Every finding on record at Paradigm at Woodwind Lakes

Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals were stored in locked compartments under proper temperature controls, limited access, for 1 of 2 (Hall A) medications storage rooms reviewed for proper medication storage.-Medication storage room on Hall A had 4 bags of 50ml normal saline mixed with the antibiotic medication daptomycin 500mg sitting out on the countertop. The label on the outside of the bag read to refrigerate upon arrival. This failure could place residents at risk for infection, IV contamination, and treatment of the medication not being effective. Record review of Resident #71 face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and again on 05/12/26. Resident #71's diagnoses included sepsis (life threatening response to an infection in the body), metabolic encephalopathy (when the brain is not function properly due to a chemical imbalance or organ failure {one or more of the body's vital organs can no longer do its job to keep a person a live} in the body), and acute kidney failure (sudden loss of kidney function to filter waste from the blood). Record review of Resident #71's MDS dated [DATE] reflected a BIMS score of 0 indicating that Resident #71's cognition was severely impaired. Record review of Resident #71's Comprehensive Care Plan dated 04/13/26 revealed that resident was being care planned for antibiotic therapy and being at risk adverse reactions: Antibiotic Daptomycin until 06/24/26.Dx: sepsis. An intervention included to follow standard precautions to prevent cross contamination and spread of infection. Record review of Resident #71's Physician Order Summary included the following order: -Dated 05/19/26 Daptomycin intravenous 500mg one time a day for sepsis secondary to post-op (period of time after a surgical procedure) surgical site infection left hip until 06/24/26. Record review of Resident #71's MAR for the month of June 2026 revealed that the facility was administering the medication as ordered by the physician. Record review of the pharmacy delivery date for the medication daptomycin 500mg IV dated 06/01/26 reflected that LVN A signed the delivery form at 8:55PM. Observation on 06/03/26 at 9:30AM of the medication storage room on the [NAME] Wing revealed four 50ml bags of normal saline mixed with the medication daptomycin 500mg sitting on top of the countertop labeled with Resident #71's name on bags. These bags were inside of large clear plastic bag. The date delivered on bags read 06/01/26. On the outside of the plastic large clear bag was a green sticker label reading in bold black print that read refrigerate upon arrival. Interview on 06/03/26 at 9:45AM with RN I said whoever accepted the medication from the pharmacy was responsible for storing the medication daptomycin 500mg IV in the fridge. RN I said daptomycin IV was supposed to be stored in the fridge at a certain temperature to be effective when administered. RN I said he had been working at the facility full time for 2-1/2 months from 6AM-6PM and was never told who was responsible for checking the medication room to ensure that medications were stored appropriately. RN I said when medications were not stored correctly, the medication may not be effective in treating what it was supposed to treat. Interview on 06/03/26 at 9:50AM with LVN O he said he was Resident #71's nurse. LVN O said the medication daptomycin 500mg IV had been placed on hold and did not know why. LVN O said he was not aware that the medication daptomycin IV had been placed on the countertop in the medication room. LVN O said he worked at the facility full time from 6AM-6PM for 4 or 5 months. LVN O said all the nurses were responsible in checking the medication room to ensure medications were stored properly daily. LVN O said when IV antibiotic medication daptomycin is not stored properly, it placed the resident at risk for increase in infections. LVN O said he had checked the medication storage room earlier but did not completely check the medication storage room. Interview on 06/03/26 at 10:10AM with LVN NT she said she was the unit manager for the [NAME] Wing. LVN NT said she had been working at the facility since April of 2026. LVN NT said it was her and the nurses on the unit that were responsible for checking the medication storage room to ensure all medications were stored appropriately every day. LVN NT said the medication daptomycin 500mg IV should not be sitting out on the countertop in the medication room and that it placed the resident at risk of not receiving effective treatment. Interview on 06/03/26 at 10:22AM with the DON said she had been the DON at the facility for 2 months. The DON said it should be the unit manager that should be checking the medication storage room to make sure medications were being stored properly. The DON said she was responsible to ensure that this was being done. The DON said by not storing the medication daptomycin 500mg IV in the fridge as instructed could affect the efficacy (desired results or the intended effect) of the medication placing the resident at risk of not receiving the therapeutic results of what the medication was ordered for. The DON said even if the medication daptomycin 500mg IV had been placed on hold, the medication should still be stored in the fridge because it just on hold, not discontinued, meaning the medication could be resumed. Further interview with the DON, she said after reviewing the pharmacy delivery of the medication daptomycin 500mg IV, it was LVN A that signed and accepted the medication on 06/01/26. Attempted interview on 06/03/26 at 1:00PM via phone with LVN A, no answer, left a voicemail with a call back number. Interview on 06/04/26 at 10:37AM with the pharmacist revealed the medication daptomycin 500mg IV needed to be refrigerator per manufactured instructions. The pharmacist said if not stored in fridge, the medication daptomycin IV would lose its stability in being effective. Record review of the facility policy on Storage of Medication revised in August 2020 revealed in part: . Medications and biologicals are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier.Medications requiring storage in cool place are refrigerated unless otherwise directed on the label.

