not part of the secured unit. The DON said Resident #1 did not have any exit seeking or wandering behaviors prior to the incident on 12/2/24 and the facility conducted a PIP in December 2024, after the incident with Resident #1 occurred and determined they will conduct more frequent elopement drills on each shift and audit admission assessments for all new admissions. The DON said Resident #1 was not injured during the incident and was reassessed and placed on the secured unit after the incident where Resident #1 remained. The DON said an elopement risk assessment was part of the facility's admission paperwork and should have been completed upon Resident #1's admission. The DON said she started working at the facility after Resident #1's admission in August 2024 and the charge nurse at the time of any resident admission was responsible for completing the required assessments which included an elopement risk assessment. Interview and observation on 02/5/25 at 12:42 pm revealed Resident #1 ambulating in the main activity room of facility's secured unit. Resident #1 had finished eating her lunch and was appropriately groomed and dressed. Resident #1 was awake, alert, and oriented and pleasantly confused. She was easily distracted but also easily redirected. Resident #1 did not want to continue speaking with surveyor and declined to be interviewed at that time or at any other time. The IJ began on 12/2/24 and ended on 12/5/24. The facility corrected the noncompliance by conducting a facility QAPI/PIP on elopement and providing in-servicing and hands-on training regarding elopement for facility staff prior to surveyor entrance. Telephone interview with MA B on 2/20/25 at 11:26 am revealed they could not remember all the specific details about the elopement of Resident #1 but remembered giving Resident #1 her 5pm medications between 5:00-5:30pm. MA B said Resident #1 was returned to facility around dusk and was not injured and placed on the secured unit after the incident. MA B said Resident #1 never wandered or tried to elope prior to the incident on 12/2/24. MA B said they did not know what staff member first identified Resident #1 was missing or when, but said staff immediately conducted an elopement drill and swept the entire building looking for Resident #1 and did a head count to ensure no other residents were missing. MA B said they had been trained both before and after the incident with Resident #1 on elopement procedures. MA B said that they knew how to check to make sure all exit/entry doors were securely closed and that they responded to any alarms or door sounds immediately to ensure there are no residents trying to elope. Telephone interview on 2/20/25 with LVN A on 2/20/25 at 11:37 am revealed Resident #1 walked around a lot and did not require any assistive devices to ambulate. LVN A said they worked the 6am-6pm shift on 12/2/24 with Resident #1. LVN A said that Resident #1 was sometimes confused but was awake, alert, and oriented to person and place and had never tried to leave the facility prior to the incident on 12/2/24. LVN A said Resident #1 would greet other resident's family members and visitors as they arrived and left the facility but had never tried to leave the facility on her own. LVN A said she did not recall any specific times she last saw Resident #1 on 12/2/24 or when Resident #1 returned to the facility but heard about the incident after it happened. LVN A said she would have given Resident #1 her 4:00pm medications. LVN A said they had been trained by the facility on ANE and had elopement drills before and after the incident on 12/2/24. LVN A said they learned how to split up the search to conduct a more thorough and timelier search of the interior and exterior of the facility to get a more immediate head count and to immediately report to the abuse coordinator/administrator. LVN A said they also learned how to check all the exit/entry doors were secured and closed. LVN A said they learned to ensure an admission elopement assessment had been completed on all new admissions and to document any wandering or exit seeking behaviors. LVN A said the ADON was the charge nurse for Resident #1 at the time of the incident because the scheduled charge nurse called in to say they would be late. Telephone interview on 2/20/25 at 4:11pm with LVN B revealed they gave Resident #1 two medications at 8:00pm on 12/2/24. LVN B said Resident #1 was back at the facility and moved to secured unit by that time. LVN B said before the incident Resident #1 had never tried to escape, elope, or leave. LVN B said they were trained upon hire and at least monthly on ANE and elopement procedures. LVN B said they learned how to split up the search to conduct a more thorough and timelier search of the interior and exterior of the facility to get a more immediate head count and to immediately report to the abuse coordinator/administrator. LVN A said they also learned how to check all the exit/entry doors were secured and closed. LVN B said they also learned to ensure an admission elopement assessment had been completed on all new admissions and to document any wandering or exit seeking behaviors. Interview on 2/20/25 at 4:15 pm with MA C revealed they worked the evening shift 12/2/24 and were trained on ANE and elopement procedures prior to the incident with Resident #1 on 12/2/24. MA C said Resident #1 had not tried to elope or get out of the facility prior to the incident on 12/2/24. MA C said Resident #1 liked coffee and walked around the facility but not wandering or going in and out of other resident rooms. MA C said after a couple of times after family members came to see Resident #1 or took her out on pass Resident #1 would seem sad but still never tried to elope until 12/2/24. MA C was unsure if Resident #1 had any visitors that day or if Resident #1 had been out on pass. MA C said the ADON initiated an elopement drill which the facility called a and they searched entire building inside and outside after Resident #1 was missing. MA C said that she knew that code orange was facility code for elopement and that an immediate search and lock down of facility needed to be conducted both inside and outside of the facility in addition to resident head count and Administrator notification if resident could not be found. Telephone interview on 2/20/25 at 4:32pm with CNA B revealed they were the assigned CNA and worked with Resident #1 on 12/2/4 during the evening shift. CNA B said they last saw Resident #1 at 6pm. CNA B said they gave Resident #1 a shower before dinner and remembered seeing Resident #1 seated in the activity room/communal area because there was an activity in progress. CNA B said they went to give another resident a shower and by the time the other shower was finished 30-40 minutes later they were told by LVN A to start a code orange. CNA B said they looked everywhere for Resident #1 and the ADON and other staff also went outside looking for Resident #1. CNA B said they looked in every resident room, every bathroom, every closet, and it was confirmed Resident #1 was missing but all other residents were accounted for. CNA B said they did not see Resident #1 return but heard the resident went to secured unit and ADON was managing it. CNA B said everyone was retrained on ANE and elopement drills and procedures immediately after the incident. CNA B said they had been trained on elopement procedures before the incident on 12/2/24. CNA A said they knew to look in all closets, bathrooms, resident rooms, and areas both inside and outside facility and to conduct a resident head count to ensure which residents were accounted for and which one may be missing. CNA A said they also learned to report any missing resident to administrator immediately if resident not found and to check all entry/exit doors to ensure they were secure. Telephone interview on 2/20/25 at 4:50pm with the ADON revealed they only worked a few months at the facility and remembered the incident with Resident #1 who somehow got out of the facility side door. The ADON said Resident #1 was calm and had not tried to exit the facility before 12/2/24. The ADON said they were covering for 6pm-6am shift charge nurse and helping the floor because the assigned 6pm-6am nurse was running late. The ADON said they last saw Resident #1 around 6:00pm-6:30pm. The ADON said they were trained on ANE and a code orange before hire and after the incident. The ADON said they believed they were called around 6:30 by Resident #1's family member saying the police had Resident #1 by a tire shop up the road and were bringing Resident #1 back to the facility. The ADON said they immediately initiated a code orange and confirmed Resident #1 was missing but no other residents. The ADON said when police arrived with Resident #1 accompanied by family member, they had staff complete an SBAR, skin, elopement risk and pain assessments as well as an incident report and Resident #1 was placed on secured unit. Interview on 2/20/25 at 4:55pm with Housekeeper said they had been trained monthly on elopement drills and at least quarterly on ANE. Housekeeper said code orange meant a resident had eloped and to monitor exit/entry doors and help search for resident inside and outside of facility as assigned by the charge nurses. Housekeeper said they were to report any resident elopement immediately to Administrator. Interview with CNA C on 2/20/25 at 5:03pm who worked 6am-6pm shift but worked 6pm-6am shift too at times. CNA C said they knew to look in all closets, bathrooms, all resident rooms, and areas both inside and outside facility and to conduct a resident head count to ensure which residents were accounted for and which one may be missing. CNA A said they also learned to report any missing resident to administrator immediately if resident not found and to check all entry/exit doors to ensure they were secure. Interview with SW on 2/20/25 at 5:08pm they said they had been trained on ANE and the facility code orange or elopement drill upon hire in November 2024 and after incident with Resident #1. SW said elopement drills were monthly and they learned to notify Administrator/Abuse Coordinator immediately and do a sweep search of building, all areas inside and outside and monitor and check exit/entry doors to ensure they remained secured. The SW said they would be part of the follow up safety rounds and psychosocial assessments for residents after any elopement. Interview with Receptionist on 2/20/25 at 5:12pm they said they had been trained upon hire 2/3/25 on ANE and resident elopement. Receptionist said they were trained to monitor main front entry/exit and unsure door remained securely closed and only opened via code. Receptionist showed a binder of current facility resident face sheets with resident photos to assist with identifying residents. Receptionist said they were trained code orange meant a resident had eloped and to monitor exit/entry doors and help search for resident inside and outside of facility as assigned by the charge nurses. Receptionist said they also learned to report any missing resident to administrator immediately if resident not found and to check all entry/exit doors to ensure they were secure. Record review of the facility's Elopement policy dated Revised May 2024 revealed the following Elopement Mitigation Strategies: *Appropriateness of resident placement within the facility upon admission and during their stay. *Completion of routine elopement risk assessments. *Providing the resident with appropriate supervision *Conducting routine elopement drills . Missing Resident 1. Once it has been established that a resident is missing, activate the emergency response paging system Code Orange, Room***to engage all staff in the search process. a. Establishing that a resident is missing should involve: i. Reviewing the resident's capacity for leaving the facility. ii. Reviewing if the resident signed out of the facility. iii. Contacting the resident's responsible party/and or family to identify if the resident left with them . 2. The DON/Designee completes/updated a missing resident profile and makes copies to distribute/utilize during the search efforts. 3. The Administrator/Designee organizes and institutes an immediate and thorough search of the facility and surrounding grounds including but not limited to: a. A search of the area outside the nearest exit to the resident's room or exit where he/she was last seen. b. The entire unit of where the resident resides or was last seen. c. The remainder of the facility (all rooms, closets, storage facilities, bathrooms). d. Grounds, extending beyond the fence line . 5.The search should continue with staff members searching the streets and local areas (at least a 2-mile radius). Record review of the facility's grievance log from August 2024 through February 2025 revealed no concerns from Resident #1's family members and no concerns regarding any elopements. Record review of the facility's incident and accident log with a date range of 8/1/24 through 2/20/25 revealed only one elopement incident on 12/2/24 related to Resident #1. There were no other elopements related to any other resident at the facility from 8/1/24 through 2/20/25. Record review of the facility's Reporting incidents and accidents in-service acknowledgement dated 12/2/24 revealed charge nurses, MAs, and CNAs received training for how to investigate and follow up on incidents and accidents and completing incident and accident documentation. The signature page included the ADON, the nurse who was assigned to Resident #1 on 12/2/24 the evening of the elopement. The ADON, LVN A, LVN B, MA A, MA B, MA C, CNA A and CNA B were all interviewed about this in-service. Record review of the facility's Ensuring doors are locked behind staff entering and exiting secured unit in-service acknowledgement dated 12/2/24 revealed nursing staff/nursing administration received education on alarms sounds and doors security. The signature page included ADON, the nurse who was assigned to Resident #1 on 12/2/24 the evening of the elopement. The ADON, LVN A, LVN B, MA A, MA B, MA C, CNA A and CNA B were all interviewed about this in-service. Record review of the facility's Rounding in-service acknowledgement dated 12/2/24 revealed nursing staff received education on being expected to perform room to room rounds during shifts, shift changes and checking the census for their hall. The signature page included ADON, the nurse who was assigned to Resident #1 on 12/2/24 the evening of the elopement. The ADON, LVN A, LVN B, MA A, MA B, MA C, CNA A and CNA B were all interviewed about this in-service. Record review of facility's Abuse and Neglect in-service acknowledgement dated 12/2/24 revealed nursing staff received education on being expected to follow federal guidelines for ANE, prevention of ANE, reporting of ANE, and investigating allegations of ANE. The signature page included ADON, the nurse who was assigned to Resident #1 on 12/2/24 the evening of the elopement. The ADON, LVN A, LVN B, MA A, MA B, MA C, CNA A and CNA B were all interviewed about this in-service. Record review of facility's Elopement in-service acknowledgement dated 12/2/24 revealed nursing staff received education on facility staff received education on what to do when a resident was missing or eloped and calling of a Code Orange, the code used by the facility to communicate to all staff that a resident was missing or eloped. The signature page included ADON, MA A, MA B and CNA A who were the staff assigned to Resident #1 on 12/2/24 the evening of the elopement. The ADON, LVN A, LVN B, MA A, MA B, MA C, CNA A and CNA B were all interviewed about this in-service. Record review of facility's Facility Elopement Drill: Elopement/Missing Resident in-service acknowledgement dated 12/5/24 revealed facility staff received education on what to do when a resident was missing. The ADON, LVN A, LVN B, MA A, MA B, MA C, CNA A and CNA B were all interviewed about this in-service. Record review of facility's Code Orange Drill in-service acknowledgement dated 12/5/24 revealed nursing staff received education on what to do when a resident is missing or eloped. The ADON, LVN A, LVN B, MA A, MA B, MA C, CNA A and CNA B were all interviewed about this in-service. Record review of the facility Wander/Elopement Drill Report revealed there were elopement drills conducted on 12/5/24 at 5:40 am, 10:00 am and 6:45 pm. The signature pages included the ADON, LVN A, MA A, MA B, CNA A and CNA B who were the staff assigned to Resident #1 on 12/2/24 the evening of the elopement. Record review of facility's QAPI Action Plan dated 12/2/24 revealed the following: PIP opportunity Elopement .Date initiated 12/2/24 .Issue: Elopement procedures were not accurately followed .Immediate Intervention: Elopement drill performed. Educated all staff regarding policies and procedures for elopement. Re-education: Inservice all staff on the importance of immediately identifying elopement risks and immediate interventions to ensure the safety of residents . Record review of facility Wander/Elopement Drill Report revealed there was an elopement drill conducted on 1/7/25 at 10:10 am and 8:43pm. Record review of facility's 2025-2026 QAPI Committee Meeting Performance Improvement Plans .Current Active PIP's .Elopement Procedures, Admission Process .Incidents and Accidents .Action Items .Ensuring accurate and timely completion of documentation.

Based on interviews and record review, the facility failed to utilize the services of a registered nurse for at least eight consecutive hours per day, seven days per week for 4 days out of 30 days (9/1/24 (Sunday), 9/14/24 (Saturday), 9/15/24 (Sunday), and 9/29/24() reviewed for nursing services. The facility failed to ensure a registered nurse was scheduled for eight consecutive hours per day, seven days per week on the following dates: 9/1/24 (Sunday), 9/14/24 (Saturday), 9/15/24 (Sunday), and 9/29/24 (Sunday). This deficient practice could place residents at risk of not receiving adequate care by not having staff available with the ability to perform assessments as needed. Findings included: Interview with the DON on 2/11/25 at 2:14 p.m. revealed that she started with the facility on October 25, 2024, which revealed she was not working at the facility during September of 2024. The DON said that the DON would be RN coverage on the days they are working which would have been Mondays through Fridays. Interview with the DON on 2/11/25 at 2:57 p.m. revealed that RN G provided RN coverage for 9/1/24, 9/14/24, 9/15/24, and 9/29/24. The surveyor requested DON A to provide timecards for these dates. Interview with the Administrator on 2/11/25 at 4:01 p.m. revealed that human resources completed the PBJ report. The Administrator said that the human resources employee who completed the report in September of 2024 was no longer working at the facility. The Administrator said that there should be 8 hours of RN coverage per 24 hours. The Administrator said she was not aware of any problems with RN coverage prior to her starting at the facility in December of 2024. The Administrator said that there are two weekend supervisors which are RN I and she did not know the name of the other supervisor at the time of the interview. Interview with DON A on 2/11/25 at 4:06 p.m. revealed that RN I and RN J are the current weekend supervisors. On 02/11/25 at 4:09 p.m., an attempt was made to call RN J in attempt to obtain more information. RN J is a RN Weekend Supervisor per DON A interview, but there was no answer and the mailbox was full and voice message was unable to be left. On 2/11/25 at 4:09 p.m., an attempt was made to call RN I in an attempt to obtain more information. RN I is a RN Weekend Supervisor per Administrator and DON A interview, and a message was left with surveyor contact information. Interview with the ADON on 2/11/25 at 4:28 p.m. revealed that they said they were not aware of any previous problems with RN coverage. The ADON said they started with facility in December of 2024 which revealed they were not working at the facility in September of 2024. On 2/11/25 at 4:40 p.m., an attempt was made to contact Human Resources who was working during September of 2024 and a message was left with surveyor contact information. On 2/11/25 at 4:41 p.m., an attempt was made to contact DON B who was working during September of 2024 and a message was left with surveyor contact information. Record Review of Nursing Time Detail Report 8.1.24 to 2.10.25 revealed during the month of September 2024 that RN J clocked in and out on 9/7/24, 9/8/24, 9/21/24, 9/22/24, 9/28/24 for at least 8 consecutive hours. No other RNs were seen as clocking in during the month of September including the dates of 9/1/24, 9/14/24, 9/15/24, and 9/29/24. Record Review of timecards for RN H for September of 2024 revealed they clocked in at 6 p.m. on 8/31/24 and clocked out at 6:30 a.m. on 9/1/24. RN H clocked in at 6:02 p.m. on 9/1/24 and clocked out at 6:30 a.m. on 9/2/24. There was not 8 consecutive hours of RN coverage on 9/1/24 as there was 6.5 hours from midnight to 6:30 a.m. and 5 hours and 58 minutes from 6:02 p.m. to midnight. Record Review of timecards for RN G for September of 2024 revealed that she clocked in at 6:17 p.m. on 9/14/24 and clocked out at 5:03 a.m. on 9/15/24. RN G clocked in at 9:26 p.m. on 9/15/24 and clocked out at 6:06 a.m on 9/16/24. RN G clocked in at 6:27 p.m. on 9/29/24 and clocked out at 1 a.m. on 9/30/24. On 9/14/24 RN G worked 5 hours and 43 minutes. On 9/15/24 RN G worked 5 hours and 3 minutes from midnight to 5:03 a.m. and 2 hours and 23 minutes from 9:26 p.m. to midnight which was not 8 consecutive hours. On 9/29/24 RN G worked 5 hours and 33 minutes. Record Review of Incidents By Incident Type report revealed the following information. On 9/1/24 there was one fall incident. On 9/15/24 there was one fall incident. On 9/19/24 there was one fall incident. On 9/29/24 there was one incident of physical aggression initiated and one incident of physical aggression received. On the dates of 9/1/24, 9/14/24, 9/15/24, and 9/29/24 there was not an increase in incidents documented when compared to the rest of the month.

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety in the facility's one of one only kitchen reviewed for kitchen sanitation. -The facility failed to label, and date left over foods items in 3 of 3 coolers in the kitchen. -The facility failed to ensure that food brought from home by staff were, label. dated and was stored in a designated refrigerator outside the kitchen. These failures could place residents at risk for food-borne illness and food contamination. The findings include: Observation and interview with [NAME] H on [DATE] at 9:15AM, revealed, -one of one stove in the kitchen revealed the door to the stove was broken and was held in place with a piece of cardboard. In an interview, cook H said the door had been broken for some times but did not say for how long. she said she could not answer the question. - Cooler #1 had left over coleslaw in a plastic unlabeled, dated [DATE] to [DATE]. Left over Tuna in a plastic container unlabeled and dated [DATE]. [NAME] H said that was a wrong date. -Cooler #2 had a pan of unlabeled and undated brown substance in a full-size baking pan. [NAME] H said, she I think it was some type of meat. Two unknown substances in a local grocery bag unlabeled and undated identified by [NAME] H as Resident's food. -Cooler # 3 had 4 serving sizes of left over pudding covered with plastic wrap unlabeled and undated. Two serving sizes of Jello covered with plastic wrap unlabeled and undated, one half open. All unlabeled and undated food items were identified by [NAME] H. She said all precooked, leftover food items and food products out of the original container should be labeled and dated by the person storing the food in the cooler, refrigerator or freezer for identification and safety. During an interview with the Dietary Manager on [DATE] at 3:30PM, she said the unlabeled and undated food items in a local grocery bag was for Dietary Aide M and he knows not to leave his food in the kitchen cooler unlabeled and undated. She said all food items out of the original containers should be labeled and dated with open date and expiration date for identification, used by date, for safety because consuming expired food items may result in food poisoning and food borne illness. She said the door latch to the stove had been bad around Christmas. She said she did not remember the date, but she told the Maintenance Manager that no longer worked at the facility. She said she did not write down the conversation. During an interview with Dietary Aide M on [DATE] at 3:00PM, he said the food in the cooler was his left-over chicken and he would not keep his left over in the cooler. He said he would not do that again and walk away. During an interview with the facility's Administrator on [DATE] at 1:00PM, she said all food brought from home for residents was kept in a refrigerator in her office with label and date for a few days as specified by the family member. She said employees should not store their left-over food and food products in the kitchen refrigerator or cooler. Record review of facility policy titled Nutritional Services Policies and Procedures Revised [DATE] reflected: Subject: Food Safety in Receiving and Storage read in part, It is the policy of this facility that food will be received and stored by methods to minimize contamination and bacterial growth. #3 Place food that is repackaged in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. Label both the container and its lid with the common name of the contents and the date it was transferred to the new container.

Based on observation, interview, and record review, the facility failed to assist residents in obtaining routine dental care for 1 of 8 residents (Resident #14) reviewed for dental services The facility failed to ensure Resident #14 was referred to the dentist after complaining of tooth pain. The failure could place residents at risk of pain and decline in health. Findings included: Record review of Resident #14'sAdmission record dated 11/18/2024 revealed a [AGE] year-old female who readmitted to the facility on [DATE]. Her diagnosis included pain, COPD, HTN and dementia. Record review of quarterly MDS assessment dated [DATE] for Resident #14 MDS reflected did not indicate any problems with oral health. Resident #14's BIMS indicated a score of 7 indicating severe cognitive impairment. Record review of Resident #14's care plan indicated the following: DENTAL CARE: Resident #14's has dental concerns and is at risk for increased pain and infections AEB broken teeth, Date Initiated: 06/26/2024, Revision on: 06/26/2024.Resident #14 will receive adequate nutrition/hydration, pain will be relieved with pain medications or other intervention and no signs of infection will occur over the next 90 days, Date Initiated: 06/26/2024, Revision on: 07/16/2024, Target Date: 10/08/2024. During observation and interview on 2/10/2025 at 9:00am. Resident #14 stated she had pain in her mouth and had not seen the dentist in sometime. Resident #14 stated she told the nurse and the SW of her pain and wishes to see the dentist. Resident #14 opened her mouth and she had some missing teeth and foul odor coming from her mouth. Resident #14 stated it is difficult for her to chew her food due to pain. In an interview with DON on 02/10/2025 at 9:45am, the DON said she was new and just started and she is getting to know the residents. The DON said all residents should be assessed upon admission for dental needs. DON stated that all needs should be discussed during care plan meetings. In an interview with DON on 02/11/2025 at 9:30am, the DON said she followed up with Resident #14's teeth after the surveyor made mention of concerns. The DON said she should have been referred to the SW by the nurse. In an interview on 2/11/2025 at 9:55am with LVN A she said she smelled Resident#14's breath when giving medication but thought she had bad breath. LVN A stated Resident #14 complained sometimes that her mouth hurt, and she would call the doctor and provide her with pain medication. LVN A said if residents need to see the dentist, she would tell the SW. In an interview on 2/11/2025 at 10:30am with SW she said she just returned to the facility from being out for 3 weeks due to injury. SW stated she was working on getting Residents seen by the dentist and she started working at the facility in November of 2024. SW said she was trying to play catch up from previous SW. SW said she was not sure if resident was on the list but can recall she did not have the funds or something with her insurance that did not allow her to be seen. SW said if residents do not have the funds or something the facility will cover I think. In an interview on 2/11/2025 at 11:00am with facility Administrator, she said if Residents cannot pay for dental services the company will cover the cost for the resident if her or she is in pain. The administrator said she was not aware of Resident #14 needing dental services and all residents should be screened upon admission and if services is needed a referral is to be made. Record review of facility policy on dental services in admission agreement packet states the following: Dental Services: The facility does not provide dental services all dental services will be the responsible parties responsibility or paid through Medicaid services. Facility policy did not state if they would provide services for resident if dental services is needed.

Based on Record review and interview, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System within 14 days after a facility completes the resident's assessment for 2 (Resident #36, and CR #81) of 18 residents reviewed for MDS transmission, in that: -The facility failed to transmit a completed Admission MDS assessment for Resident #36 within 14 days of completion. -The facility failed to complete and transmit a Discharge MDS assessment for CR #81 within 14 days after completion. These failures could place residents at-risk of not having their assessment and care plan completed timely, which could result in denial of services and or payment for services. Findings include: #36 Record review of Resident #36's face sheet dated 02/10/25 revealed, a [AGE] year-old female, with an original admitted [DATE] and re admitted on [DATE]. Her diagnoses included acute Dementia (a group of symptoms affecting memory, thinking and social abilities),. chronic kidney disease (Mild to Moderate damage to the kidney), essential hypertension (abnormal high blood pressure), Diabetes mellitus (a group of diseases that affect how the body uses blood, depression and communication deficit (Difficulty in communication that arises from impairments in cognitive process). Record review of Resident #36's Admission MDS dated [DATE] reflected it was signed as completed 08/18/24 which was 16 days after admission. CR #81 Record review of CR#81's face sheet dated 02/11/25 revealed, an [AGE] year-old female, with an admitted [DATE]. Her diagnoses included cerebral infarction (damage to brain tissue or a blood vessel blockage in the brain), communication deficit (Difficulty in communication that arises from impairments in cognitive process) generalized anxiety disorder, and diabetes mellitus (a group of diseases that affect how the body uses blood sugar), and depression. Record review of CR #81's discharge MDS dated [DATE] revealed it was signed as completed on 09/18/24, 24 days after completion. During an interview on 01/12/25 at 2:00PM, the MDS coordinator said she completed the MDS as required, but she had to wait for RN to sign as completed. She said she did not complete CR #81's MDS because CR #81 was a short stay Resident and the MDS was done by a staff that no longer work for the facility. She said not completing the MDS in a timely manner could result in care plan not being completed and delay in care and services as well as denial of payment for services by payer source. During an interview with the Facility's Corporate MDS Coordinator on 02/12/25 at 3:40PM, she said the MDS staff had to wait for the RN signatures and that may result in the MDS being transmitted late. She said she would transmit CR #81 as soon as possible. During an interview with the DON on 02/11/24 at 4:00PM, she said she was not trained to sign the MDS and there was a Cooperate corporate staff that signed off on the MDS. Policy on MDS completion and transmission was requested on 02/11/25 at 4:00 PM. MDS coordinator said she follows the RAI manual.

Based on interviews and records reviewed, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #1) of 8 residents reviewed for incontinent care. -The facility failed to replace Resident #1's foley catheter's drainage bag after it was removed by the resident. This failure could place residents at risk for urinary tract infections. The findings included: Record review of Resident #1's Admission Record, dated 08/15/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's diagnoses included retention of urine (inability to completely empty the bladder) and obstructive and reflux uropathy (when urine can't flow (either partially or completely) through ureter, bladder, or urethra due to some type of obstruction. Instead of flowing from kidneys to bladder, urine flows backward, or refluxes, into kidneys). Record review of Resident #1's physician orders revealed a urethral indwelling urinary catheter with catheter care on 08/05/24. Record review of Resident #1's Admission MDS assessment, dated 08/02/24, revealed a BIMS score of 1, indicating severe cognitive impairment. Further review revealed the resident required partial/moderate assistance with toileting. Record review of Resident #1's undated care plan revealed the resident had a need for an indwelling foley catheter and was at risk for increased UTIs and skin breakdown related to obstructive uropathy. Interventions included providing catheter care and perineal hygiene as indicated. In an interview on 08/15/24 at 12:31 p.m., CNA B said on 08/13/24, she took Resident #1 back to her room after dinner and when they were in the room the resident pulled off her catheter drainage bag. She said she left the resident in the room and notified Nurse A about the catheter bag and as soon as she went back to the resident's room, she found her on the floor. She said she notified Nurse A and they both went to the resident's room. She said Nurse A checked the resident and sent them out to the hospital. She said Nurse A did not put on another catheter bag. She said it took EMS approximately 10 minutes to arrive at the facility. In an interview on 08/15/24 at 1:03 p.m., Nurse A said she was at the nurse's station between 7:00 p.m. and 8:00 p.m. when CNA A came and told her Resident #1 pulled off her catheter drainage bag. She said when she was on her way to check on the resident, another CNA told her the resident was on the floor. She said the catheter bag was on the resident's room floor. She said she assessed the resident, called the DON, and then called 911. She said the catheter bag was not put back on because she would have had to go to the closet located in the middle of the hallway on station 1 to get a new bag. She said the closet was locked and she could not give the key to the CNA because it also opened the medication cart, oxygen storage, and medication room. She said she wanted to make sure the resident was not dizzy or closing her eyes. She said Resident #1's safety was the priority and not her catheter bag. She said at that time there was a CNA in the room with her and the resident. She said she was not sure, but she thinks there were two other nurses on shift with her on the night of 08/13/24. She said she did not ask the CNA to get another nurse so they could get another catheter bag. She said it took EMS approximately 5-8 minutes to arrive at the facility. She said the potential harm that could have resulted from having open tubing and no attached catheter bag was that it was an open portal and could cause a UTI if it touched the floor or cross contamination but said the foley catheter tubing was attached to her leg and the tubing was not touching the floor. She said Resident #1 was wearing pants at that time. In an interview on 08/15/24 at 2:18 p.m., the DON said the resident had a leg strap to help keep the catheter drainage bag in place. She said her understanding was Resident #1 took her catheter bag off and at some point, the bag was on the floor. She said the Nurse A called 911 and they came and got the resident before the nurse was able to get the resident a new bag. She said she did not know for certain how long it took EMS to arrive at the facility, but they usually responded very quickly. She said the nurse was focused on neuros, keeping the resident stable, and was hyper focused on calling 911 since the resident hit her head. She said her expectation would be to get another catheter bag to make sure it was draining and not pulled out of place. She said had Resident #1 not hit her head, she thinks all of this would have taken place. She said there could have been a potential for exposure to pathogens since it was an entry into the body. Record review of the facility's policy titled Competency of Nursing Staff, dated 07/21/21, read in part . licensed nurses and nursing assistants employed (or contracted) by the facility will . and b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care .

Based on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care. The facility failed to utilize emergency transport after Resident #1 had an unwitnessed fall which resulted in a subdural hematoma and 2.5-hour delay in care. Resident #1 was sent to the hospital and placed in the ICU. An Immediate Jeopardy (IJ) situation was identified on 7/26/24 at 6:10 PM. While the IJ was removed on 07/28/24, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for delay in needed treatment and care, resulting in further injury, hospitalization , and/or death. Findings included: Record review of Resident #1's face sheet dated 7/26/24 revealed an [AGE] year-old female who was admitted originally to the facility on [DATE] and most recently on 4/24/24 with diagnoses including Dementia (group of symptoms affecting memory, thinking and social abilities), insomnia (Trouble falling and/or staying asleep), glaucoma (eye conditions that damage the optic nerve), blindness right and left eye, bipolar (eye conditions that damage the optic nerve). Record review of Resident #1's MDS dated [DATE], revealed her BIM score was 00 which indicated she had severe cognitive impairment. Resident #1 used a wheelchair for mobility, required supervision or touch to transfer to the wheelchair, sit to stand, and was independent to walk 10 feet. Record review of Resident #1's care plan dated 7/26/24 revealed the following in part: A. Focus: Sits and crawls on floor, will attempt to stand on WC or dining room table, 7.24.24 fall w/injury to face, sent to hospital. Date initiated 10/10/22 and revised on 7/25/24. Goal: none Intervention/Task: Observe for early warning signs of behavior - approach in a calm manner, call by name, remove from unwanted stimuli. Date initiated 10/10/22 . B. Focus: [Resident #1 reside in life engagement unit [secured unit] due to need for structured environment and poor safety awareness. Date initiated 10/10/22. Goal: Dignity will be maintained thru [through] next review. Date initiated 10/10/22. Interventions/Task: .Keep environment free of possible hazards . C. Focus: [Resident #1] is at risk for falls and fall related injuries R/T gait imbalance impaired memory, and Dementia .5/8/24 [Resident #1 on floor, bruises noted to rt back shoulder area, bruises to lt buttocks. 6/14/24 actual fall, lost balance, hitting head. Bruise to head. 7/1/24 unwitnessed fall causing laceration to lip and rt side of forehead. Sent to ER for eval. 7/3/24 put feet on dining room table while still in wheelchair. Pushed and caused self to tip over backwards. No injuries. Date initiated 9/23/23. Goal: [Resident #1] will be free from fall related injuries over the next 90-day review period. Date initiated 9/26/23. Interventions/Task: Anticipate needs - provide prompt assistance. D. Focus: [Resident #1] reside in secure unit for wandering elopement risk need for controlled environment poor safety awareness. Date initiated 4.25.24. Goal: . [Resident #1 will be safe thru [through] next review. Date initiated 4.25.24. Interventions/Task: Keep environment free of possible hazards . Record review of Resident #1's orders dated 7/26/24 revealed that her observation behaviors were crawling on the floor and standing on furniture. Record review of Resident #1's progress notes dated 7/24/24 (written by LVN A) reflected the following: Text: At about 7:45p [pm] pt. was found on floor in room, under her wheelchair with a small laceration above L eye. the L eye is swollen shut and she has a busted lip. [Pain medication] 325mg 2 tabs was given for pain/discomfort and icepack to eye. V/S [vital signs] are 126/71 P [pulse] 54, SpO2 97% and T [temp]-97.2 [degrees]. DON and on-call notified. Pt. to be sent out to [Hospital] for ER CT scan Record review of Resident #1's hospital admission report dated 7/24/2024 revealed the following in part: .07/24/24 2238 [10:48 PM] Presentation Chief Complaint Fall, Head injury Onset Occurred Today, Unknown Symptom Duration Constant Progression since Onset .Notes [AGE] year-old female patient was brought in by EMS alert but nonverbal, found on the floor as an unwitnessed fall. She has a hematoma above the left eye with a small abrasion to that area that caused some bleeding on the scene. Patient had no vomiting no other symptoms. Neurologically at baseline per EMS transport staff from the nursing home . Acute 5.8 mm subdural hematoma [A condition due to bleeding under the membrane covering the brain] along the right tentorium [extension of one of the membranes covering the largest part of the brain] . reviewed the head CT. There is a thin layer of blood overlying the tentorium on the right without mass effect. No convexity subdural hematoma or brain contusion. Plan: 1. Admit to ICU and repeat head CT in AM 2. No need for anticonvulsants [drugs that prevent or reduce seizures by stabilizing nerve cell activity in the brain]. 7. In an interview on 7/26/24 at 4:12 PM, LVN A said she was called to Resident #1's room by CNA B after Resident #1 was found on the floor. She said she completed and documented a head-to-toe assessment, skin assessment and took Resident #1's vitals. She said Resident #1's vitals were stable and within normal range. She said she made notifications, one of which was the on call medical professional. She said NP A directed her to send Resident #1 to the ER. LVN A said she sent Resident #1 via non-emergency transportation to the ER because Resident #1 had falls before, did not have bleeding and her vitals were within her normal limits. LVN A said she called 3 transportation services and selected the services with the shortest response time (1 1/2 hour). She said she performed neuro checks for approximately 1 hour and a half until Resident #1 went to sleep approximately around 9:00 PM. LVN A said she passed medications on another hall until EMS picked up Resident #1 approximately at 10:00 PM. She said she was not required to document the neuro check and had not been trained to document the neuro checks. She said she did not think Resident #1 was at risk by going out non-emergency transports versus going out sooner with 911. Interview on 7/26/24 at 10:58 AM, CNA A said she was called around 7:30 PM by CNA B to assist with Resident #1. CNA A said Resident #1 was on the floor under her wheelchair. She said CNA B then went to tell LVN A what happened. CNA A said LVN A came in, completed the assessment and they turned Resident #1 over and placed her back in bed. CNA A said Resident #1 had a bump over her left eye and a cut to her lip. She said she continued her duties after Resident #1 was put back in bed. She said Resident #1 was sent out the emergency room , but it was after 9:30 PM. In an observation on 7/26/24 at 11:55 AM, Resident #1 was in bed in the ICU unit of the hospital. Her eyes were closed and she had the covers to her chin. She had a dark purple bruise above her left eye and a family member stood over her wiping her face. In an attempted interview on 7/26/24 at 11:55 AM, the surveyor introduced themselves to Resident #1 and asked her how she felt. Resident #1 did not respond or open her eyes to acknowledge the surveyor. The family member told the surveyor that she was non-verbal. In an interview on 7/26/24 at 12:05 PM, RN A at hospital stated that Resident #1 was admitted to the ICU on 7/24/24 at 11:30 PM after she had received several CT head scans. Her injuries were bruising of the left eye and a subdural hematoma. She explained that the hospital's EMS had an urgent response time and a 2.5-hour delay in emergency services was detrimental because you could not determine how bad a head injury was until after a resident received their scans. RN stated luckily Resident #1's hemorrhagic area was not too big because if it had been larger, Resident #1 would have needed surgery. In an interview on 7/26/24 at 12:13 PM, a family member of Resident #1, stated she had a missed call from the facility regarding the fall of Resident #1 on 7/24/24 at 8:36 PM. She called the facility back for further information at 9:58 PM and was told that Resident #1 had just left the facility and was headed to the hospital. She stated that she arrived at the hospital after 10 PM and she waited for Resident #1 to arrive at 10:30 PM. She explained that the hospital was not busy and she believed that there was a delay in care on the facility's part. In an interview on 7/26/24 at 1:56 PM with CNA A, she explained that some of Resident #1's behaviors were trying to climb tables, her wheelchair, and she would climb on the floor. In the room, there were two wheelchairs pushed seat first to the opposite wall of Resident #1's bed. CNA A stated that when they were preparing residents for bed, they like to tend to Resident #1 first so they could know her whereabouts as they tended to other residents. She explained that when she would work with Resident #1, she would normally take the wheelchairs out of the room because the resident was a fall risk and liked to stand up on the wheelchair. She explained that on the night on 7/24/24, CNA B called her to come down to Resident #1's room because she found her on the floor. When she came into her room, Resident #1 was laying on the floor in fetal position underneath one of her wheelchairs. They called for LVN A, who came in and assessed the resident. In an interview on 7/26/24 at 2:15 PM with the ADON, she stated that she was off on 7/24/24. She explained that the protocol for an unwitnessed fall with head injury was to call the physician, the DON, then fill out physician orders. Nurses were to perform, vitals, a pain assessment, fall assessment, skin assessment, document any risks, and complete a SBAR (change in condition documentation). She stated that if she saw a situation that seemed to be an emergency, she would use her nursing judgement to call 911 and let the physician know that she did. She stated that all nurses can notify the doctor after hours through an app (online application). She said that she always educated staff that if they could not reach anyone after 20 minutes, they were to contact the physician directly. Interview on 7/26/24 at 2:31 PM, the DON said she was notified Resident #1 was found on the floor with a head injury. LVN A gave Resident #1 ice for the swelling, Tylenol, and sent her a picture. Once she saw the picture, she told LVN A that she thought Resident #1 needed a CT scan and the physician notified, also agreed. She said she initially thought LVN A sent Resident #1 out via 911. She said after an interview with LVN A, she found out that Resident #1 was sent out via non-emergency transport. The DON said Resident #1 was picked up at approximately 10:00 PM. She said LVN A was told by the on call NP to send to the ER which did not necessarily mean 911. She said because Resident #1 was stable, not on anticoagulants, not bleeding, and was at baseline she would have preferred emergency services, but non emergent services was fine in this incident. In an interview on 7/26/24 at 2:55 PM, CNA B said she found Resident #1 on the floor in her room in the fetal position with her wheelchair on top of her. CNA B said she asked for help from CNA A and LVN A. CNA B said LVN A came, removed the wheelchair off of Resident #1 and began the assessments and tookher vitals. She said Resident #1 had a bump over her left eye and her lip was split. She said Resident #1 was sent to the ER but she could not remember what time Resident #1 left. She said Resident #1 did not leave within the first hour after the incident. CNA A said Resident #1 had a behavior of crawling on the floor and standing up on wheelchairs and furniture. In an interview on 7/26/24 at 3:13 PM, the Medical Director said she was notified of Resident #1's unwitnessed fall. The Medical Director said NP A was the on-call respondent. She said based on what she was told, Resident #1 vitals were stable and there was no blood, it was fair to send Resident #1 out within a few hours by non-emergency transportation. In an interview on 7/28/24 at 4:31 p.m., NP A said she was notified Resident #1 was found on the floor with a wheelchair on top of her. NP A said she was told Resident #1 had an injury to her head and was not bleeding. NP A said she was notified Resident #1's vitals were with in normal range. She advised LVN A to send Resident #1 to the ER. NP A said it was a nursing judgement call whether to send out Resident #1 by 911 or non-emergency transport to ER was the facilities choice. Record review of facility policy Nursing Policies and Procedures - Fall Management (revised 1/2019) revealed the following in part: Policy: It is the policy of this facility to evaluate extent of injury after a fall, prevent complications and to provide emergency care . Purpose: 1. To identify resident at risk in a timely manner .4. To respond to a fall in a manner that will ensure the resident is treated timely and safely .In the Event of a Fall: 1. The resident will be checked for any abnormalities: i.e. A. Deformed, discolored or painful body parts. B. Bumps. C. Bruises D. Cuts. E. Abrasions F. Scrapes G. Confusion H. Level of consciousness. 