Based on observation, interview and record review the facility failed to ensure that food was prepared, distributed, and served food in accordance with professional standards for food service safety in one of one kitchen in that. _The facility failed to ensure that equipment was cleaned.The facility failed to ensure that plates, bowls, and cups with dried food particles, and glasses with water spots and stains were not stored with clean plates, bowls and glasses._The facility failed to ensure that menu items on the steam table were maintained at 135 degrees F and above.-The facility failed to ensure that chicken salad was on ice and served for lunch at the correct holding temperature of 41 degrees F and below.-The facility failed to ensure that pans with food particles on them were not stored with clean pans.- The facility failed to ensure that foods in the freezer were labeled and dated. - The facility failed to ensure that the dry storage room had no expired food items. These failures placed all residents who ate food prepared by the kitchen at risk of foodborne disease and other illnesse Observation on 6/2/2026 between 8:30- 9:30 am revealed the following: [NAME] J was observed plating resident's food for breakfast. [NAME] J touched the stove knob, the frying pan, pick plates, touched the counter of the steam table and without changing gloves picked up bread and cooked bacon and placed them on the resident's plate. Observation also revealed chipped plates, and bowls were stored with unchipped plates and bowls. Regular plates and divided plates with food particles were stored with clean plates and divided plates. The oven doors and racks had an accumulation of grease and burnt food particles on them. The deep fat fryer had brown oil with burnt food particles in it. The casing (holder) for the table mounted can opener had an accumulation of black stuff and grease on it. In the freezer were fries, spinach, Tator tots, squash in plain plastic bags not labeled or dated. Collard greens with no date. Pots and pans had grease and dried food particles in them. Muffin pans with dried food particles in them. Coffee cups with white power looking stuff in them. Water jugs with plastic, glue from the tapes use to secure the labels on the water jugs and paper on them. In an interview on 6/2/26 at 9:00 am the Dietary Manager said the deep fat fryer and the oven were on the schedule to be cleaned that day. The DM said she will have to find another way of labeling water jugs, because of the glue from the tapes that were left on the jug when they were removed to be washed. Observation on 6/3/2026 at 12:10 pm of the steam table for lunch revealed menu items not at the correct holding temperature: Pureed pork at 120.7 degrees F and chicken salad at 45.6 degrees F. Observation 6/3/2026 at 12:15 pm revealed [NAME] J plating food and touching the stove knob and touching the food and not changing gloves. [NAME] J was observed at that time plating chicken salad for a resident. The pan with the chicken salad was on the counter not on ice. The temperature was taken at that time, and it was 45 degrees. The Dietitian was about to put the chicken in the cooler, but the DM told her to discard the chicken salad. Observation of the dry storage room on 6/3/2026 at 12:30pm revealed 4 cases of thick and easy water with best used date of 4/30/2026. The DM discarded the water when the surveyor brought it to her attention. In an interview on 6/3/26 at 12:55 pm with the DM she said that if food was not at the correct temperature residents could get sick. She said ready to eat food should be served with a tong and not be touched with bare hands. She said if gloves were used, they should be changed after each task. Regarding the thickened water she said she had just started working at the facility and was in the process of changing and putting polices in order. She said staff should be checking for expired foods and food that are closed to be expired using the fist in first out method (FIFO), (a storage method where the oldest was used first). Interview with [NAME] J on 6/5/2026 at 8:30 am she said ready to eat food should not be touched with bare hands. She said she should be using tongs to pick up ready to eat food. She said touching the food after doing multiple tasks could cause residents to get sick. She said she will be using tongs to pick up ready to eat food. Further interview on 6/5/2026 at 8:35 am with [NAME] J she said she was in-serviced on the use of tongs to pick up ready-to-eat food. She said she did not remember being in-serviced on ready to eat foods before this in-service. She said not changing gloves or using tongs could