3. Obtain vital signs .5. Initiate neurological checks for any fall where a resident his his/her head or for any unwitnessed fall .Note1. If condition from fall is life threatening, the nurse shall initiate EMS (Emergency Medical Services) stat and then place a call to physician, hospice, and family/responsible party . This was determined to be an Immediate Jeopardy (IJ) on 7/26/24 at 6:10 PM. The DON and ADON were notified. The DON was provided with the IJ template on 7/26/24 at 6:10 PM. The following Plan of Removal submitted by the facility was accepted on 07/27/24 at 4:00 PM: Facility- IJ Plan of Removal for F684 7/26/2024 Allegation F684: Quality of Care The facility failed to obtain emergency services for unwitnessed fall for Resident #1 after a fall on 7/24/24 that resulted in bruising to a subdural hematoma to the left side of her head. Resident #1 arrived at the ER approximately two and a half hours after the injury had occurred. On 7/24/24 Resident #1 was transferred to the hospital. LVN A was suspended pending investigation 7/25/24 based on Self Report to HHSC. The Administrator and Director of Nursing notified the Medical Director of the IJ on 7/26/24. The Regional Nurse Consultant provided 1:1 education with the DON on 7/26/24 on the following topics: o Conducting an Investigation Post Falls o Fall Management o Changes of Condition Warranting 911 Transfer o Neuros Vital Signs Status Post Falls The Director of Nursing initiated education with Licensed staff members on 7/26/24 on: o Fall Management o Change of Condition Warranting 911 Transfer o Neuro Vital Signs Status Post Falls o Incident & Accident Quick Guide *All License Staff will be Educated Prior to Working & Complete Post Test to Demonstrate Competency. All Training to be Completed by 7/27/24. Audit of Resident Falls x last 30 Days Completed; DON & ADON Assessed Residents Identified to ensure there were no adverse effects status post fall that had not been addressed. Assessments Completed 7/26/24. Ad Hoc QAPI Conducted 7/26/24 with Medical Director, Administrator, DON, & ADON. Monitoring Day 1: Saturday July 27th, 2024 In an interview on 7/27/24 at 4:08 PM with the DON, she stated she was educated on doing neuro checks and what the time frame was. The neuro documentation sheets were changed to front and back copies to help keep up with them. She discussed that if there were any changes in neuro responses, it was an acute change and it was an emergency. There was also a quick guide for falls created a copy is held at each nurse's station for them to review. The quick guide gives examples for everything that was required and considerations of what to do after a fall. Fall management covered that prior to a fall, and doing a fall assessment, nurses needed to pay attention to the score. They were responsible for recognizing the score and putting something in place at that time. Some patients have fall injuries and may need a fall mat. If it is a trip hazard, nurses have to wave that out. Nurses need to make sure that anytime there is a fall intervention in place it makes sure that we are looking at each person's care plan. The nurse can add interventions in the risk management, and it will be reviewed by the IDT team and DON in the morning. In the event of a fall, herself and the Regional Nurse covered to make sure they did skin assessment, initiated neuro checks, evaluated cause of fall, and did a complete vital sign, neuro check, and range of motion. Staff must notify her of all falls and if the doctor they are trying to reach had not responded in 1 hour, they must notify the Medical Director. Nurses must notify RP and if a resident is their own RP, instead of leaving blank that section blank in the documentation, nurses are to add the resident's name to state they are their own RP. Everything must be documented and passed on to the report. If the condition was life threatening, they would notify EMS, then they would call the doctor and notify the DON. They also covered in the education that anytime a resident changes the level of plane it is still a fall. Unless there was evident of something otherwise, if a resident is on the floor, then a fall is considered to have happened. The DON stated she discussed with nurses the signs of a head Injury such as unequal pupils, loss of consciousness, change in cognition, nausea and vomiting, and/or a headache. If the resident already had a something nurses were monitoring like aspirin or blood thinners, the nurse would send the resident out to be evaluated. The facility added a table for what type of treatment would need to be done for time frames to be viewed at the nurses station as well. If there were any abnormal neuro changes, muscle or skeletal issues, they needed to be in the ER within an hour. If there was any bleeding or anything with large lacerations, residents could be sent out, stating that They are nurses and should still be ale to use judgement. In an interview on 7/27/24 at 4:38 PM, LVN B stated that she had worked at the facility for 5 months and worked from 6AM- 6PM. She stated for the fall protocol, they covered the procedure for and an unwitnessed and witnessed fall. An unwitnessed fall automatically needed neuro checks. They were to do assessments, vitals before they have been moved, and check for pain and any possible dislocations. Nurses were to do a whole assessment, notify the doctor and receive orders, and notify the DON, and family. Witnessed falls with head injury called for the same procedure except they would medicate immediately, do neuro checks, and vitals. If there was an emergency and they needed to call 911, nurses can call them and let the doctor and family know. Some examples of emergencies were an acute change in cognition, head injuries, suspected dislocation, pain upon movement, headaches, and suspected bleeding. Everything that needed to be documented after a fall would be the SBAR, risk management, pain assessment, skin assessment, fall assessment, and neuros. LVN B stated that the quick guide for fall assessments was located at the nurse's station and they gave each nurses a copy after the in-service. In an interview with on 7/27/24 at 4:47 PM with LVN C, she stated that she had started work at the facility on 6/5/24 and worked the 6AM- 6PM shift. She explained the fall protocol was to assess the patient before the touched them for injuries and check their vitals. If it was an unwitnessed fall she would we do neuro checks and check head to toe to make sure there was no other pain. Nurses will also make sure the doctor and DON was aware. If on blood thinners, they would send the resident to the hospital. Vitals should be monitored and if they have major symptoms like bleeding, unresponsiveness, not alert and oriented, she would send them out because she did not want to take any chances. LVN C also stated that the doctor, family, and DON must be aware. For every fall, nurse complete a SBAR, fall assessment, pain assessment, skin assessment, and do neuro checks. Neuro checks were especially completed if the fall was unwitnessed or witnessed with a head injury. If there was an emergency like the patient was unresponsive or a mood change in condition, she would call 911 first and the call the doctor. She explained that they have quick sheets for fall protocols and book for the neuros that she kept at her desk at the nurse's station. In an interview on 7/27/24 at 4:53 PM with LVN D, she stated she started working at the facility on 06/01/24 and she worked the 6AM- 6PM shift. She explained that in the fall protocol in-service, they covered what to do in a witnessed and unwitnessed fall. Nurses have to do an incident t report and SBAR. If the CNAs found the resident first, she would make sure they don't touch them, and continue with vitals, neuro checks, and check for broken bones. She would also check to see if the resident was on blood thinners and if there was an emergency, she would call 911 immediately without waiting on a response from the doctor. Examples of emergencies would be if they were on a blood thinner and hit their head, visibly bleeding profusely, broken limbs, unconscious, headaches, seizures, and if there was something she couldn't control. She explained when was had to call 911 for emergency, she would notify the DON, she would stay with the resident, and assign someone else to call 911. She would also doctor or on call if they take too long, she would call the Medical Director and notify the family. If the resident was their own RP, she would write that in the risk management assessment and SBAR, as well as in her own progress note. There was a fall protocol quick note sheet she was given during the education that she placed at her desk and she stated that she also kept all of the paperwork from facility in-services in her work bag. Nursing also had a flow sheet for monitoring neuros, which was just updated. LVN C said for neuros, they have to follow up every 30 minutes, for up to 72 hours and it was self-explanatory. In an interview on 7/27/24 at 5:15 PM with the ADON, she stated that in the fall protocol nurses went over the steps of what to do when there was a fall, what documentation, and who to notify when you can and cannot notify the physician. The documentation was the risk assessment of incident report, SBAR, fall assessment, pain assessment, and skin assessment. They were to make sure to notify the physician and RP if there was one and the DON for protocol because there was a change in condition. She stated she also does a progress note. It the fall was unwitnessed and with a head injury, nurses have to start neuros. When a resident falls, they go to the resident and let CNA's know not to touch them. They perform a full head to toe assessment, do range of motion, and check skin integrity for any tears bumps bruising. Then she would assess if they were in pain and if so, immediately address with PRN pain meds, and if none I get an order form the physician. Nurses do not have to contact the physician first if there was a 911 situation. She explained she would do what was best based off her nursing judgment. Emergencies would be any changes in head or skin, nonstop bleeding, headaches non-retractive, unstable vitals, changes in neurological conditions, and vomiting. If they contact the doctor and they have not responded after 15-20 minutes, she would contact the DON and the medical director by phone call to let them know what is going on. The fall quick notes are kept at the nurse's station and it outlined step by step what also needed to be done in care of a fall, including neuro checks done every 30 minutes. In an interview on 07/27/24 at 5:30 PM with the WCN, she stated she been here since 4/22/24, and worked Monday through Friday from 8AM- 6PM. She stated that in the fall protocol, they went over what the policies were if the fall was witnessed or unwitnessed, neuro checks, and what the procedures were. When a resident falls, she would do a head-to-toe assessment, vital signs, and contact the physician and notify the family. If the fall was unwitnessed, she would start her neuro checks. She stated that she would count the vitals she did initially as her first check and start from there. Assessments completed were the neuro assessment, pain assessment, progress note, SBAR, fall assessment, range of motion, and skin assessment. If the resident was nonverbal, we look for verbal cues. Nurses can call 911 if there was an emergency and they needed medical attention before contacting the doctor. These emergencies included bleeding, possible fracture, unresponsiveness, seizures, change in condition, headaches, injuries, or bleeding. If she could not reach the doctor, she would still have to notify the DON, ADON, and the medical director. The fall protocol quick sheets were kept at the nursing stations. If the form said RP on the neuro check sheet and the resident was their own RP, she would still contact the emergency contact because she wanted to let someone know what was going on. Day 2: Sunday July 28th, 2024 In an interview on 07/28/24 at 1:10 PM with LVN E, said she was in-serviced on fall protocol policy. She said a head-to-toe assessment, neuro checks, SBAR, fall assessment, pain assessment and skin assessment had to be completed for residents who had a witness or unwitnessed fall. She said vital signs and range of motion had to be completed and documented. She said a resident who was bleeding, took blood thinners, vital sign out of normal range, unconscious, broken bones would be sent out 911. She said she would make notifications to the RP, Administrator, DON, ADON and the physician. She said there was a cheat sheet located at the nurses' station for reference if needed. In an interview on 07/28/24 at 1:37 PM with LVN F said she was in-serviced on fall protocols. She said there was a binder at the nurse's station to refer to if needed. She said residents who had a change in condition, unresponsive, on blood thinners/had bleeding, fractures would be sent out 911. She said the Doctor, DON, ADON, Administrator and RP would be notified. She said a head-to-toe assessment would be completed along with SBAR, range of motion, pain, skin and fall assessments. She said neuro checks would be completed in various intervals indicated on the neuro check form. In an interview on 07/28/24 at 2:03 PM with LVN G said with a fall and a resident has a head injury he would do assessment head to toe, take vital signs, check range of motion and call the Doctor, DON, Administrator and family. He said he would document in the nursing notes along with neuros checks, pain, fall and skin assessment. If they hit their head, we send the resident out 911 if there was bleeding, on anticoagulants, unresponsive and change of condition that was not at the resident's baseline. He said we have a binder at the nursing station to refer to if needed on the steps to take after a fall. In an interview on 07/28/24 at 2:09 PM with LVN H said she had been in-serviced and was aware of the steps to follow after a witness or unwitnessed fall. She said a head-to-toe assessment would be completed with range of motion to detect any fractures. She said residents with fractures, bleeding, on anticoagulants, and unresponsive would be sent out by 911. She said residents who had a witness or unwitnessed fall, neuro checks, SBAR, fall assessment, pain assessment and skin assessment had to be completed. She said the DON, Administrator, Family and Doctor is notified. He said there was a quick guide at the nurses' station with all of the fall protocol steps. In an interview on 07/28/24 at 2:29 PM with LVN I said he was aware of the fall protocols. He said he would check a resident's vitals, range of motion and head to toe assessment for unwitnessed or witnessed falls. He said if a resident was not responsive, bleeding, on blood thinners, change in condition, or broken bones the resident would be sent out 911. He said after a resident had a fall, neuros, fall, pain, and skin assessments had to be completed. He said there was a reference guide at the nurses' station with the fall protocol. He said the steps taken after a fall had to be documented and notifications made to the doctor, family, DON and Administrator. In an interview on 07/28/24 at 2:48 PM with LVN J said after a fall all steps taken had to be documented. She said a quick guide for falls was located at the nurse's station. She said a SBAR, risk management, pain assessment, skin assessment, fall assessment, and neuros had to be completed. She said when there was a change in condition, bleeding, head injuries, unconscious or fractures a resident would be seen out 911. She said notifications should be made to the family, DON, ADON, Administrator and the physician. In an interview on 7/28/24 at 7:12 AM with LVN K said she was in serviced on the facility's fall policy. She said all actions taken after a fall had to be documented. She said a fall assessment, neuro checks, skin and pain assessments had to be completed. She said notifications to the physician, family and DON should be completed. She said the facility placed a quick guide at the nurses' stations to reference the steps after a fall. She said residents would be sent out 911 after a fall, if they had bleeding, unconscious, range of motion issues that indicated broken bones, and abnormal vitals. Record review of facility Education In-services on Quick Guide - Falls, Change in Condition Communication, Neurological Neuro Checks, Fall Management, Investigation of Falls, Fall Management Post Test dated 7/26/24-7/28/24 revealed all staff were trained on the Fall Management Policies and tested on knowledge of the policies. The Admin was informed the Immediate Jeopardy (IJ) was removed on 7/28/24 at 7:09 PM. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on interview and record review the facility failed to accurately assess each resident's cognitive status for 2 of 18 residents (Resident #28, #42), reviewed for assessment accuracy. - The facility failed to accurately assess and document Resident #42's cognitive patterns on two different consecutive MDS assessments, and Resident # 28's Annual MDS reflected he had all his natural teeth. These failures could place residents at risk of not having accurate assessments, which could compromise their plan of care. Findings included: Resident #42 Record review of Resident #42's Admission Record dated 1/10/24 revealed a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of thrombocytopenia, (low platelet level), alcoholic cirrhosis of liver with ascites, (a stage of acute liver disease where the liver has become significantly scarred with abdominal swelling), portal hypertension (elevated blood pressure in the portal venous system (the portal vein is a major vein that leads to the liver) the most common cause of cirrhosis or scarring of the liver), and cerebral infarction (the pathological process that results in an area of dead tissue in the brain caused by disrupted blood supply and restricted oxygen supply to the brain. Record review of Resident #42's Significant change in status MDS assessment dated [DATE] revealed he was coded in section B Hearing, Speech, and Vision as sometimes understood- ability is limited to making concrete requests and sometimes understands-responds adequately to simple, direct communication only. Further record review revealed in part of section C for Cognitive Patterns .C0100. Should Brief Interview for Mental Status be Conducted? Was coded 0. No ( resident is rarely/never understood). Resident #42 was coded as having a SAMS score indicating he was severely impaired for cognitive skills for daily decision making. Record review of resident #42's Q MDS assessment dated [DATE] revealed he was coded as sometimes understood- ability is limited to making concrete requests and sometimes understands-responds adequately to simple, direct communication only. Further record review revealed in part of section C for Cognitive Patterns .C0100. Should Brief Interview for Mental Status be Conducted? Was coded 0. No (resident is rarely/never understood). Resident #42 was coded as having a SAMS score indicating he was severely impaired for cognitive skills for daily decision making . In an interview with SW on 1/8/24 at 1:38 pm she said she was responsible for completing sections B, C, D, E, F and Q of the MDS. She said she had worked at the facility for 4 years. She said she had completed Resident #42's Significant Change MDS dated [DATE] and the 12/1/23 Q MDS for Resident #42. The SW said that she coded Resident #42 incorrectly on both the 8/31/23 and 12/1/23 MDS assessments. She stated she should have attempted a BIMS if she coded that the resident was sometimes understood and sometimes understands. The SW said she did not know why or how she coded Resident #42's assessment incorrectly. The SW said she thought the corporate MDS signed attesting to the accuracy of the MDS' once completed. She said she had not been formally trained on how to complete the MDS . Interview with the Corporate MDS on 1/10/24 at 12:36pm who said that the BIMS assessment should have been attempted on Resident #42's Significant Change MDS dated [DATE] and on the 12/1/23 Quarterly MDS, based in the information the SW coded in section B on both MDS's. She said that she did not sign any MDS' in attestation of accuracy and could not speak to how accurate of an MDS it was. She said Resident #42's 8/31/23 and 12/1/23 assessments should and could be modified for accuracy because a resident should always have an accurate assessment as part of their plan of care . Resident #28 Record review of Resident #28's electronic face sheet on 01/10/24 revealed a [AGE] year-old male, initially admitted to the facility on [DATE] readmitted on [DATE] and readmitted on [DATE]. His diagnoses included Diabetes mellitus due to underlying condition with diabetic neuropathy, history of traumatic brain injury, essential hypertension, sequelae of cerebral infarction (A condition resulting from long time brain damage), constipation (inability to have regular bowel Record review of Resident #28's annual MDS assessment dated [DATE] section L oral denture section B no natural teeth or tooth decay was left blank. Section L Z was checked as None of the above indicating Resident #28 had all his natural teeth and no issue. Record review of Resident #28's care plan with a revision date of 04/19/21 and a target date of 03/12/24 revealed Resident #28 is at risk for has oral/dental health problems (r/t no teeth) Intervention: Provide mouth care as per ADL personal hygiene . Observation on 01/08/24 at 11:00AM, revealed he was in bed sleeping. He had a G-tube on at 55 cc per hour. He was clean and dry. Observation on 01/08/24 at 2:00Pm revealed he was in bed. He was awake, alert, and oriented to his name. He did not speak much but was able to say good. He was not interviewable to answer detailed questions. He could only answer yes and no questions. During an interview with the MDS nurse on 01/10/24 at 1:30 PM, she said she was responsible for ensuring that the MDS assessment accurately reflected resident's condition. She said she worked remotely and occasionally visit each resident at the facility. She said she completed the MDS by reviewing documentations from all disciplines and importing the findings into the MDS. She stated Resident #28 had no natural teeth. She said the MDS was coded wrong. She said inaccurate assessment may prevent residents from getting the care needed. She said she would modify the MDS and submit it . Record review of Facility's policy on resident assessment dated ,d+[DATE] read in part: It is the policy of this facility that a registered nurse will conduct or coordinate each assessment with the interdisciplinary team. An MDS, which is a comprehensive, accurate, standardized reproducible assessment will be completed for each resident, using the RAI process. Facility staff complete a comprehensive assessment of each resident's needs, strengths, goals, life history, and preferences, and offer guidance for further assessment once problems have been identified. The comprehensive assessment is completed initially and periodically. Quarterly and Significant Change assessments are completed as required, following the RAI specific guidelines. State-specific versions of such assessments are completed within the required timeframes according to applicable law and regulations. MDS Accuracy MDS 3.0 Internal Audit Tool 1) The MDS 3.0 Internal Audit Tool will be completed on 1 MDS weekly, alternating between PPS and OBRA assessments. 2) The review is NOT to be completed by the MDS nurse that completed the MDS under review. 3) For the review, select the most recently completed MDS assessment. 4) The goal is for a 100% correct match between the facility and reviewer columns. 5) Identify reason(s) for differences and educate to reduce differences. 6) Monitor discrepancies over time Each assessment must represent an accurate picture of the resident's status during the observation period of the MDS. When the MDS is completed, only those occurrences during the observation period will be captured on the assessment. If it did not occur during the observation period, it is not coded on the MDS. 39977 .