cause residents to get sick due to cross contamination. In an interview on 6/5/26 at 8:40 am the DM said the staff had been in-serviced, and she will continue to in-service staff until they learn the correct ways to do things in food service until they are in compliance. She said she would be in-servicing staff on using tongs and if gloves were used, they should be changing them after each task. She said moving forward she was going to ensure that all staff know how to handle ready-to-eat food and the proper use of gloves. Record review of the facility's Nutrition Services Policies and Procedures dated 06/2019 read in part.Subject: Safe Food TemperaturesPolicy:It is the policy of this facility that food temperatures be maintained at acceptable levels during food storage, preparation, holding, serving, delivery, cooling and reheating. The steamtable may not be used to reheat food.Minimum safe internal cooking temperatures for some high-protein foods that require special handling are as follows:A Poultry, stuffed meats, fish, poultry and stuffed pasta: 165F for at least 15 seconds. Stuffing made from potentially hazardous foods should be cooked separately to a minimum internal temperature of 165F for at least 15 seconds.Note: Appearance in meat is not a reliable indicator of safety or risk. Only by using a food thermometer can you determine if meat has reached a sufficient temperature to destroy pathogens of public health concern.Procedures:1. Minimize the time that time/temperature control for safety (TCS) food is in the temperature danger zone (41 to 1350 F) throughout the food handling process to no more than 4 hours.2. [NAME] whole cuts of meat to at least 145F internal cooking temperature then allow it to rest 3 minutes before carving or consuming. Foods can be cooked to higher temperatures if the quality is not sacrificed.3. Reheat all previously cooked TCS food so that all parts of the food reach an internal temperature of at least 165F for 15 seconds.5. When hot pureed, ground, or diced food drops into the danger zone (below 135 F), it must be reheated to 165 F for 15 seconds.6. Hold hot foods at 140 F or higher during meal service (on the tray line). Hold cold foods at 40F or lower during meal service (on the tray line). Maintain and serve hot beverages at 140F or higher.7. Check and record tray line food temperatures on the food temperature record before each meal. If the food temperatures are not within acceptable parameters, reheat the food to at least 165F for 15 seconds (for hot foods) or discard it.9. Cooling: Improper cooling is a major factor in causing food borne illness. The ideal bacterial incubation temperature range is 70-125 F and is to be avoided. TCS food is cooled to 41 F or lower within 4 hours after reaching 135 F. (For example a cooked food is put into the refrigerator at 165 F. The clock starts when the food reaches 135 F.)11. When preparing a TCS food from ingredients at room temperature (e.g. tuna or chicken salad), cool it to 41 F within 4 hours.Guidelines for Checking Food Temperatures:1. Make certain the thermometer is clean and has been sanitized with an appropriate sanitizer (100 ppm [parts per million] bleach solution or 25 ppm iodine solution). The use of individual, foil wrapped alcohol pads also is acceptable for sanitizing probes; however, allow time for the alcohol to evaporate before inserting the probe into the food. Another method is to utilize the coffee urn making sure water temperature is 180 F.Note: The thermometer must be cleaned and sanitized between each product that is tested.2. Insert the stem of the thermometer into the thickest portion of the food being tested, so that the sensing area (usually a line or staking dimple etched into the thermometer stem) is covered approximately 1/8 to 1/4 inch above the staking dimple with the food being tested. Allow to stabilize for 15 - 20 seconds and record the temperature.3. To attain accurate readings, never insert the probe next to a bone, or allow the thermometer to touch the bottom or side of the pan.4. If temperatures do not meet requirements, notify the Nutrition Services Director (NSD) for direction.5. Stir hot foods from the middle of the pan outward during the meal service to maintain an even temperature.Calibrating the Thermometer:1. Check the thermometer for proper calibration at least weekly or more often if it has been dropped. Record on the Calibration Record form.2. For the cold temperature method, insert the sensing area of the thermometer into an equal mixture of crushed ice and water until the indicator stabilizes, and then turn the calibration nut so the indicator reads 32F.3. The hot temperature method: place the thermometer in boiling water; the temperature should be 212F.4. If the thermometer is not accurate, the NSD repairs or replaces the thermometer. Record review of the facility's Nutrition Services Policies and Procedures dated 6/2029 read in part.SUBJECT: WAREWASHING USING DISHWASHING MACHINEPOLICY:Utensils and dishes washed by a mechanical dishwasher will be clean and sanitized.PROCEDURES:1. Check the cleanliness of the machine. Fill wash and rinse tanks with clear water. Check the temperature of the wash and rinse cycles, verifying that both meet the temperatures posted on the dishwashing machine. (If the manufacturers' temperatures are not posted on the machine, request from vendor). If using a low temp machine, check the sanitizer level at contact times specified in accord with the product label. Record data on the Temperature and Sanitizer Log Form # CP1906.2. Notify Maintenance if required temperatures are not reached. Discontinue warewashing and use disposable dishes and flatware until the issue is resolved.3. Bus trays and dishes. Throw paper and disposable items in trashcan.4. Scrape food into garbage disposal.5. Separate glasses, flatware and china; stack trays.6 Presoak flatware and dishes to soften dried foods; do not soak longer than 15 minutes; long soaking may cause pitting of some items.7 Place glasses, china, and trays in dish racks with all sides of china, glasses and trays exposed to the water; do not crowd into dish racks.8 Spray dishes and flatware thoroughly with overhead spray to remove food particles.9 Wash dishes in dish machine according to equipment directions.10 Wash flatware, following these steps:A. Place flatware in a flat dish rack (no more than 60 pieces per rack).B. Run the dish rack through the dish machine.C. Sort knives, forks, and spoons.Revised 6-2019D. Place the flatware in cylinders with the handles down in the basket and send back through the dish machine (no more than 30 pieces per cylinder).E. Once the flatware has been washed the second time, use an empty cylinder to place over the full cylinder containing the clean flatware.F. Invert the cylinders so the eating end is now in the bottom of the cylinder.11. Wash hands between handling soiled and clean dishes to prevent cross contamination.12. Store clean sanitized dishes and utensils in a clean, dry location not exposed to splash or other contamination.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 2 of 6 residents (Resident #7 and Resident #4) and 2 of 2 staffs (CNA T, CNA B ) reviewed for infection control.-The facility failed to ensure CNA B donned PPE including gloves and gown before preforming incontinent care to Resident #7 with EBP sign posted on the entrance door on 6/3/2026. -The facility failed to ensure CNA T donned PPE including gloves and gown before performing incontinent care to Resident #4 with EBP sign posted on the entrance door on 6/3/2026. These failures could place residents at risk for spread of infection and cross contamination to residents causing resident illness and/or distress. Record review of Resident #7s face sheet dated 06/03/2026 revealed he was a [AGE] year-old female who was admitted to the facility on [DATE]. His medical diagnoses included reduced mobility , mild protein-calorie malnutrition, other sequelae of cerebral infarction (consequences of stroke), secondary hypertension (blood pressure), hyperlipidemia (high fat in the blood) unspecified hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (paralysis or partial paralysis following stroke affecting left non-dominant side), other lack of coordination, cognitive communication deficit, dependence on supplemental oxygen, need for assistance with personal care, muscle weakness (generalized), other abnormalities of gait and mobility and pressure ulcer of sacral region (a large, triangular bone at the base at the of the spine that connects the vertebral column to pelvis), stage 4, pressure ulcer of right hip, stage 4, pressure ulcer of left hip, stage 3 (Full thickness tissue loss with exposed bone, tendon muscle), Record review of Resident #7's admission MDS assessment, dated 12/25/25, reflected a BIMS score of 3 out of 15, which indicated severe cognition impaction. She required assistance from staff with ADL care. Record review of Resident #7's care plan, dated 10/04/25, reflected, . The resident had an ADL self-care deficit .Interventions.Personal Hygiene and Toilet use- Resident is totally dependent . Resident #7 was also care-planned for incontinent care, with interventions including changing brief in a timely manner preventing skin break down. During observation on 6/3/26 at 2:59 PM, Resident #7 had an Enhanced Barrier Precaution sign posted on her door. Resident #7 was lying in bed; CNA B did not don (put on) gloves and gown before entering Resident #7's room and set up the supplies to perform incontinent care for Resident #7.In an interview with CNA B on 6/3/26 at 3:45 p.m., she said she forgot to wear PPE before entering Resident #7's. She said she did have in-services about using PPE to prevent infection to her and the residents on EBP.Resident #4Record review of Resident #4's face sheet last captured 06/03/2026, revealed she was a [AGE] year-old female originally admitted on [DATE]. Her medical diagnoses were gastronomy status (has a gastrointestinal tube to provide nutrition and medication from opening straight into stomach), muscle weakness (generalized), muscle wasting and atrophy, not elsewhere classified, multiple sites, dysphagia (difficulty), cognitive communication deficit, moderate protein-calorie malnutrition, other lack of coordination, need for assistance with personal care, sepsis, unspecified organism, altered mental status, unspecified, type 2 diabetes mellitus with hyperglycemia (high sugar in the blood), acute respiratory failure with hypoxia (low oxygen in the blood).Record review of Resident #4 's significant change MDS, dated [DATE], reflected the BIMS score was 00 out of 15, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident was totally dependent on bed repositioning and personal hygiene. Further record review of the MDS indicated Resident #4 was incontinent of bladder and bowel. Record review of Resident's #4's care plan, dated 12/24/2025, reflected