Based on interview and record review, the facility failed to ensure that the resident and/or representative had the right to participate in the development and implementation of his or her person-centered plan of care, and to ensure that the planning process facilitated the inclusion of the resident and/or representative for one (Resident #42) of six residents reviewed for participation in care plan. The facility failed to ensure the IDT included Resident #42's RP, in the review of his comprehensive assessment and were able to discuss his individualized care needs for services to include his need for medical and nursing care, medications, therapy, psychological, and dietary needs. The failure could affect residents by placing them at risk for not receiving adequate or individualized care. Findings included: Record review of Resident #42's Admission Record dated 1/10/24 revealed a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of thrombocytopenia, (low platelet level), alcoholic cirrhosis of liver with ascites, (a stage of acute liver disease where the liver has become significantly scarred with abdominal swelling), portal hypertension (elevated blood pressure in the portal venous system (the portal vein is a major vein that leads to the liver) the most common cause of cirrhosis or scarring of the liver), and cerebral infarction (the pathological process that results in an area of dead tissue in the brain caused by disrupted blood supply and restricted oxygen supply to the brain. The Admission Record reflected 2 other family members as RP's. Record review of Resident #42's Quarterly MDS assessment dated [DATE] revealed his BIMS score was not assessed and his SAMS revealed he was coded as severely impaired for cognitive skills for daily decision making. The assessment reflected no physical or verbal behaviors, no rejection of care or wandering. Resident #42 required setup or clean-up assistance with eating and partial to moderate assistance with oral and personal hygiene, toileting, shower/bathing, upper/lower body dressing, rolling left to right, sit to lying, sit to stand and all other transfers and, used a wheelchair for ambulation. Resident #42 was always incontinent of bowel and bladder, and received antipsychotic, antianxiety, insulin and opioid medications on a routine basis. Record review of Resident #42's EMR revealed a care plan meeting dated 8/25/23. There were no other documented care plan meeting notes. In an interview with Resident #42's RP on 1/8/24 at 11:55 am, they said that they had not participated in any care plan meetings since last summer and the facility staff were hard to contact via telephone. The RP said that they periodically tried to reach staff including the SW and would leave messages and no one ever returns their telephone calls. In an interview with the SW on 1/8/24 at 1:38 pm, she said she was responsible for scheduling, setting up, and attending care plan meetings for all the residents. The SW said she was the permanent SW for the facility for 4 years and was no longer corporate. The SW said that the care plan meetings should occur at least every 3 months (quarterly). She said that Resident #42's last care plan meeting was 8/25/23. The SW said that Resident #42's RP was busy and seemed to be rushed when they visited so, the SW did not want to bother them. The SW said that Resident #42 was on hospice care services and had been expected to pass away. The SW then said that Resident #42 should have had a care plan meeting on or around 11/25/23 but had been in the hospital at that time. She said she did not know why she did not reschedule the care plan meeting once he returned to the facility on the same day (11/25/23).and she said that she needed to schedule a care plan meeting for the resident and did not know why she had not set up a meeting yet. The SW said that all residents should have a care plan meeting to review care needs and any changes to their plans of care . Subsequent record review of Resident #42's EMR on the last day of survey 1/10/24 revealed in part: Progress Notes NEW: Effective Date: 1/10/2024 8:35 Type: Care Conference Summary .Reason for Care Conference: (annual, quarterly, significant change): Follow-up with concerns from RP Record review of the facility's policy titled, Nursing Policies and Procedures, dated as revised 6/2019 revealed in part: A comprehensive care plan will be developed within 7 days after the completion of the comprehensive assessment . to the extent possible, the participation of the resident, the resident's family and/or responsible party should participate in the development of the care plan .every effort will be made to schedule care plan meetings to accommodate the availability of the resident and family or responsible party .Scheduling and preparation of the care plan meeting calendar is completed by the MDS Coordinator or designee .The MDS Coordinator and or designee will notify the resident, family and/or responsible party, and other interested parties designated by the resident, of the date and time of the care plan conference at least one week prior to the meeting.

Based on interview and record review the facility failed to complete and transmit an MDS for 2 of 3 (CR #31& CR #95) residents reviewed for closed records. 1 The facility failed to complete and transmit a discharge MDS for Resident #31 2 The facility failed to complete and transmit admission and discharge MDS for CR #95 These failures could place residents at risk of facility not providing complete and specific information for payment and quality of measure purposes. Finding included: CR #31 Record review of CR #31's Face sheet, on 01/10/24 revealed an [AGE] year-old male, initially admitted to the facility on [DATE] readmitted on [DATE] and discharged from the facility on 09/22/23. Record review of CR #31's MDS transmission records indicated the last MDS transmission was dated 08/29/23 and coded as Admission MDS. Record review revealed no discharge MDS. Record review of CR #31's nurses note dated 09/22/23 at 1:00PM read in parts resident discharged from the facility. CR #95 Record review of CR #95's electronic Face sheet, on 01/10/24 revealed a [AGE] year-old male, initially admitted to the facility on [DATE] readmitted on [DATE] and discharged from the facility on 08/29/23. His diagnoses included sepsis (infection), admitting diagnosis encephalopathy (disease that affects brain structure or function), chronic kidney disease, acute embolism, thrombosis of [NAME] ([NAME] disease), anemia, anxiety, urine retention, benign prostatic hyperplasia with lower urinary tract symptoms, and lack of coordination. Record review of CR #95' admission MDS dated [DATE]was sign as completed on 10/20/23, 32 days after admission. Record review of nurse's notes dated 12/21/23 read in part: resident found unresponsive. hospice contacted. RP contacted. RN with hospice present. resident time of death 04:49. Record review of CR #95's MDS transmission revealed no records of discharge MDS for CR #95 During an interview with MDS Coordinator on 01/10/23 at 1:30PM, she said the discharge MDS was overlooked, and she would initiate the discharge MDS. She said it was a human error. She said she had no explanation but would correct it. She said she was responsible for completing the MDS timely and getting it to the RN for signature. She said the facility was without a certified MDS for sometimes. She said the facility would have something in place to track uncompleted MDS's. Policy on MDS completion was requested from the MDS coordinator. Provided MDS policy dated 06/2019. titled Nursing policies and Procedures. Subject: Minimum Data set- policy which did not address failure to complete MDS assessment.

Based on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection for 9 of 15 residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #10, Resident #13) reviewed for pressure ulcers. 1. The facility failed to provide wound care for all Residents with wounds according to their physician orders from March and April 2023 and resulting in new pressure ulcers, worsening of existing wounds, and infected wounds for Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #10, and Resident #13. 2. The facility failed to ensure LVN A, who was the interim treatment used proper infection control measures during wound care for Resident #5, Resident #6, and Resident #13, when she did not change her gloves, did not use proper hand washing techniques, she opened wound care supplies outside of the residents room. 3. The facility failed to ensure Resident #2, Resident #4, Resident #6, Resident #8, and Resident #13's wounds were regularly assessed, treated and maintained by a physician. 4. The facility failed to provide wound care according to physician orders for Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #10, and Resident #13. An Immediate Jeopardy (IJ) was identified on 4/28/23 at 4:30 p.m. While the IJ was lowered on 5/3/23 at 10:58 a.m., the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of widespread as the facility continued to monitor the implementation and effectiveness of their plan of removal. These failures placed residents who received wound care at risk of developing new pressure wounds, worsening of existing wounds, decline in quality of care, infection, and experiencing pain. Findings include: Resident #2 Record review of Resident #2's face sheet revealed he was admitted to the facility on [DATE]. He was [AGE] years old and was diagnosed with osteomyelitis (bone infection), pulmonary embolism (blocked flow of blood), anemia, abnormal level of blood mineral, edema (swelling), cellulitis (bacterial skin infection), obstructive and reflux uropathy (disorder of urinary tract), fracture of right femur and neuralgia and neuritis (nerve pain caused by inflammation). Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed he was cognitively intact with a score of 15 for cognition and was able to understand and make himself understood. Resident #2 was totally dependent with two person assist for bed mobility, personal hygiene, and dressing and had activity that did not occur for transfers, walking in room and corridor, and activity that occurred once or twice with one person assist for locomotion on and off the unit and toilet use. Resident #2's active diagnosis included hip fracture, malnutrition, bacteremia (bacteria in blood), 2 stage 3 pressure ulcers, 2 stage 4 pressure ulcers and a skin tear. Record review of Resident #2's care plan dated 2/22/23 for unavoidable pressure ulcer development route of history of ulcers, immobility, contracture, bowel and bladder incontinence, medication use. Goal: ulcer will show signs of healing and remain free from infection by/through review date. Intervention/tasks: Administer treatment as ordered and monitor for effectiveness, Assess/record/monitor wound healing (Q Weekly and PRN) Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD .[Resident #2] was admitted with deep tissue pressure injury right heel, skin tear to posterior right thigh, [Resident #2] was readmitted with Stage 3 pressure injury to left distal lateral foot (the outside or furthest away from body), unstageable pressure ulcer to right heel, pressure to sacrum with wound vacuum, skin tear to right elbow. Stage 3 route of left dorsal foot, stage 3 to left medial ankle, stage 3 left outer ankle .Goal: [Resident #2's] pressure ulcer will show signs of healing and remain free from infection by/through the review date. Intervention/Tasks: Administer treatments as ordered and observe for effectiveness. Assist [Resident #2] to reposition and/or turn at frequent intervals to provide pressure relief. Complete a full body check weekly and document .Observe dressing q shift to ensure it is intact and adhering. Report lose dressing to treatment nurse. Observe/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length x width x depth), stage .Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. Record review of Resident #2's Physician's Orders dated 4/26/23, revealed: Wound: Abrasion to anterior right lower leg, clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily. Every day shift every other day for wound/skin management. Wound: Abrasion to posterior right lower leg, clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily, every day shift every other day for wound/skin management. Wound: Abrasion to right knee, cleanse with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily, every day shift every other day for wound/skin management. Wound: Skin tear to right iliac crest, clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily. Every day shift every other day for wound/skin management. Wound: Unstageable pressure injury to the left knee, clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily. Every day shift every other day for wound/skin management. Wound: Unstageable pressure injury to the posterior right knee, clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily. Every day shift every other day for wound/skin management. Record review of Resident #2's Medication Administration Record/Treatment Administration Record for April 2023 printed on 4/25/23 revealed: Wound: Abrasion to anterior right lower leg, Clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily. Every day shift every other day for Wound/Skin Management -Order Date-03/23/2023 at 10:42 a.m. revealed on 4/2/23, 4/4/23, 4/6/23, 4/8/23, 4/9/23, 4/10/23, 4/12/23, 4/14-24/23 treatment was not administered WOUND: Abrasion to posterior right lower leg, Clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily. Every day shift every other day for Wound/Skin Management -Order Date- 04/13/2023 at 10:59 a.m. revealed on 4/13/23-4/24/23 treatment was not administered. WOUND: Abrasion to right knee, Clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily every day shift every other day for Wound/Skin Management -Order Date- 12/16/2022 at 1:47 p.m. was not treated on 4/9/23, 4/11/23, and 4/15-4/24/23. WOUND: Skin tear to right iliac crest, Clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily. Every day shift every other day for Wound/Skin Management -Order Date- 03/17/2023 10:33 a.m. was not treated on 4/9/23, 4/11/23, and 4/15-4/24/23. WOUND: Unstageable pressure injury to the left knee, Clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily. every day shift every other day for Wound/Skin Management -Order Date- 04/13/2023 10:57 a.m. revealed on 4/13-4/23/23 treatment was not administered. WOUND: Unstageable pressure injury to the posterior right knee, Clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily. every day shift every other day for Wound/Skin Management -Order Date- 04/14/2023 06:40 a.m. revealed on 4/14-4/23/23 treatment was not administered. Record review of Resident #2's Weekly Wound Observation: Wound #7 dated 4/12/23 at 11:21 a.m. revealed: 4/12/23, [Physician] updated on wound status via phone .location right anterior lower leg, abrasion, worsening, granulation ( lumpy, pink tissue containing new connective tissue and capillaries forms around the edges of a wound) tissue present beefy red), 6x4x0.1. current treatment plan: clean with NS or wound cleanser, pat dry, apply alginate and dry dressing daily, wound progress: worsening. Wound #8 dated 4/12/23 at 11:24 a.m. revealed : 4/12/23, [Physician] updated on wound status via phone .location right iliac crest, skin tear, unchanged, granulation tissue present (beefy red), serosanguinous, 1x1x0.1, cleanse with NS or wound cleanser, pat dry, apply alginate ad dry dressing daily. Wound #1 dated 4/13/23 at 11:26 a.m. revealed: 4/13/23, [Physician] updated on wound status via phone .location left knee dated acquired 4/13/23, pressure, Stage X, first observation, no reference, granulation tissue present (beefy red), slough tissue present (yellow, tan, white, stringy), 25% moist yellow slough, moderate serosanguinous, 5x2.5x0, clean with NS or wound cleanser, pat dry, apply alginate and dry dressing daily, new wound. Wound #2 dated 4/13/23 at 11:28 a.m. revealed : 4/13/23, [Physician] updated on wound status via phone .location posterior right knee, date acquired 4/13/23, Stage X, first observation, no reference, granulation tissue present (beefy red), moderate serosanguinous, 2x2.5x0, cleanse with NS or wound cleanser, pat dry, apply alginate and dry dressing daily. Wound #3 dated 4/13/23 at 11:31 a.m. revealed : 4/13/23, [Physician] updated on wound status via phone .location posterior right lower leg, acquired 4/13/23, abrasion, first observation, no reference, granulation tissue present (beefy red), moderate serosanguinous, 4x4x0.1, cleanse with NS or wound cleanser, pat dry, apply alginate and dry dressing daily. Record review of Resident #2's SBAR (Change of Condition) dated 4/13/23 at 11:02 a.m. revealed New Wounds. Record review of Resident #2's Skin Observation dated 4/13/23 at 11:04 a.m. revealed skin check was not refused, resident's skin not intact, Resident has new areas, resident has non-pressure areas, site: left knee (front) unstageable pressure injury, right knee (rear) unstageable pressure injury, right lower leg (rear) abrasion, right iliac crest (illium top border that creates the pelvis) (front) skin tear, right lower leg (front) abrasion, right knee (front) abrasion. Record review of Resident #2's Braden Scale-Predicting Pressure Score Risk dated 4/13/23 at 11:07 a.m. revealed Resident #2 was moderate risk, scoring 13.0 and Resident #2 responded to verbal commands. Had no sensory deficit which would limit ability to feel or voice pain or discomfort. Skin was often but not always moist. Linen must be changed at least once a shift. Confined to bed. In mobility responded only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness or has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of body. Nutrition was adequate eats over half of most meals. Ate a total of 4 servings of protein per day. Occasionally refused a meal but would usually take a supplement when offered or is on a tube feeding or TPN regimen which probably meets most of nutritional needs. Required moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slided down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction. Record review of Resident #2's Skin Observation dated 4/22/23 at 12:16 p.m. and signed on 4/27/23 at 12:17 p.m. revealed new areas: left knee (front) unstageable pressure injury, right knee (rear) unstageable pressure injury, right lower leg (rear) abrasion, right iliac crest (front) skin tear, right knee (front) abrasion, right lower leg (rear) abrasion. In an observation and interview on 4/25/23 at 10:55 a.m. with Resident #2 and CNA A, Resident #2 stated the last time he had wound care done was 2 weeks ago. Resident #2 stated LVN A did wound care for him on 4/25/23. Observation of Resident #2's left leg revealed his leg was contracted behind him. CNA A stated Resident #2's bandage date was dated 4/12/23, and the Wound Care Nurse had been gone for 2 weeks. Resident #3 Record review of Resident #3's face sheet revealed he was admitted to the facility on [DATE]. He was [AGE] years old and was diagnosed with dementia, hypokalemia (blood level below normal potassium), gastro-esophageal reflux disease (acid reflux), hypertension (high blood pressure), hypothyroidism (low thyroid activity), hypo-osmolality and hyponatremia (sodium in blood low), protein-calorie malnutrition, chronic kidney disease stage 3, and methicillin resistant staphylococcus aureus infection (bacteria with antibiotic resistance). Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed he was severely impaired with a score of 6 out of 15 for cognition. Resident #3 did not walk in room and walking in the corridor only occurred once or twice with one staff assisting, he was totally dependent with one person assist for locomotion off the unit and required extensive assistance with two staff for bed mobility, and transfers and extensive assist with one person assist for locomotion on unit, dressing, toilet use and personal hygiene. Record review of Resident #3's Care Plan dated 2/22/23 revealed Stage IV pressure ulcer to left heel r/t impaired mobility. Goal: The resident's will pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions/tasks: administer medications as ordered . Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing (Q Weekly) Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. The resident requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Record review of Resident #3's Physician's Orders dated 5/1/23, revealed: Wound: Stage IV pressure injury to the left heel, Clean with NS or wound cleanser, pat dry, apply silver alginate and dry dressing daily. Everyday shift for Wound/Skin Management -Order Date- 04/06/2023 at 1:02 p.m. starting 4/7/23. WOUND: Unstageable pressure injury to the dorsal left foot, Clean with NS or wound cleanser, pat dry, apply silver alginate and dry dressing daily. Everyday shift for Wound/Skin Management -Order Date- 04/10/2023 at 11:50 a.m. starting 4/11/23. WOUND: Unstageable pressure injury to the left distal lateral foot, Clean with NS or wound cleanser, pat dry, apply silver alginate and dry dressing daily. Everyday shift for Wound/Skin Management -Order Date- 04/10/2023 at 11:49 a.m. starting 4/11/23. Record review of Resident #3's Medication Administration Record/Treatment Administration Record for April 2023 printed on 4/25/23 revealed: Wound: Stage IV pressure injury to the left heel, Clean with NS or wound cleanser, pat dry, apply silver alginate and dry dressing daily. Every day shift for Wound/Skin Management -Order Date- 04/06/2023 at 1:02 p.m. starting 4/7/23 was not administered on 4/8/23, 4/9/23, 4/11/23, 4/14-4/16/23, 4/19-4/24/23. WOUND: Unstageable pressure injury to the dorsal left foot, Clean with NS or wound cleanser, pat dry, apply silver alginate and dry dressing daily. Every day shift for Wound/Skin Management -Order Date- 04/10/2023 at 11:50 a.m. starting 4/11/23 was not administered on 4/11/23, 4/14-4/16/23, 4/19-4/24/23. WOUND: Unstageable pressure injury to the left distal lateral foot, Clean with NS or wound cleanser, pat dry, apply silver alginate and dry dressing daily. Everyday shift for Wound/Skin Management -Order Date- 04/10/2023 at 11:49 a.m. starting 4/11/23 was not administered on 4/11/23, 4/14-4/16/23, 4/19-4/24/23. Record review of Resident #3's Wound Care Physician notes dated 4/18/23 at 3:24 p.m. revealed: Wound Status: left heel, pressure ulcer, since 12/20/22, measurements 2x2.5x1 area 5, volume 5, Stage 4 Pressure injury, moderate, sero-sanguineous. Record review of Resident #3's Wound Care Physician notes dated 4/18/23 at 3:24 p.m. revealed: Wound Status: Right, Dorsal foot, measurements 2x2x0.5 area 4, volume 2, initial exam, Stage 4 pressure injury, moderate, sanguineous Record review of Resident #3's Wound Care Physician notes dated 4/25/23 at 1:34 p.m. revealed: Location: left heel since 12/20/22, measurements 1.5x1.5x1 area 2.25, volume 2.25, wound progress improving, Stage 4 Pressure injury, moderate, sero-sanguineous. Record review of Resident #3's Wound Care Physician notes dated 4/25/23 at 1:34 p.m. revealed: Wound Status: Right, Dorsal foot, measurements 2x2x0.5 area 4 and volume 2, wound progress no change, Stage 4 pressure injury, moderate, sanguineous. Record review of Resident #3's Wound Care Physician notes 4/25/23 Wound #2 Left, Dorsal foot, post debridement (removement of damaged tissue) measurements 2x2x0.6 area 4, percent debrided 50, total area debrided: 2 sq cm and volume 2.4. Record review of Resident #3's Physician progress note dated 4/23/23 revealed: Chief complaint: MRSA infection on left food wound. Skin: left heel stage 4 wound, measuring 2x2.5x1cm, 76-100% granulation; right dorsal foot stage 4 2x2x0.5x1 cm, 76-100% granulation. Labs:4/17/23 Reported left foot stage 4 wound, measuring 2x2.5x1 cm, wound culture reviewed is positive for MRSA with heavy growth, contact isolation. Record review of Resident #3's Skin Observation dated 4/10/23 at 11:45 a.m. by Physician revealed skin was not intact, resident had new areas identified, resident had pressure injuries, resident did not have non-pressure areas: left heel pressure injury, left distal lateral foot pressure injury, top of left foot pressure injury. Record review of Resident #3's Skin Observation dated 4/18/23 at 10:24 p.m. by Physician revealed skin was not intact, resident