the following: I have ADL self-care performance deficit and totally dependent on staff for all ADLs and requires assistance with activities of daily living due to decreased physical and functional mobility secondary to weakness and multiple medical comorbidities. During observation on 6/3/2026 at 3:29 PM, Resident #4 had an Enhanced Barrier Precaution sign posted on her door. Resident #4 was lying in bed; CNA T did not don (put on) gloves and gown before entering Resident #4's room to perform incontinent care.In an interview with CNA T on 6/3/2026 at 4:33 p.m., she said she forgot to wear PPE before entering Resident #4's. She said she did have in-services about using PPE to prevent infection every month at least bi-weekly. CNA T said using PPE was to prevent infection to her and the residents on EBP.Interview with the Administrator on 6/3/26 at 5:00 PM, regarding expectations for Resident #4 and Resident #7 on EBP during care. The Administrator said his expectation was for all residents with EBP signs posted on their doors, the staff were supposed to don PPE before entering their room to perform any care, to prevent infection.Record review of the facility policies and procedures revised 3/24 on Enhanced Barrier Precautions reflected:Policy: Enhanced barrier precautions (EBPs) is utilized to prevent the spread of multi-drug-resistant organisms (MDRO)Enhanced Barrier Precautions is an infection control intervention designed to reduce the transmission of multidrug-resistant organisms and employs targeted gown and glove use during high-contact resident care activities for targeted residents.Guidance/Procedure Enhanced Barrier Precautions (EBP) are used in conjunction with standard precautions and expands the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.oEBP are indicated for residents with any of the following: Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; oroWounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO. Wounds generally include chronic wounds, not shorter-lasting wounds: skin breaks/skin tears/or similar areas.o Examples of chronic wounds: pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers.o Examples of indwelling medical devices: central lines, urinary catheters, feeding tubes, and tracheostomies.oWhen EBP are indicated, EBP should be employed for the following high-contact resident care activities: Dressing, bathing/showering, transferring, providing hygiene, changing briefs, assisting with toileting, device care, and wound care. 1.In general, gowns and gloves would not be recommended when performing transfers in common areas such as dining or activity rooms, where contact is anticipated to be shorter in duration.2.Therapy consideration: if close contact is required to perform therapy functions, gown and gloves are recommended. Residents are not restricted to their rooms or limited from participation in activities. The facility has discretion in how they choose to communicate these precautions to the staff. PPE for EBP is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. The facility has discretion in using EBP for residents who do not have wounds or indwelling medical devices and are infected or colonized with an MDRO that is not currently targeted by CDC.

Based on observation, interview and record review, the facility failed to ensure residents have a right to a dignified existence and treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 (Resident #4 and Resident #7) of 8 residents reviewed for dignity.- C NA B did not knock on the residents' door prior to entering and did not provide Resident #7 privacy during incontinent care with Resident #116 (roommate) in the room on 06/03/2026.- C NA T did not knock on the residents' door prior to entering and did not provide Resident #4 privacy during incontinent care with Resident #25 (roommate) in the room on 06/03/2026.These deficient practices could lead to psychosocial harm due to feelings of low self-esteem and/or embarrassment regardless of resident cognition. Findings:Record review of Resident #7s face sheet dated 06/03/2026 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her medical diagnoses included reduced mobility, mild protein-calorie malnutrition, other sequelae of cerebral infarction (consequences of stroke), secondary hypertension (high blood pressure), hyperlipidemia (high fat in the blood), unspecified hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (paralysis or partial paralysis following stroke affecting left non-dominant side), other lack of coordination, cognitive communication deficit, dependence on supplemental oxygen, need for assistance with personal care, muscle weakness (generalized), other abnormalities of gait and mobility and pressure ulcer of sacral region ( a large, triangular bone at the base of the spine that connects the vertebral column to pelvis), stage 4, pressure ulcer of right hip, stage 4, pressure ulcer of left hip, stage 3 (Full thickness tissue loss with exposed bone, tendon muscle). Record review of Resident #7's admission MDS assessment, dated 12/25/25, reflected a BIMS score of 3 out of 15, which indicated severe cognitive impairment. She required assistance from staff with ADL care. Record review of Resident #7's care plan, dated 10/04/25, reflected, . The resident had an ADL self-care deficit .Interventions.Personal Hygiene and Toilet use- Resident is totally dependent . Resident #7 was also care-planned for incontinent care, with interventions including changing brief in a timely manner preventing skin break down.Observation on 6/3/26 at 2:59PM revealed CNA B entered Resident #7's room without knocking before entering room for incontinent care. She did not pull the privacy curtain between Resident #7 and roommate Resident #116 during incontinent care.Interview on 6/3/26 at 3:39 PM CNA B said she forgot to pull the privacy curtain and knock on the door, and she will be careful.Resident #4Record review of Resident #4's face sheet last captured 06/03/2026, reflected she was a [AGE] year-old female originally admitted on [DATE]. Her medical diagnoses were gastronomy status (has a gastrointestinal tube to provide nutrition and medication from opening straight into stomach), muscle weakness (generalized), muscle wasting and atrophy, not elsewhere classified, multiple sites, dysphagia (difficulty swallowing), cognitive communication deficit, moderate protein-calorie malnutrition, other lack of coordination, muscle wasting and atrophy, not elsewhere classified, unspecified site, need for assistance with personal care, sepsis, unspecified organism, altered mental status, unspecified, type 2 diabetes mellitus with hyperglycemia (high sugar in the blood), acute respiratory failure with hypoxia (low oxygen in the blood).Record review of Resident #4 's significant change MDS, dated [DATE], reflected the BIMS score was 00 out of 15, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident was totally dependent on bed repositioning and personal hygiene. Further record review of the MDS indicated Resident #4 was incontinent to bladder and bowel. Record review of Resident's #4's care plan, dated 12/24/2025, reflected the following: I have ADL self-care performance deficit and totally dependent on staff for all ADLs and requires assistance with activities of daily living due to decreased physical and functional mobility secondary to weakness and multiple medical comorbidities.Observation on 6/3/26 at 3:29PM revealed CNA T entered Resident #4's room without knocking before entering room for incontinent care. She did not pull privacy curtain between Resident #4 and roommate (Resident #25) during incontinent care.Interview on 6/3/26 at 4:33 PM CNA T said she forgot to pull the privacy curtain and knock on the door, and she will be careful. CNA T said not pulling the privacy curtain and not knocking on their door was disrespectful to the residents.Interview with the Administrator and DON on 06/3/26 at 5:35pm, the Administrator said that privacy curtains should be utilized during procedures. Residents having procedures done without them could have made them feel uncomfortable and not have privacy. Record review of the facility's policy on resident rights, undated, read in part, A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.Privacy and confidentiality .1. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #77) of 5 residents reviewed for comprehensive care plans. Resident #77's comprehensive care plan did not include all care areas triggered on the resident assessment. This failure could place all residents in the facility at risk of not receiving proper care to develop and improve their mental, physical and psychosocial well-being.Record review of Resident #77's admission face sheet revealed Resident # 77 was a [AGE] year-old male who was admitted on [DATE]. Resident #77's diagnoses included acute respiratory failure ( a condition that makes it difficult for the lungs to breathe in oxygen and breathe out carbon dioxide), hypertension (high blood pressure), hyperlipidemia (high level of fat in the blood), depression (a mood disorder that causes persistent sadness, and loss of interest activities), anxiety (worried thoughts and emotions), and bipolar (is a mental condition that causes extreme mood changes). Record review of Resident #77's admission MDS dated [DATE] revealed the resident was coded for B1000 as impaired for vision and uses corrective lens, C0500 as having a BIMS score of 11 indicating the resident has moderate cognitive impairment: For Bowel and bladder he was coded as occasionally incontinent of bowel and bladder. Record review of Resident #77's MDS dated [DATE] reflected these CAAs triggered: cognitive loss/dementia, visual function, communication, urinary incontinence/indwelling catheter, psychosocial well-being and falls. Review of Resident #77's comprehensive care plan initiated 4/29/2026 revealed it did not include cognitive loss, visual function, urinary incontinence/indwelling catheter, psychosocial well-being and falls. Observation on 06/04/2026 at 10:15 am of Resident #77 revealed he was in bed, alert and oriented clean and groomed with no odor. His call light was within reach. During an interview on 06/04/2026 at 10:15 am Resident #77 said he was never abused since being admitted at the facility. He said his only problem was not getting his blood thinner medication for his blood clots. During an interview on 06/04/2026 at 12:55 pm with MDS Coordinator N she said it was an oversight why all triggered areas were not addressed on Resident #77's care plan. She said when completing the care plans, she interviews and observed residents, reviewed activities of daily living notes and nurse's notes. She said she also interviewed the CNAs and nurses to ensure all areas were addressed on the care plan. She said moving forward she was going to ensure all triggered areas of the CAAS were addressed. She said she was going