did not have new areas, resident had pressure injuries and no non-pressure areas: left ankle (outer) open area noticed dressing intact. Record review of Resident #3's Skin Observation dated 4/26/23 at 9:28 p.m. by Physician revealed skin was not intact, resident did not have new areas, resident had pressure injuries and no non-pressure areas: left heel, left lateral and distal foot-pressure area. Record review of Resident #3's Skin Observation dated 4/29/23 at 7:54 p.m. by Physician revealed skin was not intact, resident did not have new areas, resident had pressure injuries and no non-pressure areas: left ankle (inner), left ankle (outer), left heel. Record review of Resident #3's Weekly Wound Observation dated 4/11/23 at 11:16 a.m. by Physician revealed MD was updated on 4/11/23, left heel, acquired 12/20/22, pressure, granulation tissue present (beefy red), serosanguinous, moderate, measurement 3x1.6x0.7. Record review of Resident #3's Weekly Wound Observation dated 4/11/23 at 11:18 a.m. by Physician revealed MD was updated on 4/11/23, Dorsal left foot, acquired 4/10/23, pressure, original X, first observation, no reference, granulation tissue present (beefy red), slough tissue present (yellow, tan, white, stringy), 50% moist yellow slough, moderate serosanguinous, measurement 1.5x1.5x0. Treatment: Clean with NS or wound cleanser, pat dry, apply silver alginate and dry dressing daily. Wound Progress New. Record review of Resident #3's Weekly Wound Observation dated 4/11/23 at 11:21 a.m. by Physician revealed MD was updated on 4/11/23, Left Distal Lateral Foot, acquired 4/10/23, pressure, original X, first observation, no reference, granulation tissue present (beefy red), moderate serosanguinous, measurement 3x1.6x0.5. Treatment: Clean with NS or wound cleanser, pat dry, apply silver alginate and dry dressing daily. Wound Progress New. Record review of Resident #3's Weekly Wound Observation dated 4/18/23 at 1:40 p.m. by Physician revealed MD was updated on 4/18/23, Dorsal left foot, acquired 4/18/23, pressure, original IV, first observation, no reference, granulation tissue present (beefy red), moderate serous, measurement 2x2x0.5 area 4 volume 2. Treatment: Clean wound to left dorsal foot with ns/wound cleanser, pat dry, apply calcium alginate with silver and dress with dry dressing daily. Wound Progress initial exam. In an interview on 4/25/23 at 11:04 a.m. Resident #3 he stated he had not had wound care for 2 weeks, and the nurse just did wound care on him on 4/25/23. In an interview on 4/25/23 at 11:27 a.m. with LVN A she stated Resident #3 had a dressing on, but there was no date before she went in on 4/25/23 to complete Resident #3's wound care. LVN A stated she only did wound care on her days off at the facility for the entire building. In an observation and interview on 5/2/23 at 11:07 a.m. with LVN D, she stated Resident # 3 has an infection, MRSA, of the wounds. LVN D stated she had to make sure because she did not want to lie about what their isolation precaution was because this surveyor asked. LVN D stated it was staph infection and Resident #3 was on an antibiotic. Observation of wound care administered for Resident #3 revealed her techniques were good. Resident #4 Record review of Resident #4's face sheet revealed he was admitted to the facility on [DATE]. He was [AGE] years old and was diagnosed with urinary tract infection, hypertension (high blood pressure), colostomy status, acquired absence of left leg below knee, acquired absence of kidney, seizures, and pain. Record review of Resident #4's Admission MDS dated [DATE] revealed a BIMS score of 13 for cognition and was able to understand and make himself understood. Resident #4 did not walk in room or corridor, required extensive assistance with 1 person assist with toilet use, limited assistance with dressing with 1 person assisting, and personal hygiene with 2 person assisting. Resident #4 had 1 Stage IV pressure ulcer. Record review of Resident #4's Care Plan revealed pressure wounds and is at risk for further skin breakdown, infection, worsening of existing pressure wounds, new pressure wound formation AEB. admitted with Stage IV sacral pressure ulcer. Goal: [Resident's] skin will remain clean, dry and wound(s) will heal without further complications over the next 90 days. Interventions/tasks: Assist with turning/repositioning during rounds and PRN, encourage po/fluid intake within dietary limits, keep family/RP/MD informed of resident's wound healing progress, perform treatments per order- if no improvement- report to MD, provide pressure reducing device for ed and wheelchair, RD to review resident's medical record and make recommendations. Record review of Resident #4's Physician's Orders dated 4/26/23, revealed: Clean Stage IV Sacral wound with ns, pat dry, apply alginate and cover with dry absorptive dressing every day. One time a day for wound care. Record review of Resident #4's Wound Care Physician notes dated 4/18/23 at 7:11 p.m. wound location Sacral, Pressure ulcer, date acquired 4/13/23, wound measurements: 13x18x3 area 234 and volume 702. Wound encounter initial, moderate serous, surrounding skin maceration. Record review of Resident #4's Weekly Wound Observation by MD dated 4/29/23 at 7:27 p.m. Location Left Sacral, Pressure ulcer IV, granulation tissue present (beefy red), serosanguinous, measurements: 16x8x0.5. Record review of Resident #4's Medication Administration Record/Treatment Administration Record for April 2023 revealed: Clean Stage IV Sacral wound with ns, pat dry, apply alginate and cover with dry absorptive dressing q day. one time a day for Wound Care -Order Date- 04/20/2023 at 3:06 p.m. was not administered 4/20-4/22/23, and 4/24/23. Record review of Resident #4's Skin Observation dated 4/18/23 at 12:55 p.m. revealed skin check was not refused, skin was not intact, no new areas were identified, and resident did have pressure injuries: right knee (front), left knee (front) and Sacrum wound. Record review of Resident #4's Skin Observation dated 4/29/23 at 7:36 p.m. revealed skin check was not refused, skin was not intact, no new areas were identified, and resident did have pressure injuries: right buttock Stage 4 and left buttock stage 4. Record review of Resident #4's Skilled Progress notes dated 4/14/23 at 12:14 p.m. revealed Wound management: pressure sore in sacrum. In an observation and interview on 5/1/23 at 1:00 p.m. with Resident #4 he was observed in the dining area sitting in a wheelchair. Resident #4 stated that for 2 or 3 days the facility staff started trying to do wound care. Resident #4 stated the facility was giving it an effort now to do the wounds, because they never offered to help him when he was on contact isolation. Resident #4 stated the nurses were not wound care nurses and his wounds were bad. Resident #4 stated that his wounds could kill him. He stated before that he would go to LVN A for her to change the wound dressing. Resident #4 stated he went to LVN A daily to get supplies off of her cart and go do his own wounds and LVN A never offered to help him with the wounds. Resident #4 stated LVN A never asked him if he needed any kind of assistance. Resident #4 stated he found out they lied to the State, saying he was refusing his meds and refusing wound care. Resident #4 stated that it was a lie, and one of the nurses (unknown name) told him. Resident #4 stated he would not refuse his pills, and especially his blood pressure medication. Resident #4 stated he should not have to tell them how to do their job. Resident #5 Record review of Resident #5's face sheet revealed he was admitted to the facility on [DATE]. He was [AGE] years old and was diagnosed with functional quadriplegia, urinary tract infection, hypertension (high blood pressure), pressure ulcer of sacral region, Stage 3, and chronic pain. Record review of Resident #5's Quarterly MDS dated [DATE] revealed a BIMS score of 15 for cognition indicating he was cognitively intact and was able to understand and make himself understood. Resident did not walk in room, corridor, no locomotion on and off the unit, transfer occurred once or twice with 2 person assist, he was totally dependent on two staff for dressing, toilet use, extensive assistance with two person assist for bed mobility, and extensive assistance with one person assist with eating and personal hygiene. Resident #5 had 1 Stage 3 pressure ulcer. Record review of Resident #5's Care Plan dated 3/30/23 revealed a stage III pressure ulcer to the left hip r/t functional quadriplegia, incontinence bowel and bladder, impaired mobility. Goal: the resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. Intervention/Tasks: Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing (Weekly) measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Follow facility policies/protocols for the prevention/treatment of skin breakdown. The resident requires supplemental protein, amino acids, vitamins, minerals as ordered to promote healing. Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Record review of Resident #5's Physician's Orders dated 5/1/23, revealed: Treatment Clean pressure wound to left lateral ankle with ns/wound cleanser, pat dry, apply calcium alginate and dress with dry dressing daily every day shift started on 4/27/23. License nurse to monitor: Left Ankle for any abnormalities or changes to surrounding skin for s/s of infection, pain associated with site, and for presence of dressing every shift. Document plus(+) sign for no observed changes and a minus (-) sign for any observed changes, notify MD, and document findings in a progress note. Every shift started 4/30/23. License nurse to monitor: Left Hip for any abnormalities or changes to surrounding skin for s/s of infection, pain associated with site, and for presence of dressing every shift. Document plus(+) sign for no observed changes and a minus (-) sign for any observed changes, notify MD, and document findings in a progress note. Every shift started 4/30/23. License nurse to monitor: Right Hip for any abnormalities or changes to surrounding skin for s/s of infection, pain associated with site, and for presence of dressing every shift. Document plus(+) sign for no observed changes and a minus (-) sign for any observed changes, notify MD, and document findings in a progress note. Every shift started 4/30/23. Wound: Stage III pressure injury to the left hip, clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily. One time a day for wound/skin management started 1/20/23. Wound: Stage III pressure injury to the right hip, clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily. One time a day for wound/skin management started 4/29/23. Conduct weekly skin evaluation. Document UDA under assessments skin observations. Notify MD of new skin conditions. Every evening shift every Wednesday and Saturday for skin management started on 12/31/22 at 2 p.m. Wound: Stage III pressure injury to the left hip, Clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily started 1/20/23 at 6 p.m. Record review of Resident #5's Medication Administration Record/Treatment Administration Record for April 2023 printed on 4/25/23 revealed: WOUND: Stage III pressure injury to the left hip, Clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily. Everyday shift for Wound/Skin Management -Order Date- 01/19/2023 at 11:41 a.m. was not administered on 4/2/23, 4/8/23, 4/11/23, 4/14/23, 4/19-22/23, and 4/24/23. Record review of Resident #5's Wound Care Physician notes dated 4/4/23 at 1:34 p.m. revealed: Wound Status: Left hip, pressure ulcer, measurements 6x4x1 area 24 and volume 24, Wound progress no change, Stage 4 pressure injury, and moderate sero-sanguineous. Debridement Details: left hip, surgical, measurements 6x4x1.1 area 24 and percent debrided 25. Total area debrided: (sq cm) 6, volume: 26.4. Record review of Resident #5's Wound Care Physician notes dated 4/18/23 at 3:24 p.m. revealed: Wound Orders: left hip: Cleanse wound with Normal saline, apply alginate, cover wound with dry absorptive dressing, change dressing daily, reposition per facility protocol, off-load wound. Wound Left lateral ankle: Cleanse wound with normal saline, apply alginate, cover wound with dry absorptive dressing, change dressing daily, reposition per facility protocol, off-load wound. Record review of Resident #5's Wound Care Assessment Details dated 4/18/23 at 3:24 p.m. revealed: Left hip, pressure ulcer, date acquired 1/16/23, acquired at facility, wound measurements: 2.5x4.5x1 area 11.25 and volume 11.25. Wound description: wound progress deteriorating, Stage 4 pressure injury, moderate sero-sanguineous. Record review of Resident #5's Wound Care Assessment Details dated 4/18/23 at 3:24 p.m. revealed: Left lateral ankle, pressure ulcer, acquired at facility, wound measurements: 0.8x0.5x0.2 area 0.4 and volume 0.08. Wound description: wound progress initial exam, Stage 4 pressure injury, moderate serous. Record review of Resident #5's Wound Care Assessment Details dated 4/25/23 at 1:34 [TRUNCATED]

Based on observation, record review and interview the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 3 of 15 residents (Resident #1, Resident #4 and Resident #9) reviewed for quality of care. -The facility failed to follow up with physician for Resident #1's legs that were observed to be swollen, red, flaky with drainage. -The facility failed to accurately assess Resident #1's skin weekly as ordered by the physician. -The facility failed to establish wound care services for Resident #1 as ordered. -The facility failed to provide Resident #1 with pain medication as needed, per physician orders. -The facility failed to provide ancillary services for Resident #1 as ordered. -The facility failed to perform proper wound care techniques for all residents needing wound care for Resident #1, Resident #4 and Resident #9. -Resident #4 developed 2 stage 4 pressure ulcers after admission to the facility. One ulcer was measure at 16x8x.5 cm. -Resident #4 was not provided colostomy care/assistance by facility staff An Immediate Jeopardy (IJ) was identified on 4/28/23. The IJ template was provided to the facility on [DATE] at 4:30 p.m. While the IJ was removed on 5/3/23 at 10:58 a.m., the facility remained out of compliance at a severity level of actual harm that is an Immediate Jeopardy and a scope of pattern because all staff had not been trained on Quality of Care. These failures placed residents at risk of not receiving quality care and services to meet their physical, mental and psychosocial needs. Findings include: Resident #1 Record review of Resident #1's face sheet revealed he admitted to the facility on [DATE] and readmitted on [DATE]. He was a [AGE] year-old male with a diagnosis of Peripheral Vascular Disease (a systemic disorder that involves the narrowing of peripheral blood vessels), malaise (general feeling of discomfort), Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors), pain in right shoulder, and cervical region radiculopathy (nerve in the neck is compressed or irritated). Record review of Resident #1's care plan dated 3/7/23 revealed, Focus: Pain [Resident #1] complains of increased pain/discomfort and is at risk for further episodes of increased pain/discomfort and injury. Goal: [Resident #1] will maintain current levels of ADLs and any pain/discomfort will be relieved within 1 hour of delivery of pain medication or other intervention over the next 90 days. Intervention/Tasks: Allow to verbalize feelings of pain/discomfort .Monitor effectiveness of pain medication-report to MD of any noted, observe for s/sx of increased pain/discomfort-assess resident for possible causes, give pain medications, treatments, relaxation modalities, etc., check for relief, and utilize 0-10 numbers pain scale to assess pain level. [Resident #1] is at risk for poor circulation, irregular pulse, and chest pain AEB due to diagnosis of PVD. Goal: [Resident #1] will not develop complications related to disease process over the next 90 days. Intervention/Tasks: Administer medications as ordered, document any s/sx of PVD in the clinical record, encourage resident to be active and exercise within limitations, monitor lab works for abnormalities-report to MD of any noted, monitor for skin breakdown with close attention to lower extremities, and podiatry visits as needed. Record review of Resident #1's Admission MAR dated 2/24/23 revealed he was cognitively intact with a score of 14 out of 15 for cognition and was able to recall, understand and make himself understood. Resident #1's functional status revealed he did not walk in corridor, did not have locomotion on or off the unit and activity occurred once or twice with 1 person assist for walk in room, extensive assistance with two person assist for bed mobility, transfer, dressing, toilet use and extensive assistance with one person assist for eating and personal hygiene. Record review of Resident #1's physician orders revealed: Conduct weekly skin evaluation. Document UDA under assessments- skin observations. Notify MD of new skin conditions. Every evening shift every Wednesday for skin Management start date 3/15/23. Doxycycline Monohydrate 100 MG Capsule Give 1 capsule orally two times a day for Related to cellulitis (x10 days). for 10 Days Administer 1 capsule PO (100 mg Doxycycline) twice daily (for 10 days) related to cellulitis. -Order Date- 04/20/2023 5:15 p.m. was administered. Consult: May be seen and treated by a Dentist order date 3/29/23. Consult: May be seen and treated by a Podiatrist order date 3/29/23. Consult: May be seen and treated by an Optometrist/Ophthalmologist order date 3/29/23. Observation: Pain-Observe every shift. If pain present, complete pain flow sheet and treat trying non-pharmacologic interventions prior to medicating if appropriate. Document in the PNs. Every shift order started 2/18/23 and revision date 2/20/23. Lasix oral tablet 40 mg (Furosemide) give 1 tablet 1 time a day for edema revision dated 4/21/23 Aquaphor External Ointment (Emollient) Apply to lower legs topically two times a day for dermatitis revision date 4/20/23 Acetaminophen-Codeine #3 Oral Tablet 300-30 mg (Acetaminophen w/Codeine) Give 1 tablet by mouth every 6 hours as needed for pain start date and revision date 2/26/23 Tylenol Oral tablet 325 mg (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for pain start date 3/12/23 revision date 3/13/23 Record review of Resident #1's Medication Administration Record/Treatment Administration Record for April 2023 revealed: Conduct Weekly Skin Evaluation. Document UDA under Assessments - Skin Observations. Notify MD of New Skin Conditions. Every evening shift every Wed for Skin Management-Order Date- 03/09/2023 6:14 a.m. was documented as completed as ordered. Aquaphor External Ointment (Emollient) Apply to lower legs topically two times a day for dermatitis -Order Date- 04/20/2023 10:27 a.m. was administered as ordered. Observation: Pain - Observe every shift. If pain present, complete pain flow sheet and treat trying non-pharmacologic interventions prior to medicating if appropriate. Document in the PNs. Every shift -Order Date- 02/17/2023 at 10:34 p.m. revealed: no pain level recorded on: 4/6/23, resident had 0 pain on 4/4/23, 4/5/23, 4/7/23, 4/8/23, 4/9/23, 4/11/23, 4/13/23, 4/17/23, 4/19/23, 4/20/23, 4/21/23, 4/22/23, and 4/24/23. Acetaminophen-Codeine #3 Oral Tablet 300-30 MG (Acetaminophen w/ Codeine) Give 1 tablet by mouth every 6 hours as needed for pain -Order Date- 02/26/2023 at 3:45 p.m. revealed medication was administered on 4/1/23, 4/4/23, 4/6/23, 4/7/23, 4/8/23, 4/15/23, 4/16/23, 4/25/23, 4/26/23 and 4/27/23. Tylenol Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for Pain -Order Date- 03/12/2023 at 0931 revealed no medication was administered on 4/1-4/16/23 and 4/20-4/24/23, 4/26/23 and 4/27/23. Record review and interview on 4/26/23 at 10:10 a.m. with LVN A revealed Resident #1's last administration of Acetaminophen-Codeine #3 Oral tablet 300-30 MG was on 4/24/23 at 11:42 p.m. Record review of Resident #1's Skin Observation dated 3/8/23 at 6:11 a.m. revealed skin check was not refused, and skin was intact. Record review of Resident #1's Skin Observation dated 4/12/23 at 6:29 a.m. revealed skin check was not refused, and skin was intact. Record review of Resident #1's Skin Observation dated 4/27/23 at 7:36 p.m. revealed skin check was not refused, and skin was intact. Record review of Resident #1's Braden Scale-Predicting Pressure Score Risk dated 3/3/23 at 11:48 a.m. revealed mild risk with a score of 16. Moisture: Occasionally moist, Bedfast. Confined to bed, mobility slightly limited, Nutrition adequate, friction & Shear: no apparent problem. Record review of Resident #1's Braden Scale-Predicting Pressure Score Risk dated 3/31/23 at 1:54 a.m. revealed no risk with a score of 21. Moisture: Occasionally moist, Walks frequently, mobility no limitation, Nutrition adequate, friction & Shear: no apparent problem. Record review of Physician A Progress note dated 3/14/23 at 7:20 p.m. revealed: 3/14/23 [Resident #1] was seen lying in bed. He was moved to a new room recently. Has been having pain in legs, PRN Tylenol #3 helps. Record review of NP Progress note dated 3/19/23 at 11:51 a.m. revealed: 3/16/23 [Resident #1] was seen lying in bed. He report tingling pain to his LE is not well controlled. Report he was taking gabapentin 800 mg qid at home with good effect, medication currently schedule tid. He has swelling to his LE, denies SOB or cough. Staff report no concern. Record review of Resident #1's Progress notes dated 4/12/23 at 11:53 p.m. revealed Found on floor in front of his wheelchair lying on his left side. Assisted to feet and bedside by CNAx2. Brief dry, changed. VS stable. Denies hitting head. ROM to all extremities at baseline. Skin tear noted to right lateral lower leg. Cleansed with wound cleaner and dry dressing applied. Unit Manager updated, MD updated. Neuro checks initiated. Record review of Resident #1's Progress notes dated 4/16/23 4:40 p.m. revealed Status post related to skin tear. Record review of Resident #1's Progress notes dated 4/24/23 at 10:45 p.m. written by RN B revealed Bilateral lower extremities pain at a 6/10 on a pain scale. PRN pain medication administered. Record review of Resident #1's Progress notes dated 4/24/23 at 11:42 p.m. written by RN B revealed Resident denies pain at this time and is in no apparent distress and/or discomfort. PRN Administration was: Effective. Follow up Pain Scale was 0. Record review on 4/25/23 of Resident #1's Progress notes from the Social worker did not reveal referrals, as of 4/25/23 for the dentist, podiatrist, or ophthalmologist. In an observation and interview on 4/25/23 at 10:15 a.m. with Resident #1 he was observed standing in the hallway wearing a robe, 3 shirts and an adult brief when he asked this Surveyor to speak with him. He stated he had not received any services and his legs were swollen, red and draining blood and fluid. Resident #1 stated he was supposed to have cream to apply on his legs and the staff put the cream on it one day and they (unknown staff) told her (unknown staff) not to do it again. Resident #1 stated the staff do not do it so he has deteriorated. Resident #1 stated his feet were so irritated that they kept him up all night and he could not sleep and could not bear to have socks on them. Resident #1 stated he tells all the staff about what he needs, and he told them that he was in pain, and no one has helped him. Resident #1 stated he just gets the run around and they cover up for one another and they threaten to send the resident to the psychiatric unit. Resident #1 stated he had not received his pain pills for 3 days and he continued asking the nurses and the CNAs about his pain medicine. Observation of Resident #1's legs revealed they were swollen, flaky, red and draining fluid. Resident #1 showed this Surveyor his feet and observation revealed they were swollen, red, flaky, draining, his toenails were very long and his right second toe appeared to cross over the first toe and he stated he needed to see a podiatrist. Observation revealed Resident #1's teeth were observed broken and brown and he stated he had lots of cavities on the top part of his mouth. Resident #1 stated he had an accident and his teeth got broken and some were broken because of a fight. Record review of Resident #1's Progress notes dated 