to update the care plan. In an interview on 06/04/2026 at 2:20pm the DON said her expectation of the MDS nurse was to complete comprehensive care plans that address all triggered areas of the MDS. She said the MDS nurse was to ensure that care plans were accurate and complete. She said if care plans were not accurate then that could prevent residents from getting the care and treatment they need. She said they were talking about looking at the MDS and the skilled charting and how they could do better charting and care plans. She said they will continue to look at the MDS by reviewing the baseline care plan and change in conditions and then update the care plan. Record review of the facility's policy titled, Care Plan Revisions, with revision date 5/2022, revealed, Care plans will be modified as needed by the MDS Coordinator or other designated staff member.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one resident (Resident #99), of four residents reviewed for ADLs.The facility failed to provide nail care to Resident #99.This deficient practice could place residents at risk of skin breakdown and reduced feelings of self-worth.Findings include:Record review of Resident #99's face sheet dated 06/03/26 revealed he was initially admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. Resident #99 had diagnoses which included heart failure (heart not pumping blood efficiently to meet body's needs for oxygen), diabetes mellitus (high blood sugar), and hypertension (high blood pressure).Record review of Resident #99's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14, indicating intact cognition. Further review of the MDS revealed the resident needed supervision with minimum assistance.Record review of Resident #99's care plan initiated on 07/22/23 revealed the resident had a self-care deficit and was at risk for further decline in ADLs. Intervention: provide assistance of 1 staff member for personal hygiene/grooming.Record review of Resident #99's POC(point of care) response history shower record for May 2026 did not reveal whether the resident's fingernails were cut.During an observation on 06/02/2026 at 9:43 a.m., Resident #99 had three fingernails on the left hand which were about 1.75 cm long and had dark brown substances under the fingernails. He also had four fingernails on the right hand which were about 1.5 cm long and also had brown substances under the nails.During an interview on 06/02/26 at 9:43 a.m., Resident #99 said he wanted his fingernails cut. He said the aides gave him showers three times a week and when the aides asked him if he wanted his fingernails cut, he would say yes. He said he did not ask the aides because the aides were supposed to ask him. Resident #99 said the staff did not clean his fingers after meals and that was why he had dirt in his fingernails. He said he did not feel groomed because of the dirt under his fingernails.During an interview on 06/02/26 at 10:05 a.m., CNA T said Resident #99's fingernails were cut two times a week and as needed by the aides and shower technician. She said Resident #99's fingernails were supposed to be cleaned daily and as needed. CNA T said she did not notice Resident #99's fingernails were long and had substances under the fingernails until then. She said Resident #99 could scratch himself, which could cause skin tears, and the areas could become infected.During a telephone interview on 06/02/26 at 4:41 p.m., RN O said she did not look at Resident #99's fingernails when she made rounds, but when she observed Resident #99's fingernails now it revealed both hands had long fingernails and some of the fingernails were dirty. She said resident fingernails were cut whenever the fingernails were long and the fingernails were cleaned daily, and it was the responsibility of all nursing staff. She said the resident could scratch himself when his fingernails were long and he could get an infection from the germs under the dirty fingernails.During an interview on 06/04/26 at 8:20 a.m., the DON said CNA T should have cut Resident #99's fingernails and if the resident was diabetic, then the nurse would cut the resident's fingernails. The DON said if the facility staff could not cut Resident #99's fingernails, then the podiatrist would cut the resident's fingernails. She said Resident #99 could have skin breakdown and infection if Resident #99's fingernails were dirty. She said the resident's fingernails were cleaned as soon as the staff noticed the nails were dirty.Record review of the facility policy on activities of daily living revised 1/2026 did not contain instructions on fingernail care, but the definition revealed, .activities of daily living include personal care tasks such as bathing.grooming.