4/25/23 at 1:19 p.m. written by RN C revealed NP notified of need for script for APAP #3 refill. In an interview on 4/25/23 at 2:10 p.m. with Resident #1 he stated he had not had his pain med's all day and he asked since 6 a.m. this morning. Resident #1 stated he asked 2 CNA's (unknown name). Observation revealed Resident #1 was seen walking around the facility by the Nurses desk wearing 3 shirts, an open robe and adult briefs. In an interview on 4/25/23 at 2:25 p.m. with Resident #1 and LVN B at the Nurses Desk. LVN B stated she would check to see when the last time Resident #1 received his pain med's. LVN B was observed administering 2 regular Tylenol pills to Resident #1 and LVN B stated that Resident #1 ran out of Tylenol 3. LVN B stated Resident #1 had orders for PRN-Tylenol and Tylenol 3 and the last time he (Resident #1) received pain meds was late last night on 4/24/23 at 10 p.m. LVN B stated Resident #1 usually asked for the Tylenol 3 once or twice a day. Observation revealed LVN B offered Resident #1 to talk to his Physician to get something scheduled. In an observation and interview on 4/26/23 at 9:58 a.m. with LVN A she called the pharmacy to see if the Tylenol 3 was in the building and she found that Codeine #3 was delivered this morning at 6 a.m. and was signed by the ADON. LVN A stated the last time the Tylenol #3 was given was on 4/24/23 at 10:45 p.m. by RN B. LVN A stated when the resident gets down to 7 pills they have to order the meds electronically, but the pharmacy does not check their records daily. LVN A stated the facility delayed the meds because the pharmacy does not send the meds. In an interview and record review on 4/26/23 at 11:09 a.m. with the Social Worker (SW) he stated if a resident needed services, nursing would give him the information in the morning meeting or the resident would let him know themselves about services needed. The SW stated the family member of the residents also told him about any services they need for the resident in care plan meetings. The SW stated if the resident's insurance is between their Medicare ending for skilled services and there is a period where Medicaid is still processing if they need an appointment ASAP then he would try to get them an appointment outside of the facility with their Medicare insurance. The SW stated Optometry was coming May 1st, and podiatry on 5/4/23. He stated the only way they check to see if a resident needed services is if someone tells him. The SW stated the facility had not checked all the residents to see if they needed ancillary services, because he had never seen the local company the facility used just check all the residents. The SW did print out the list of residents who were scheduled to receive dental, optometry and podiatry services and observation revealed Resident #1 was not listed on any of the scheduled services. The SW stated he just signed Resident #1 up for services on his legs because he received a text message on 4/25/23 telling him he needed an appointment. The SW stated Resident #1 was Medicaid pending, so it's hard-to-get services for him. The SW stated that was the gray area from changing from being short skilled and Medicaid pending. The SW stated he had interacted multiple times with Resident #1 and he also scheduled appointments for him. The SW stated Resident #1 was the type of person who would tell everyone who was willing to listen about what he needed. The SW stated he did not know why Resident #1 did not see the wound care physician. The SW stated he was aware that Resident #1's glasses and clothing had gone missing, and he did go through the process of looking for his items that were missing. He stated the facility policy is that they were not responsible if things are lost or stolen, and it is in the contract the resident's sign when they admit to the facility. The SW stated he just received a text message about all the issues Resident #1 had on yesterday. In an interview on 4/26/23 at 4:10 p.m. with the DON she stated that her expectation was for the floor nurses to do wound care every day. The DON stated on today, the facility was supposed to have a 1 p.m. meeting and her ADON is licensed for wound care, and he was supposed to train the nurses. She lost the wound care nurse about 2 weeks ago. The nurses were supposed to do wound care daily. The DON stated the facility had been hiring Agency staff so they stopped the agency staff from coming on Sunday. The DON stated the ADON, worked on last night to teach the Nurses. The DON stated after the previous Wound Care Nurse left, they were so confused so when the wound care nurse left it took them down quick. The DON stated they will do a course to understand Stage 1 and Stage II. The DON stated the facility hired Agency Nurses a lot. Now on the weekends they have their own nurses to do the weekend wound care. The Wound Care Nurse was also the Manager on duty on the weekends. The DON stated all the nurses have to do their wounds on the floor. She stated a new wound care nurse is supposed to start tomorrow and The Wound Care Physician recommended him. The DON stated she asked LVN A to do the wounds on her day off. The DON stated she is not a wound care nurse. Observation with LVN A for Resident #6's wound care revealed LVN A thought LOTA was Triple antibiotic ointment. On the treatment they write it as TAO-Triple antibiotic ointment. The DON stated they have to show the nurses how to understand the orders and she was planning to complete some in-services. The DON stated Resident #4 almost never got his morning med's and she has been DON for 2 months. The DON stated she was also a Nurse Practitioner. The DON stated Resident #1's legs were swollen and weeping (leaking fluids). She stated Resident #1 was on the list for podiatry services now. The DON stated Resident #1 would have to pay out of pocket because they do not take Resident #1's insurance. The DON stated Resident #1 was diagnosed with PVD and he was taking Lasix. The DON stated Resident #1's skin assessments were not accurate and that her goal was they are supposed to comment on the skin assessments for the skin issues. The DON stated she would address it that they need to address skin issues for Resident #1. She stated the staff must sign the MAR, because it would be considered not done. The DON stated she was not aware of Resident #1 being out of Tylenol 3 for 3 days and the Nurse should have taken the medication from the e-kit. The DON stated Resident #1 takes the Tylenol #3 every 8 hours 3 times a day. The DON stated once a patient is down to 5 days to be taken the nurses were supposed to start following up. The DON stated that is why they changed from agency staff and she had been carrying the load of nursing herself . In an interview on 4/29/23 at 10:16 a.m. with the Regional Nurse she stated the facility failed because wound care was not being completed on a daily basis according to the physician order. The facility did a 100% audit on all narcotic sheets and if it was not at the facility, they ordered it. The Regional Nurse stated she did not know why the nurse did not get Resident #1's med's from the e-kit. In a telephone interview on 4/29/23 at 11:45 a.m. with Physician A she stated Resident #1 had a diagnosis of Parkinson's disease, bilateral low extremity swelling and the NP noted that it looked more like cellulitis. Physician A stated she saw Resident #1 on Tuesday, 4/25/23 when she was there, and it had only been 48 hours since he (Resident #1) had been on antibiotics. Physician A stated Resident #1 stated he was in pain, so they discussed scheduled Tylenol 3, PRN and he is on gabapentin. Physician A stated Resident #1 mentioned he had more pain weeks prior, so she increased his dose. She stated Resident #1 had bilateral swelling, so they ordered IV clindamycin but then the nurses called her and said he was refusing the IV line, so it was changed to pills. Physician A stated they want him to keep his legs elevated, they ordered the Aquaphor on Sunday, 4/23/23 and the NP said Resident #1 was not always compliant with the Aquaphor. Physician A stated she knew his (Resident #1) legs were swollen, and he was being treated for cellulitis, but she was not aware Resident #1's legs were weeping. Physician A stated she would leave it up to the wound care team and they might have tried compression wraps. Physician A stated she might have offered Resident #1 compression wraps if she had known. She stated they started him (Resident #1) on ammonium lactate on yesterday, 4/28/23. Physician A stated usually when the facility was low on meds, they should notify the NP to make sure Resident #1 did not run out. Physician A stated they do not want Resident #1 running out of meds. Physician A stated Resident #1 had a pretty good memory, but they did not specifically talk about the Aquaphor on Tuesday 4/25/23, they focused on his pain. In an interview on 4/30/23 at 2:57 p.m. with the SW he stated he knew about Resident #1 needed dental services when he got the text message. The SW stated Resident #1 told him about the dental. The SW stated Resident #1 came into the facility as skilled nursing and he did not know what visit Resident #1 went to outside the facility. The SW stated he just set Resident #1 up to receive all 3 disciplines, but he was not aware of his legs weeping. In an interview on 5/1/23 at 8:08 a.m. with the NP she stated Resident #1 had edema and when she saw him his legs were not weeping. The NP stated they put Resident #1 on Lasix to get the extra fluid out of his legs. The NP stated the treatment for weeping is a diuretic and she would have suggested a different treatment. The NP stated when the legs are weeping the fluid is trying to find a way out. The NP stated if the leaking was too much, they do wraps on the legs so that it does not weep all over the floor. The NP stated they adjusted all of Resident #1's meds and made scheduled and went up on Tylenol 3 and gabapentin. The NP stated now Resident #1 was not only getting the PRN pain meds, he has it scheduled and getting PRN in between. The NP stated Resident #1 also had neuropathy (damage to nerve causing numbness or weakness) in his legs and that was why he took a high dose of gabapentin on the maximum dose. In an observation and interview on 5/1/23 at 12:09 p.m. with Resident #1 revealed he was sitting in a sitting walker with his legs wrapped and dated 4/30/23 and his legs were on top of 2 pillows in a wheelchair with the extenders on it. Observation revealed a skin growth on Resident #1's right side of his forehead and eye lid. Resident #1 stated he was told about the medical appointments. Resident #1 stated the SW continued telling him that he was going to do things and he never did. Resident #1 stated that in 2 months the SW stated he would come back, and he never did. He was supposed to set it up. Resident #1 stated he already told the SW about his teeth, eyes, feet and everything months ago. Resident #4 Record review of Resident #4's face sheet revealed he was admitted to the facility on [DATE]. He was [AGE] years old and was diagnosed with urinary tract infection, hypertension, colostomy status, acquired absence of left leg below knee, acquired absence of kidney, seizures, and pain. Record review of Resident #4's Care Plan dated 4/20/23 revealed pressure wounds and is at risk for further skin breakdown, infection, worsening of existing pressure wounds, new pressure wound formation AEB. admitted with Stage IV sacral pressure ulcer. Goal: [Resident's] skin will remain clean, dry and wound(s) will heal without further complications over the next 90 days. Interventions/tasks: Assist with turning/repositioning during rounds and PRN, encourage po/fluid intake within dietary limits, keep family/RP/MD informed of resident's wound healing progress, perform treatments per order- if no improvement- report to MD, provide pressure reducing device for ed and wheelchair, RD to review resident's medical record and make recommendations. Record review of Resident #4's Care Plan dated 4/20/23 did not reveal Resident #4 refused wound care and assistance for colostomy. Record review of Resident #4's Admission MDS dated [DATE] revealed a BIMS score of 13 for cognition and was able to understand and make himself understood. Resident #4 did not walk in room or corridor, required extensive assistance with 1 person assist with toilet use, limited assistance with dressing with 1 person assisting, and personal hygiene with 2 person assisting. Resident #4 had 1 Stage IV pressure ulcer. Record review of Resident #4's Physician's Orders dated 4/26/23, revealed: Clean Stage IV Sacral wound with ns, pat dry, apply alginate and cover with dry absorptive dressing everyday. One time a day for wound care. Record review of Resident #4's Wound Care Physician notes dated 4/18/23 at 7:11 p.m. wound location Sacral, Pressure ulcer, date acquired 4/13/23, wound measurements: 13x18x3 area 234 and volume 702. Wound encounter initial, moderate serous, surrounding skin maceration. Record review of Resident #4's Weekly Wound Observation by MD dated 4/29/23 at 7:27 p.m. Location Left Sacral, Pressure ulcer IV, granulation tissue present (beefy red), serosanguinous (yellowish fluid with a small amount of blood), measurements: 16x8x0.5. Record review of Resident #4's Medication Administration Record/Treatment Administration Record for April 2023 revealed: Colostomy Care every day shift every 3 day(s) Remove - bag/wafer, cleanse site with normal saline, observe for any abnormalities, skin prep stoma border, allow areas to dry, apply new wafer/bag -Order Date- 04/14/2023 12:40 p.m. was marked as completed. Carvedilol Oral Tablet 12.5 MG (Carvedilol) Give 1 tablet by mouth two times a day for Hypertension -Order Date- 04/14/2023 at 11:55 a.m. -D/C Date- 04/15/2023 4:29 p.m. was administered for 1 day. Colostomy Observation every shift Monitor Resident's colostomy. Ensure Colostomy is intact, free from s/s of infection and functioning properly. Notify MD for any changes. -Order Date- 04/14/2023 1240 was not administered on 4/20/23 at 10 p.m., 4/23/23 at 10 p.m. Acetaminophen-Codeine #3 Oral Tablet 300-30 MG (Acetaminophen w/ Codeine Give 1 tablet by mouth every 6 hours as needed for chronic pain -Order Date- 04/16/2023 4:36 p.m. was not administered at all. Cyclobenzaprine HCl Oral Tablet 10 MG (Cyclobenzaprine HCl) Give 1 tablet by mouth every 12 hours as needed for Pain -Order Date- 04/14/2023 12:04 p.m. was not administered at all. Clean Stage IV Sacral wound with ns, pat dry, apply alginate and cover with dry absorptive dressing q day. one time a day for Wound Care -Order Date- 04/20/2023 at 3:06 p.m. was not administered 4/20-4/22/23, and 4/24/23. Record review of Resident #4's Skin Observation dated 4/18/23 at 12:55 p.m. revealed skin check was not refused, skin was not intact, no new areas were identified, and resident did have pressure injuries: right knee (front), left knee (front) and Sacrum wound. Record review of Resident #4's Skin Observation dated 4/29/23 at 7:36 p.m. revealed skin check was not refused, skin was not intact, no new areas were identified, and resident did have pressure injuries: right buttock Stage 4 and left buttock stage 4. Record review of Resident #4's Skilled Progress notes dated 4/14/23 at 12:14 p.m. revealed Wound management: pressure sore in sacrum. In an interview on 4/25/23 at 11:45 a.m. with LVN A she stated Resident #4 refused wound care today when this Surveyor asked to watch her perform wound care. In an observation and interview on 5/1/23 at 1 p.m. with Resident #4 he was observed in the dining area sitting in a wheelchair. Resident #4 stated he was okay if the facility would get the supplies they need. Resident #4 stated he had an ostomy bag, but the facility ran out of the supplies he needed. Observation revealed Resident #4 had an undated wound bandage instead of an colostomy bag, and Resident #4 stated it was because the facility did not have any. Resident #4 stated that for 2 or 3 days the facility staff had started trying to do wound care. Resident #4 stated the facility was giving it an effort now to do the wounds, because they never offered to help him when he was on contact isolation. Resident #4 stated the nurses were not wound care nurses and his wounds were bad. Resident #4 stated that his wounds could kill him. Resident #4 stated when he admitted to the facility, the DON put him on Cipro (not found in orders) to try to knock out some of his UTI because of an indwelling catheter. He stated his catheter was supposed to be changed every 2 and a half weeks according to his urologist. He stated he had a stint in his kidney keeping him alive and they started him on Cipro one day then the next day they d/c'd it, then they wanted to give it and then they d/c'd it again and now his body built up a tolerance to it. LVN A stated she would give him a colostomy bag 4 days ago and he did not give it until 4 a.m. in the morning. Resident #4 stated all around his stomach was bleeding because his stool was real watery. He stated before that he would go to LVN A for her to change the wound. Resident #4 stated he went to LVN A daily to get supplies off of her cart and go do his own wounds and LVN A never offered to help him with the wounds. Resident #4 stated LVN A never asked him if he needed any kind of assistance. Resident #4 stated he found out they lied to the State, saying he was refusing his med's and refusing wound care. Resident #4 stated that it was a lie, and one of the nurses (unknown name) told him. Resident #4 stated he would not refuse his pills, and especially his blood pressure medication. Resident #4 stated he did refuse Keppra and they are supposed to D/c it but they have not done it yet. He stated he was never epileptic and was never on seizure meds and he had not had any seizures in over 2 years. Resident #4 stated you cannot stop taking Klonopin and he said you can look that up on your phone. Resident #4 stated he should not have to tell them how to do their job. He says he needs to go to the hospital on IV antibiotics. In an interview on 5/1/23 at 1:12 p.m. RN A asked what was on Resident #4's colostomy. RN A stated Resident #4 did the colostomy for himself, but LVN A gave him the 4x4's. RN A went to get the colostomy bags in the nurses station supplies and could not find them. Resident #4 stated he had been having a bandage on for 2 days. RN A returned to Resident #4 and gave him a colostomy bag and she offered to put it on for him. Resident #9 Record review of Resident #9's face sheet revealed she was admitted to the facility on [DATE]. She was [AGE] years old and was diagnosed with Fracture of right femur, presbyopia (the gradual loss of your eyes' ability to focus on nearby objects), Chronic obstructive pulmonary disease (constricted in breathing), and chronic atrial fibrillation (irregular and rapid heart beat). Record review of Resident #9's Quarterly MDS dated [DATE] revealed a BIMS summary score of 11 out of 15 indicating moderate cognitive impairment. Resident #9's functional status revealed she required limited assistance for dressing and supervision only for all other activities of daily living. Record review of Resident #9's Care Plan dated 2/22/23 revealed [Resident] is at risk for pressure ulcer due to mobility. Goal: [Resident] will have intact skin, free of redness, blisters or discoloration by/through review date. Complete a full body check weekly and document. Follow facility policies/protocols for the prevention/treatment if skin breakdown. Record review of Resident #9's Order Summary Report dated 4/26/23 revealed: Conduct weekly skin evaluation. Document UDA under assessments-Skin observations. Notify MD of new skin conditions. Every day shift every Monday for skin management started 11/21/22. Record review of Resident #9's Medication Administration Record/Treatment Administration Record for April 2023 revealed: Conduct Weekly Skin Evaluation. Document UDA under assessments-skin observations. Notify MD of new skin conditions. Every day shift every Monday for skin management order date 11/14/22 at 1:20 p.m. revealed evaluations were documented every Monday. Woun [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide services according to the care plan for 3 of 21 residents (#11, #7 and #13) reviewed for smoking. The facility failed to supervise Resident #11 when smoking after she had been evaluated as an unsafe smoker and had a history of [REDACTED]. Resident #7 was assessed as an unsafe smoker and the facility did not supervise her when she smoked. Resident #7 had a history of [REDACTED]. Resident #13 was assessed as an unsafe smoker the facility did not supervise him when he smoked. Resident #13 also had a history of [REDACTED]. An IJ was identified on 10/30/2015. While the IJ was removed on 11/03/2015, the facility remained out of compliance at a scope of pattern and a severity of No actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility needing more time to monitor the effectiveness of its training. The failure affected three residents and placed 18 residents that smoke at risk [MEDICAL CONDITION] serious injuries. Findings Include: Resident #11 Record review of Resident #11's clinical chart revealed the [AGE] year old resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident #11's Care Plan dated 8/30/2015 and revised on 10/6/2015 stated that the resident was an unsafe smoker and had a history of [REDACTED]. Record Review of the Care Plan dated 8/30/2015 shows the following approaches had check marks next to them to indicate they were to be followed by the facility; inform resident of facilities smoking policy and potential consequences of noncompliance, provide information and education in smoking cessation options, smoking in designated areas only, smoking materials maintained by staff, supervised smoking per determined need, evaluate for any assistive devices and educate individual regarding health related risk of continued smoking. Record review of Resident #11's Safe Smoking Evaluation dated 10/1/2015 read in part .the resident was determined to be an unsafe smoker. Observation and interview on 10/29/2015 at 11:45 a.m. revealed Resident #11 outside smoking and was not supervised by any staff. Resident #11 at 11:45 a.m. said stated, I smoke outside when I want. I get cigarettes from the nurses. Interview on 10/29/2015 at 12:00 noon with the Administrator in the smoking area revealed that all residents that were outside were safe smokers and did not have to be supervised. Of the smokers that were outside, Residents #11 was present and said to be safe smokers. Interview on 10/29/2015 at 12:08 p.m. with Minimum Data Set (MDS) Nurse A revealed that Resident #11 was an unsafe smoker due to her previous history of smoking in her room. MDS Nurse A stated the resident's cigarette bag was kept in the nursing station, behind the desk. MDS Nurse stated that all non-dependent smokers' bags were kept there. Interview with Resident #14 on 10/29/2015 at 12:22 p.m. while smoking, revealed that if someone was supposed to be watched, the staff came out to check on them, but they did not stay with them constantly. Interview on 10/29/2015 at 2:30 p.m. with Administrator revealed that non-dependent residents who smoked kept their cigarettes and lighters in their room. The Administrator stated that Resident #11 kept her smoking materials on her because she was nondependent. Observation on 10/29/2015 at 2:35 p.m. revealed Resident #11 in her room smoking in her bathroom. Her bathroom door was halfway open and she was sitting on the toilet in the dark. The room smelled of cigarette smoke. Resident #11 denied smoking. Her roommate stated she was on her second cigarette. Interview with Licensed Vocational Nurse (LVN) F on 10/29/2015 at 2:36 p.m. while in Resident #11's room, she said it smelled like smoke in the room because Resident #11 was a chain smoker. Resident #11 had left the room before the surveyor had returned with LVN F. Resident #11's bathroom smelled of perfume. LVN F said the bathroom did not smell bad, it smelled nice. Observation and interview on 10/29/2015 at 3:05 p.m. revealed Resident #11 was outside smoking a cigarette and she was not supervised by any staff. Resident #11 said she got her cigarettes from the nurses. Interview on 10/29/2015 at 3:35 p.m. with LVN F, she stated the nurses' desk held Resident #11's smoking materials because she was not a dependent smoker. Interview on 10/29/2015 at 3:40 p.m. with LVN G, she said that she didn't think they kept Resident #11's bag at the nurses' station anymore. LVN G then went through all the bags at the nurses' station and Resident #11's bag was not there. Interview on 10/29/2015 at 3:42 p.m., the DON she stated she was not sure if Resident #11 had a bag or not. Observation on 10/29/2015 at 3:45 p.m. revealed Resident #11 outside on the bench smoking. There was no staff present. Record review of Resident #11's Safe Smoking Evaluation dated 10/30/2015 revealed that resident was determined to be an unsafe smoker and required Frequent supervision needed while smoking. Resident #7 Record review of Resident #7's clinical chart revealed the [AGE] year old resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #7's Care Plan dated 10/12/2015 read in part; the resident was an unsafe smoker and requires constant supervision during smoking activity. Record Review of the Care Plan dated 10/12/2015 revealed the following approaches had check marks next to them to indicate they were to be followed by the facility; inform resident of facilities smoking policy and potential consequences of noncompliance, provide information and education in smoking cessation options, smoking in designated areas only, smoking materials maintained by staff, supervised smoking per determined need and educate individual regarding health related risk of continued smoking. Record Review of Resident #7's Safe Smoking Evaluation form dated 7/15/2015 read in part . the resident is determined to be an unsafe smoker. The evaluation also has a no checked next to the section reading, the resident remains alert during the course of smoking. Resident #7 was observed outside smoking on 10/29/2015 at 11:45 p.m. There were no staff members present. She said that she came outside and smoked by herself and that she got her cigarettes from the nurses. Interview on 10/29/2015 at 12:00 noon with the Administrator in the smoking area revealed that all residents that were outside were safe smokers and did not have to be supervised. Of the smokers that were outside, Residents #7 was present and said to be safe smokers. Observed Resident #7 on 10/31/2015 at 6:13 p.m. in the smoking area alone, smoking a cigarette and was not supervised by staff. Resident #7 was seated in her wheelchair, but leaning to the left over the wheelchair armrest. Interview on 10/31/15 at 6:15 p.m. with RN N revealed that Resident #7 could not independently ambulate in the wheelchair. Interview on 10/31/15 at 6:55 p.m. with LVN M revealed that he was unaware of where Resident #7 obtained a cigarette and a lighter. LVN M stated Resident #7 required supervision during smoking activity. Resident #13 Record review of Resident #13's clinical chart revealed the [AGE] year old resident was admitted to the facility on [DATE]. Record review of Resident #13's Care Plan dated 9/30/2015 stated that the resident was an unsafe smoker, noncompliant with smoking policy and has a history of smoking inside the facility. Record Review of Resident #13's Safe Smoking Evaluation form dated 9/4/2015 read in part . the resident is determined to be an unsafe smoker. Observation and interview on 10/29/2015 at 11:45 a.m. revealed Resident #13 outside smoking a cigar without any staff present. Resident #13 said that he smoked every day and that the residents were always alone outside while smoking. Interview on 10/29/2015 at 12:00 noon with the Administrator in the smoking area revealed that all residents that were outside were safe smokers and did not have to be supervised. Of the smokers that were outside, Residents #13 was present and said to be safe smokers. Record Review of the facilities policy states, If it is determined that the resident is an unsafe smoker, the resident is required to wear a protective smoking vest/apron and all unsafe smokers should be supervised at all time. An IJ was identified on 10/30/15 at 11:25 a.m. and the Administrator was informed at that time. A Plan of Removal (POR) for the IJ was submitted on 10/30/15 at 3:22 p.m. and after several revisions were made it was accepted on 11/03/15 at 9:48 a.m. The POR included in part: I. A. Resident identified on 10/30/15 (Resident #11) was educated on the facility smoking policy regarding smoking in the room on 10/30/15. The responsible party of resident (Resident #11) was contacted on 10/30/15 and made aware of the facility policy regarding smoking in the room or unattended smoking and informed that the next infraction would lead to discharge. A discharge letter was issued and responsible party was made aware on 11/1/15 for patient (Resident #11). On 11/2/15 arrangements were made to discharge patient to another facility, pending family arrival. Patient will also be check on every hour for whereabouts and room assessed for signs of smoking. Additionally, resident (Resident #7) identified on 10/31/15 to be smoking unattended was re-educated on the facility smoking policy regarding smoking unsupervised and family member was contacted to make aware of policy, noted that next infraction would lead to discharge. Facility staff will check each hour for whereabouts of patients listed above to ensure that smoking continues to occur at the designated times in the designated place and document their findings. B. Nursing and administrative staff immediately performed assessment of all residents who smoke to validate current smoking status this was started and completed on 10/30/15. All residents safe/unsafe smokers will be supervised by facility staff at designated times to ensure that the unsafe smokers remain safe. C. The Administrator trained staff beginning on 10/30/15 and will complete training 10/31/15 regarding the facility safe smoking policy to include times for smoke breaks for all residents who smoke, a list of all residents who smoke D. An Emergency Resident Council Meeting was conducted by the Administrator to review safe smoking policy to include the changes in the smoking times supervision of all smoke breaks on 10/30/15. E. The Administrator/Designee will conduct every two hour checks of designated smoking area during the designated smoking times (6:30 a.m., 9:00 a.m., 11:00 a.m., 1:00 p.m., 3:30 p.m., 6:30 p.m. and 9:00 p.m.) to assure that the supervision of residents who smoke is maintained. Any resident that is identified to have violated the smoking policy i.e., smoking in their rooms would result in a warning in accordance with Safe Smoking Policy for first infraction and notice of discharge for any additional violations. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: In an interview on 11/3/2015 at 10:00 a.m. with CNA R, she said residents were always supervised while smoking and no resident was to be outside alone smoking and a smoking schedule was followed. She further said that they had an in-service on Monday, 11/2/2015, regarding smoking. In an interview with Medication Aide (MA) I on 11/3/2015 at 10:05 a.m. revealed that staff was in-serviced on Thursday or Friday regarding residents smoking. She said that staff was to remain with residents at all times while smoking and there is now a set smoking schedule. In an interview on 11/3/2015 at 10:30 a.m. with LVN D she revealed that staff had an in-service recently and residents have set smoking schedules and staff will remain with residents at all times while smoking. In an interview on 11/3/2015 at 10:35 a.m. with Administrator, he revealed that an in-service was done on 10/30/2015 regarding residents and smoking. He further revealed that all residents will be supervised while smoking and there is now designated times for all smokers. In an interview on 11/3/2015 at 10:50 a.m. with Rehab Program Manager, he revealed that an in-service regarding residents and smoking was done on 10/30/2015. He further revealed that all smokers are to be supervised while smoking and there is now a set schedule for smoking. In an interview on 114/3/2015 at 10:55 a.m. with Speech Therapist, she said that an in-service was done on 10/30/2015 regarding residents and safe smoking. She said all residents are to be supervised while smoking and there is now designated times and the hours are posted. In an interview on 11/3/2015 at 10:59 a.m. with Housekeeping H, she said that an in-service was performed on 10/30/2015. She further said that all residents will be supervised while smoking, hours are posted and residents will smoke only in the designated area. In an interview on 11/3/2015 at 1:15 p.m. with Dietary Aide, she said that an in-service was done on Friday and all residents will be supervised by staff while smoking. She further said that smoking times are posted and there is a designated area for smoking. In an interview on 11/3/2015 at 1:15 p.m. with Resident #12 he said that residents can only go out to smoke at designated times now and only with a staff member. Observation on 11/3/2015 at 1:15 p.m. Residents outside smoking in designated smoking area with staff present. An IJ was identified on 10/30/2015. While the IJ was removed on 11/03/2015, the facility remained out of compliance at a scope of pattern and a severity of No actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility needing more time to monitor the effectiveness of its training. The Administrator listed 21 residents as smokers.

Based on interview and record review the Administrator and DON failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practical physical, mental and psychosocial well-being for three of nine residents (Resident #11, Resident #7, and Resident #13) reviewed for smoking. The Administrator failed to: -- implement the facility smoking policy to ensure that residents assessed to be unsafe smokers were not left alone while smoking. --supervise the DON to ensure nursing staff supervised dependent or unsafe smokers and the designated smoking times. --supervise the DON to ensure that nursing staff were keeping the smoking items for residents assessed as dependent smokers. The DON failed to: Monitor Nursing staff to make sure they were following the plan of care for residents that were assessed as dependent or unsafe smokers. An IJ was identified on 10/30/2015. While the IJ was removed on 11/03/2015, the facility remained out of compliance at a scope of pattern and a severity of No actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility needing more time to monitor the effectiveness of its training. These failures affected three smoking residents and placed 18 residents at risk [MEDICAL CONDITION] serious injuries. Findings include: Record review of Resident #11's Care Plan dated 8/30/2015 and revised on 10/6/2015 revealed that the resident was an unsafe smoker and had a history of [REDACTED]. Resident #11 was observed outside on 10/29/2015 at 11:45 a.m. outside smoking and was not supervised by any staff. Record review of Resident #7's Care Plan dated 10/12/2015 read in part; the resident was an unsafe smoker and requires constant supervision during smoking activity. Resident #7 was observed outside smoking on 10/29/2015 at 11:45 p.m. Record review of Resident #13's Care Plan dated 9/30/2015 stated that the resident was an unsafe smoker, noncompliant with smoking policy and has a history of smoking inside the facility. Record Review of Resident #13's Safe Smoking Evaluation form dated 9/4/2015 read in part . the resident is determined to be an unsafe smoker. Resident #13 was observed outside on 10/29/2015 at 11:45 a.m. smoking a cigar without any staff present. Observation and interview on 10/29/2015 at 11:45 a.m. revealed Resident #11 outside smoking and was not supervised by any staff. Resident #11 at 11:45 a.m. said stated, I smoke outside when I want. I get cigarettes from the nurses. Observation and interview on 10/29/2015 at 11:45 a.m., Resident #7 was sitting outside in her wheelchair in the designated smoking area. Resident #7 was smoking at this time and there were no staff members present. Resident #7 said that she was a smoker and came outside to smoke whenever she wanted. She said she got her cigarettes from the nurses. Interview on 10/29/2015 at 12:00 noon with the Administrator in the smoking area revealed that all residents that were outside were safe smokers and did not have to be supervised. Of the smokers that were outside, Residents #7, #11 and #13 were present and said to be safe smokers. In an Interview with Resident #14 on 10/29/2014 at 12:22 p.m. in the designated smoking area, he said that if a resident needed to be watched while smoking the staff would come out and check on the residents but they did not stay with the residents constantly. In an Interview with Resident #15 on 10/29/2015 at 12:25 p.m. in the designated smoking area, he stated, Staff never out here with us. Interview on 10/29/2015 at 2:30 p.m. with Administrator revealed that non-dependent residents who smoked kept their cigarettes and lighters in their room. The Administrator stated that Resident #11 kept her smoking materials on her because she was nondependent. Observation and interview on 10/29/2015 at 2:35 p.m. revealed a smell of cigarette smoke in Resident #11's room. Resident #11's roommate said that Resident #11 was currently in the bathroom smoking and on her second cigarette. The bathroom door was opened halfway and Resident #11 was in the bathroom in the dark. When asked, Resident #11 denied she was smoking in the bathroom at this time. Interview with Licensed Vocational Nurse (LVN) F on 10/29/2015 at 2:36 p.m. while in Resident #11's room, she said it smelled like smoke in the room because Resident #11 was a chain smoker. Resident #11 had left the room before the surveyor had returned with LVN F. Resident #11's bathroom smelled of perfume. LVN F said the bathroom did not smell bad, it smelled nice. Observation and interview on 10/29/2015 at 3:05 p.m. revealed Resident #11 was outside smoking a cigarette and she was not supervised by any staff. There were no staff present in the smoking area. Resident #11 said she got her cigarettes from the nurses. Interview on 10/29/2015 at 3:40 p.m. with LVN G, she said that she didn't think they kept Resident #11's bag at the nurses' station anymore. LVN G then went through all the bags at the nurses' station and Resident #11's bag was not there. Interview on 10/29/2015 at 3:42 p.m., the DON said that she was not sure if Resident #11 had a bag or not. She said that Resident #11 had been caught smoking in the facility before but did not offer any more information. Observation on 10/29/2015 at 3:45 p.m. revealed Resident #11 outside on the bench smoking. There were no staff members present. In an interview on 10/29/2015 at 5:35 p.m. with LVN F, she said Resident #11 was a dependent smoker. She also said Resident #11's smoking bag, which contained her cigarettes and lighter was kept at the Nurses' station in the back of the facility located near the smoking area. In an interview with the Administrator on 10/30/2015 at 1:50 p.m., he said that he was aware that an unsafe smoking resident was seen smoking unsupervised in the designated smoking area on three separate occasions. He said that all smoking residents had been evaluated to see if they were safe or unsafe smokers. He said that if they were evaluated to be safe smokers they were given a bag with a lock to keep their cigarettes, cigars, and lighters in. The residents were given the key to their own bags and these bags were to be kept in the residents rooms. He said that the residents who were evaluated as unsafe smokers had to be supervised and the nursing staff was responsible for keeping their smoking items at the nursing station in a locked bag. The Administrator said that there were specific times posted for the unsafe smokers that needed supervision and the times are as follows: 6:30 a.m., 10:30 a.m., 4:00 p.m., and 7:30 p.m He said that the safe smokers were allowed to smoke in the designated smoking area unattended anytime between 6:00 a.m. and 8:30 p.m. daily. In an interview with the DON on 10/30/2015 at 1:50 p.m., she said all smokers had been evaluated as safe or unsafe and smokers. Staff had been provided education and in-serviced on safe smoking procedures and policies. Staff is aware that unsafe smokers were to be supervised while smoking. The DON said the unsafe smokers had a set time schedule. The schedule is as follows: 6:30 a.m., 10:30 a.m., 4:00 p.m., and 7:30 p.m She said that the safe smokers were able to smoke in the designated smoking area unattended between the hours of 6:00 a.m. and 8:30 p.m. The DON said that she was aware that an unsafe smoking resident was seen smoking outside unattended on three separate occasions. Observed Resident #7 on 10/31/2015 at 6:13 p.m. in the smoking area alone, smoking a cigarette and was not supervised by staff. Resident #7 was seated in her wheelchair, but leaning to the left over the wheelchair armrest. In an interview on 10/31/2015 at 6:55 p.m. with LVN M, he said that he was unaware of where Resident #7 obtained her cigarette and lighter. LVN M said that Resident #7 was listed as an unsafe smoker and she required supervision during smoking. Observation and interview on 10/29/2015 at 11:45 a.m. revealed Resident #13 sitting outside in the designated smoking area, in wheelchair smoking a cigar. No staff were present at that time. Resident #13 said that he smoked cigars every day and that the smokers were always alone outside. Record Review of Safe Smoking Policy dated June 2015 revealed: SAFE SMOKING DETERMINATION An evaluation is conducted for all residents who smoke (including those who use e-cigarettes) upon admission, readmission, when there is a significant change of status, quarterly, and annually thereafter on all residents who smoke or who use e-cigarettes, in order to: -Assess the resident ' s cognitive status to determine if the resident is capable of safe smoking: -Interview the resident to determine their ability to verbalize and understand the smoking rules; and -Observe the resident's ability to smoke in a safe manner. The Determination of whether a resident is a safe or unsafe smoker is based on the results of the Nursing Admission Assessment and the Safe Smoking Evaluation. Smoking Policy also stated: All unsafe smokers should be supervised at all times. Smoking policy further revealed that staff members are to maintain all smoking materials for unsafe smokers, and safe smokers as appropriate (e.g., cigarettes, cigars, pipes, lighters, lighter fluid, e-cigarettes, etc.). Staff members distribute smoking materials to residents at smoking times. Safe smokers with lock boxes in their room may maintain their own smoking materials. Record review of the facility's smoking schedule (no date) revealed smoking break times for dependent/unsafe smokers as follows: and that staff will be assigned at the designated times. 6:30 a.m. 10:30 a.m. 4:00 p.m. 7:30 p.m. Smoke schedule further revealed that Independent/Safe smoking hours are 6:00 a.m.-8:30 p.m. An IJ was identified on 10/30/15 at 11:25 a.m. and the Administrator was informed at that time. A Plan of Removal (POR) for the IJ was submitted on 10/30/15 at 3:22 p.m. and after several revisions were made it was accepted on 11/03/15 at 9:48 a.m. The POR included in part: I. A. Resident identified on 10/30/15 (Resident #11) was educated on the facility smoking policy regarding smoking in the room on 10/30/15. The responsible party of resident (Resident #11) was contacted on 10/30/15 and made aware of the facility policy regarding smoking in the room or unattended smoking and informed that the next infraction would lead to discharge. A discharge letter was issued and responsible party was made aware on 11/1/15 for patient (Resident #11). On 11/2/15 arrangements were made to discharge patient to another facility, pending family arrival. Patient will also be check on every hour for whereabouts and room assessed for signs of smoking. Additionally, resident (Resident #7) identified on 10/31/15 to be smoking unattended was re-educated on the facility smoking policy regarding smoking unsupervised and family member was contacted to make aware of policy, noted that next infraction would lead to discharge. Facility staff will check each hour for whereabouts of patients listed above to ensure that smoking continues to occur at the designated times in the designated place and document their findings. B. Nursing and administrative staff immediately performed assessment of all residents who smoke to validate current smoking status this was started and completed on 10/30/15. All residents safe/unsafe smokers will be supervised by facility staff at designated times to ensure that the unsafe smokers remain safe. C. The Administrator trained staff beginning on 10/30/15 and will complete training 10/31/15 regarding the facility safe smoking policy to include times for smoke breaks for all residents who smoke, a list of all residents who smoke D. An Emergency Resident Council Meeting was conducted by the Administrator to review safe smoking policy to include the changes in the smoking times supervision of all smoke breaks on 10/30/15. E. The Administrator/Designee will conduct every two hour checks of designated smoking area during the designated smoking times (6:30 a.m., 9:00 a.m., 11:00 a.m., 1:00 p.m., 3:30 p.m., 6:30 p.m. and 9:00 p.m.) to assure that the supervision of residents who smoke is maintained. Any resident that is identified to have violated the smoking policy i.e., smoking in their rooms would result in a warning in accordance with Safe Smoking Policy for first infraction and notice of discharge for any additional violations. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: In an interview on 11/3/2015 at 10:00 a.m. with CNA R, she said residents were always supervised while smoking and no resident was to be outside alone smoking and a smoking schedule was followed. She further said that they had an in-service on Monday, 11/2/2015, regarding smoking. In an interview with Medication Aide (MA) I on 11/3/2015 at 10:05 a.m. revealed that staff was in-serviced on Thursday or Friday regarding residents smoking. She said that staff was to remain with residents at all times while smoking and there is now a set smoking schedule. In an interview on 11/3/2015 at 10:30 a.m. with LVN D she revealed that staff had an in-service recently and residents have set smoking schedules and staff will remain with residents at all times while smoking. In an interview on 11/3/2015 at 10:35 a.m. with Administrator, he revealed that an in-service was done on 10/30/2015 regarding residents and smoking. He further revealed that all residents will be supervised while smoking and there is now designated times for all smokers. In an interview on 11/3/2015 at 10:50 a.m. with Rehab Program Manager, he revealed that an in-service regarding residents and smoking was done on 10/30/2015. He further revealed that all smokers are to be supervised while smoking and there is now a set schedule for smoking. In an interview on 114/3/2015 at 10:55 a.m. with Speech Therapist, she said that an in-service was done on 10/30/2015 regarding residents and safe smoking. She said all residents are to be supervised while smoking and there is now designated times and the hours are posted. In an interview on 11/3/2015 at 10:59 a.m. with Housekeeping H, she said that an in-service was performed on 10/30/2015. She further said that all residents will be supervised while smoking, hours are posted and residents will smoke only in the designated area. In an interview on 11/3/2015 at 1:15 p.m. with Dietary Aide, she said that an in-service was done on Friday and all residents will be supervised by staff while smoking. She further said that smoking times are posted and there is a designated area for smoking. In an interview on 11/3/2015 at 1:15 p.m. with Resident #12 he said that residents can only go out to smoke at designated times now and only with a staff member. Observation on 11/3/2015 at 1:15 p.m. Residents outside smoking in designated smoking area with staff present. An IJ was identified on 10/30/2015. While the IJ was removed on 11/03/2015, the facility remained out of compliance at a scope of pattern and a severity of No actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility needing more time to monitor the effectiveness of its training. The Administrator listed 21 residents as smokers.

Based on observation, interviews, and record reviews the facility failed to ensure the environment remained as free of accident hazards as possible and residents received adequate supervision to prevent accidents for three of nine residents (Residents #11, #7 and #13) reviewed for smoking. This was evidenced by: The facility failed to supervise Resident #11 when smoking after she had been evaluated as an unsafe smoker and had a history of [REDACTED]. Resident #7 was assessed as an unsafe smoker and the facility did not supervise her when she smoked. Resident #7 had a history of [REDACTED]. Resident #13 was assessed as an unsafe smoker the facility did not supervise him when he smoked. Resident #13 also had a history of [REDACTED]. An IJ was identified on 10/30/2015. While the IJ was removed on 11/03/2015, the facility remained out of compliance at a scope of pattern and a severity of No actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility needing more time to monitor the effectiveness of its training. These failures affected three residents and placed eighteen additional residents that smoke at risk for burns and serious injuries. Findings Include: Resident #11 Record review of Resident #11's clinical chart revealed the [AGE] year old resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident #11's care plan dated 07/17/2015 and a review date of 10/6/2015 revealed, there was a care plan addressing her cognitive deficit. She had short-term memory loss and moderate cognitive impairment. The care plan indicated that Resident #11 was at risk for accidents and hazards related to cognitive deficit. Record review of Resident #11's Care Plan date 7/17/2015 with review dates of 5/13/2015, 8/30/2015 and 10/6/2015 revealed she had a care plan addressing her smoking. Resident #11 was at risk for injury related to smoking and required constant supervision during smoking. The approaches included: inform resident of facility's smoking policy and potential consequences of noncompliance, Smoking in designated areas only, Smoking materials maintained by staff, Supervised smoking per determined need, and Continue to encourage resident to smoke in designated area at designated times. Care Plan had X's on Safe Smoker and Unsafe Smoker with dates of 5/13/2015 and 8/30/2015. There was also: Smoking in room and Non-compliant with smoking schedule hand written on the care plan. Record review of Resident #11's Care Plan dated 7/17/2015 with a review date of 1/6/2015 and 10/6/2015 revealed that Resident #11 stole cigarettes from others. The approach was redirect as needed. Record review of Resident #11's Safe Smoking Evaluation dated 10/01/2015 revealed that resident was determined to be an unsafe smoker. Observation on 10/29/2015 at 11:45 am revealed Resident #11 sitting on bench smoking in designated smoking area. There was no staff present. Interview on 10/29/2015 at 12:00 p.m. with Administrator revealed that residents Resident #11, Resident #7, and Resident #13, currently out in the designated smoking area, had been evaluated as Safe Smokers and could smoke in the designated area anytime unsupervised. In an Interview with Resident #14 on 10/29/2014 at 12:22 p.m. in the designated smoking area, he said that if a resident needed to be watched while smoking the staff would come out and check on the residents but they did not stay with the residents constantly. In an Interview with Resident #15 on 10/29/2015 at 12:25 p.m. in the designated smoking area, he stated, Staff never out here with us. Interview on 10/29/2015 at 2:30 p.m. with Administrator revealed that non-dependent residents who smoked kept their cigarettes and lighters in their room. The Administrator stated that Resident #11 kept her smoking materials on her because she was nondependent. Observation and interview on 10/29/2015 at 2:35 p.m. revealed a smell of cigarette smoke in Resident #11's room. Resident #11's roommate she said that Resident #11 was in the bathroom smoking and on her second cigarette. The bathroom door was opened halfway and Resident #11 was in the bathroom in the dark. When asked Resident #11 denied she was smoking in the bathroom at this time. In an interview with Licensed Vocational Nurse (LVN) F on 10/29/2015 at 2:36 p.m. in Resident #11's room, she said it smelled like smoke in the room because the resident was a chain smoker. Resident #11 had left the room before the surveyor had returned with LVN F. The restroom smelled of perfume. LVN F said the restroom did not smell bad, it smelled nice. Observation and interview on 10/29/2015 at 3:05 p.m. Resident #11 was sitting outside smoking a cigarette in the designated smoking area. There was no staff present. Resident #11, she said she got her cigarettes from the nurses. In an interview on 10/29/2015 at 3:08 p.m. with LVN G, she said that all residents currently outside smoking were non-dependent and could smoke alone. Resident #11 was outside smoking at that time. No staff were present. In an interview on 10/29/2015 at 3:40 p.m., LVN G said that she didn't think they kept Resident #11's bag at the nurses' station anymore. She then went through all the bags at the nurses' station and Resident #11's bag was not there. Interview on 10/29/2015 at 3:42 p.m. with the DON, revealed that she was not sure if Resident #11 had a bag or not. She further revealed that Resident #11 had been caught smoking in the facility before but did not offer anymore information. In an interview on 10/29/2015 at 3:35 p.m., LVN F said Resident #11 was a dependent smoker. She also said Resident #11's smoking bag, which contained her cigarettes and lighter was kept at the Nurses' station in the back of the facility located near the smoking area. Observation on 10/29/2015 at 3:45 p.m. revealed Resident #11 sitting outside on bench smoking in designated smoking area. There were no staff members present. Record review of Resident #11's Safe Smoking Evaluation dated 10/30/2015 revealed that resident was determined to be an unsafe smoker and required Frequent supervision while smoking. Resident #7 Record review revealed Resident #7 was a [AGE] year old female admitted to the facility on [DATE] with a readmitted [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #7's Care Plan dated 10/12/2015 revealed she was at risk for injury related to smoking. She was classified as an unsafe smoker; and required constant supervision during smoking activity. Approaches included: smoking in designated areas only, smoking materials maintained by staff, supervised smoking per determined need. Record review of Safe Smoking Evaluation for Resident #7 dated 6/11/2015 revealed that resident was an unsafe smoker and required constant supervision during smoking. The evaluation revealed that Resident #7 fell asleep easily and had a history of [REDACTED]. Record review of Safe Smoking Evaluation for Resident #7 dated 07/15/2015 revealed that resident was an unsafe smoker and required constant supervision while smoking. Observation and interview on 10/29/2015 at 11:45 a.m. revealed Resident #7 sitting outside in her wheelchair in the designated smoking area. Resident #7 was smoking at that time and there were no staff members present. Resident #7 said that she was a smoker and came outside to smoke whenever she wanted. She said she got her cigarettes from the nurses. Observation on 10/31/2015 at 6:13 p.m. revealed Resident #7 outside smoking in designated smoking area alone without staff supervision. Resident was seated in wheelchair but leaning heavily to the left over the wheelchair armrest. In an interview on 10/31/2015 at 6:55 p.m. with LVN M, he said that he was unaware of where Resident #7 obtained her cigarette and lighter. LVN M further revealed that Resident #7 was listed as an unsafe smoker and she required supervision during smoking. Resident #13 Record review of face sheet revealed Resident #13 was a [AGE] year old male who was admitted to the facility on [DATE]. Record review of Resident #13's MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating moderate cognitive impairment. Record review of Resident #13's Care Plan dated 4/8/2015 with a review date of 6/23/2015, 9/6/2015, and 9/30/2015 revealed that Resident #13 had a history of [REDACTED]. The approaches included smoking in designated areas only, supervised smoking per determined need, and smoking materials maintained by staff. There were check marks in both: Safe Smoker and Unsafe Smoker. Constant supervision during smoking activity was also checked. Record review of Resident #13's Care Plan dated 4/8/2015 with a review date of 6/23/2015 and 9/6/2015 revealed: Cognitive Deficit: Resident has cognitive losses as evidenced by: short-term memory loss, long-term memory loss as evidenced by modified independence. Record review of Resident #13's Safe Smoking Evaluation dated 6/23/2015 revealed the resident was determined to be an unsafe smoker and constant supervision was needed while smoking. Record review of Resident #13's Safe Smoking Evaluation dated 9/04/2015 revealed the resident was determined to be an unsafe smoker and required constant supervision while smoking. Observation and interview on 10/29/2015 at 11:45 a.m. revealed Resident #13 sitting outside in the designated smoking area, in wheelchair smoking a cigar. No staff members were present at this time. Resident #13 said that he smoked cigars every day and that the smokers were always alone outside. Record Review of Safe Smoking Policy dated June 2015 states: SAFE SMOKING DETERMINATION An evaluation is conducted for all residents who smoke (including those who use e-cigarettes) upon admission, readmission, when there is a significant change of status, quarterly, and annually thereafter on all residents who smoke or who use e-cigarettes, in order to: -Assess the resident's cognitive status to determine if the resident is capable of safe smoking: -Interview the resident to determine their ability to verbalize and understand the smoking rules; and -Observe the resident's ability to smoke in a safe manner. The Determination of whether a resident is a safe or unsafe smoker is based on the results of the Nursing Admission Assessment and the Safe Smoking Evaluation. Smoking Policy also stated: All unsafe smokers should be supervised at all times. Smoking policy further revealed that staff members are to maintain all smoking materials for unsafe smokers, and safe smokers as appropriate (e.g., cigarettes, cigars, pipes, lighters, lighter fluid, e-cigarettes, etc.). Staff members distribute smoking materials to residents at smoking times. Safe smokers with lock boxes in their room may maintain their own smoking materials. Record review of the facility's smoking schedule (no date) revealed smoking break times for dependent/unsafe smokers as follows: and that staff will be assigned at the designated times. 6:30 a.m. 10:30 a.m. 4:00 p.m. 7:30 p.m. Independent/Safe smoking hours were 6:00 a.m.-8:30 p.m. An IJ was identified on 10/30/15 at 11:25 a.m. and the Administrator was informed at that time. A Plan of Removal (POR) for the IJ was submitted on 10/30/15 at 3:22 p.m. and after several revisions were made it was accepted on 11/03/15 at 9:48 a.m. The POR included in part: I. A. Resident identified on 10/30/15 (Resident #11) was educated on the facility smoking policy regarding smoking in the room on 10/30/15. The responsible party of resident (Resident #11) was contacted on 10/30/15 and made aware of the facility policy regarding smoking in the room or unattended smoking and informed that the next infraction would lead to discharge. A discharge letter was issued and responsible party was made aware on 11/1/15 for patient (Resident #11). On 11/2/15 arrangements were made to discharge patient to another facility, pending family arrival. Patient will also be check on every hour for whereabouts and room assessed for signs of smoking. Additionally, resident (Resident #7) identified on 10/31/15 to be smoking unattended was re-educated on the facility smoking policy regarding smoking unsupervised and family member was contacted to make aware of policy, noted that next infraction would lead to discharge. Facility staff will check each hour for whereabouts of patients listed above to ensure that smoking continues to occur at the designated times in the designated place and document their findings. B. Nursing and administrative staff immediately performed assessment of all residents who smoke to validate current smoking status this was started and completed on 10/30/15. All residents safe/unsafe smokers will be supervised by facility staff at designated times to ensure that the unsafe smokers remain safe. C. The Administrator trained staff beginning on 10/30/15 and will complete training 10/31/15 regarding the facility safe smoking policy to include times for smoke breaks for all residents who smoke, a list of all residents who smoke D. An Emergency Resident Council Meeting was conducted by the Administrator to review safe smoking policy to include the changes in the smoking times supervision of all smoke breaks on 10/30/15. E. The Administrator/Designee will conduct every two hour checks of designated smoking area during the designated smoking times (6:30 a.m., 9:00 a.m., 11:00 a.m., 1:00 p.m., 3:30 p.m., 6:30 p.m. and 9:00 p.m.) to assure that the supervision of residents who smoke is maintained. Any resident that is identified to have violated the smoking policy i.e., smoking in their rooms would result in a warning in accordance with Safe Smoking Policy for first infraction and notice of discharge for any additional violations. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: In an interview on 11/3/2015 at 10:00 a.m. with CNA R, she said residents were always supervised while smoking and no resident was to be outside alone smoking and a smoking schedule was followed. She further said that they had an in-service on Monday, 11/2/2015, regarding smoking. In an interview with Medication Aide (MA) I on 11/3/2015 at 10:05 a.m. revealed that staff was in-serviced on Thursday or Friday regarding residents smoking. She said that staff was to remain with residents at all times while smoking and there is now a set smoking schedule. In an interview on 11/3/2015 at 10:30 a.m. with LVN D she revealed that staff had an in-service recently and residents have set smoking schedules and staff will remain with residents at all times while smoking. In an interview on 11/3/2015 at 10:35 a.m. with Administrator, he revealed that an in-service was done on 10/30/2015 regarding residents and smoking. He further revealed that all residents will be supervised while smoking and there is now designated times for all smokers. In an interview on 11/3/2015 at 10:50 a.m. with Rehab Program Manager, he revealed that an in-service regarding residents and smoking was done on 10/30/2015. He further revealed that all smokers are to be supervised while smoking and there is now a set schedule for smoking. In an interview on 11/3/2015 at 10:55 a.m. with Speech Therapist, she said that an in-service was done on 10/30/2015 regarding residents and safe smoking. She said all residents are to be supervised while smoking and there is now designated times and the hours are posted. In an interview on 11/3/2015 at 10:59 a.m. with Housekeeping H, she said that an in-service was performed on 10/30/2015. She further said that all residents will be supervised while smoking, hours are posted and residents will smoke only in the designated area. In an interview on 11/3/2015 at 1:15 p.m. with Dietary Aide, she said that an in-service was done on Friday and all residents will be supervised by staff while smoking. She further said that smoking times are posted and there is a designated area for smoking. In an interview on 11/3/2015 at 1:15 p.m. with Resident #12 he said that residents can only go out to smoke at designated times now and only with a staff member. Observation on 11/3/2015 at 1:15 p.m. Residents outside smoking in designated smoking area with staff present. An IJ was identified on 10/30/2015. While the IJ was removed on 11/03/2015, the facility remained out of compliance at a scope of pattern and a severity of No actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility needing more time to monitor the effectiveness of its training. The Administrator listed 21 residents as smokers.

Based on interview and record review the facility failed to ensure that each resident received the necessary care and services to attain and maintain the highest physical well-being for 1 of 10 residents reviewed for assessments. The facility failed to accurately assess CR #6 upon admission, in that the medical record contained information reflecting that the resident was a diabetic and was taking [MEDICATION NAME] 5 mg twice a day and needed blood sugar level monitoring. The facility also failed to present this information on admission to the facility attending physician. This resulted in CR #6 not receiving [MEDICATION NAME] for 28 days. CR #6 was transferred to the hospital with high blood sugar levels on 3/19/12 and admitted with initial blood sugar of 683 mg/dl and [DIAGNOSES REDACTED]. This failure affected one resident and had the potential to prevent 102 residents from receiving proper assessment, evaluation and treatment to prevent worsening of health conditions. Complaint # 6 The findings include: Resident CR# 6 Record review of the facility's face sheet for CR# 6 revealed a female who was admitted to the facility from home on 02/20/12. Medical history included [MEDICAL CONDITION], senile delusion, [MEDICAL CONDITIONS] and diabetes mellitus II. CR #6 was discharged to the hospital on [DATE] with high blood sugar levels. Record review of documentation located on CR# 6 close file revealed a medication list dated 11/28/2007 with documentation of a circle around the words discontinued beside the [MEDICATION NAME] medication. Further review of the medical records revealed another Medication List dated 12/22/09 and completed by CR #6 ' s primary care Physician with documentation of [MEDICATION NAME] (Diabetic medication) 5 mg tablet take 1 by mouth every morning and ? tablet every evening, with meals for Diabetes Mellitus II. Record review of additional documentation located in CR #6 ' s close file revealed a report from the primary care Physician dated 10/10/11 that included a summary of the visit for primary [DIAGNOSES REDACTED]. Record review of the facility's admission orders [REDACTED]. The [DIAGNOSES REDACTED]. No MEDICATION ORDERS FOR [REDACTED] Record review of the physician's telephone orders revealed documentation of untimed orders dated 02/20/12 for CR# 6 including; admit to Nursing facility under care of facility physician and add to Diagnoses: [REDACTED]. Record review of the facility's Initial Medical Nutritional Therapy Review dated 02/20/12 for Resident CR# 6 revealed documentation of diet ordered was RCS mechanical soft and was to be eaten in the dining room on the Secured Unit. The [DIAGNOSES REDACTED]. Further review of the documentation revealed laboratory values significant to diet included, blood glucose of 139 ( above normal). Record review of the facility' s blood laboratory test dated 02/22/12 for CR # 6 revealed documentation including adult female normal value between 70 to 110 and resident ' s value was documented as 139. Record review of the facility's History and Physical dated 02/25/12 for CR# 6 revealed documentation including that the resident was admitted from home due to wandering. Medical history included hypertension, [MEDICAL CONDITION], lipidemia, gets more agitated, calm most days. Family history included, mother positive for diabetes mellitus and father had diabetes mellitus. Record review of the MAR indicated [REDACTED]. Record review of the TAR dated 02/12 and 03/12 for CR# 6 revealed no documentation for blood sugar check. Record review of CR# 6 care plans dated 3/1/12 revealed problem of potential for [DIAGNOSES REDACTED]/[MEDICAL CONDITION] (low/high blood sugar) and the goal documented for blood sugar to remain stable within MD prescribed parameters through next review date of 06/01/12. The approaches included to observe for signs and symptoms of hypo/[MEDICAL CONDITION], excessive thirst, frequent urination, clammy skin, confusion, RCS diet as ordered, observe for dietary compliance, monitor labs as ordered, notify MD as indicated. Further review of the resident's care plans revealed a problem of potential for weight loss/nutrition dated 2/22/12 related to mental status and mechanical altered diet and [DIAGNOSES REDACTED]. Record review of the facility's Nursing Weekly/Monthly summary notes dated 03/12/12 for CR# 6 revealed no documentation for monitoring related to signs of increased/decreased blood sugar levels. Record review of the facility transfer form dated 3/19/12 for CR #6 revealed that at the time of the transfer the Resident was ambulatory, alert, but disoriented and was at risk for falls and elopement. Record review of the hospital History and physical dated 03/19/12 for CR# 6 revealed a female with history of Alzheimer [MEDICAL CONDITION], depression, hypertension and diabetes mellitus. She was recently in a nursing home for the last 3 weeks and they were not giving her the medications for diabetes, which was to take [MEDICATION NAME], 2 times per day. She was taking [MEDICATION NAME] at home but for the last 3 weeks the nursing home did not give the [MEDICATION NAME]. The resident became very lethargic and the nursing facility checked CR# 6's blood sugar and it read high so CR# 6 was transferred to hospital. Resident was ambulatory and independent at the nursing facility. In the emergency department, CR # 6 was found to have blood sugars of more than 600 and she was given initially insulin [MEDICATION NAME] 10 units which did not bring the blood sugar down much, so she was started on insulin drip. The latest finger stick was in the 400's. Record review of the Emergency department hospital blood sugar laboratory results dated [DATE] at 8:58 a.m. for CR# 6 revealed blood sugar of 683 mg/dl with the normal range documented as 74 to 106 mg/dL. Record review of the hospital Discharge summary for CR# 6 revealed that the resident remained in the hospital until 04/20/12. CR #6 was then transferred to another skilled nursing facility and CR #6 was now unable to ambulate, non-verbal and with diabetic medications of [MEDICATION NAME] twice daily by mouth, [MEDICATION NAME]by injection before each meal and at bedtime and insulin NPH by injection twice daily. In an interview on 05/03/12 at 3:55 pm with LVN H about CR# 6 she said she was unaware of any diabetes [DIAGNOSES REDACTED]. In an interview on 05/03/12 at 4:30 pm with the DON about CR# 6's [DIAGNOSES REDACTED]. The DON made no comments about the other medication lists dated 12/22/09 and 10/10/11 that reflected that CR #6 had orders for [MEDICATION NAME] and to monitor blood sugar levels. The DON was asked who completed the admission nurse's assessment for CR# 6 and the DON said, the nurse that did it was unavailable as he passed away. In a phone interview on 5/4/12 at 9:45 am with a family member for CR #6 she said that she received a call from a facility nurse on 3/19/12 asking her if CR #6 was a diabetic. She stated that she provided the facility with the community physician's information on CR #6's diabetic condition, her diabetes medication and glucometer on admission and was surprised with the question. The family member said that she was informed that day (3/19/12) that CR #6 was going to the emergency room with high blood sugar. She said that the facility did not give CR #6 diabetes medication for three weeks. The family member said that CR #6 remained in the hospital for a long time and had not fully recovered from being without the medication from 2/20-3/19/12. In an interview on 05/04/12 at 11:50 a.m. with LVN I about CR# 6' s she said " CR# 6 was checked each week by the doctor or nurse practitioner and there were no orders for administration of insulin medication or checking the resident's blood sugar. We had clinical meetings and the nursing administration went through the record and checked the chart and signed off, we just follow what they say " . LVN I was asked if any bottles of medication were brought from home for CR# 6 and she said that she was not aware of any bottles and didn't remember any bottles. CMS form 672 revealed a census of 102 residents.