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 6 residents (Resident #7 and Resident #4) reviewed for incontinent care. -The facility failed to ensure CNA B cleaned Resident #7's buttocks before putting on a clean brief during incontinent care on 6/3/26. -The facility failed to ensure CNA T cleaned Resident #4 's buttocks before putting on a clean brief during incontinent care on 6/3/26. This failure could place residents at risk for pain, infection, injury, and hospitalization. Finding included Record review of Resident #7's face sheet dated 06/03/2026 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her medical diagnoses included reduced mobility, mild protein-calorie malnutrition, other sequelae of cerebral infarction (consequences of stroke), secondary hypertension (high blood pressure), hyperlipidemia (high fat in the blood), unspecified hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (paralysis or partial paralysis following stroke affecting left non-dominant side), other lack of coordination, cognitive communication deficit, dependence on supplemental oxygen, need for assistance with personal care, muscle weakness (generalized), other abnormalities of gait and mobility and pressure ulcer of sacral region (a large, triangular bone at the base of the spine that connects the vertebral column to pelvis), stage 4, pressure ulcer of right hip, stage 4, pressure ulcer of left hip, stage 3 (Full thickness tissue loss with exposed bone, tendon muscle). Record review of Resident #7's admission MDS assessment, dated 12/25/25, reflected a BIMS score of 3 out of 15, which indicated severe cognitive impairment. She required assistance from staff with ADL care. Record review of Resident #7's care plan, dated 10/04/25, reflected, . The resident had an ADL self-care deficit .Interventions.Personal Hygiene and Toilet use- Resident is totally dependent . Resident #7 was also care-planned for incontinent care, with interventions including changing brief in a timely manner preventing skin break down. Observation of incontinent Care on 6/3/26 at 2:59 PM, performed by CNA B, revealed CNA B did not wash hands then donned clean gloves. CNA B picked up clean and wet wipes, unfastened the soiled brief, and using wet wipes cleaned the groin. Resident #7 was repositioned on her left side. Resident #7 was soiled of urine and feces. CNA B cleaned in between the buttocks several times using wet wipes. She did not clean around the buttocks, changed gloves, she then placed a clean brief on and fastened it.Interview on 6/3/26 at 3:45PM with CNA B, regarding incontinent care, she said she did a good job, C NA B was asked why she did not cleaned around buttocks, she said she was nervous and she did not want to mess up the dressing to the sacral area Oh, I forgot CNA B said she had in-services on incontinent care, and she knew not cleaning the buttocks could cause more skin breakdown, odors and urinary tract infection.Resident #4Record review of Resident #4's face sheet last captured 06/03/2026, reflected she was a [AGE] year-old female originally admitted on [DATE]. Her medical diagnoses were gastronomy status (has a gastrointestinal tube to provide nutrition and medication from opening straight into stomach), muscle weakness (generalized), muscle wasting and atrophy, not elsewhere classified, multiple sites, dysphagia (difficulty swallowing), cognitive communication deficit, moderate protein-calorie malnutrition, other lack of coordination, muscle wasting and atrophy, not elsewhere classified, unspecified site, need for assistance with personal care, sepsis, unspecified organism, altered mental status, unspecified, type 2 diabetes mellitus with hyperglycemia (high sugar in the blood), acute respiratory failure with hypoxia (low oxygen in the blood).Record review of Resident #4 's significant change MDS, dated [DATE], reflected the BIMS score was 00 out of 15, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident was totally dependent on bed repositioning and personal hygiene. Further record review of the MDS indicated Resident #4 was incontinent to bladder and bowel. Record review of Resident's #4's care plan, dated 12/24/2025, reflected the following: I have ADL self-care performance deficit and totally dependent on staff for all ADLs and requires assistance with activities of daily living due to decreased physical and functional mobility secondary to weakness and multiple medical comorbidities. Observation of incontinent Care on 6/3/26 at 3:29 PM, performed by CNA T, revealed CNA T washed her hands and then donned clean gloves. CNA T picked up clean and wet wipes, unfastened the soiled brief, and using wet wipes cleaned the groin. Resident #4 was repositioned on her right side. Resident #4 was soiled of urine and feces. CNA T cleaned in between the buttocks several times using wet wipes. She did not clean around the buttocks, changed gloves, she then placed a clean brief on and fastened it.Interview on 6/3/26 at 4:33PM with CNA T regarding incontinent care, she said she did a good job, she was asked why she did not clean around buttocks, she said she did not want the dressing to come off the sacral area. CNA T said she had in-services on incontinent care weekly, and she knew not cleaning the buttocks could cause more skin breakdown, odors and urinary tract infection.In an Interview with the DON -RN on 6/3/26 at 5:00pm, she said that she was in charge of doing the in services for incontinent care. She said she randomly went into rooms to observe staff to ensure they were doing care properly. She said she checked to see their technique, hand washing and customer service. She said her last in-service on incontinent care was on 3/4/26. She said that all C NA's were checked off and trained. DON said she was going to do more frequent skill check offs with staff.Interview with the Administrator on 6/4/26 at 5:00 PM, regarding expectation for incontinent care, she said her expectation was for incontinent care to be done in a manner to prevent urinary tract infection. Record review of the facility's policy for Perineal Care, revised on 12/2023 read in part: The facility will provide perineal care in a manner that maintains privacy, reduces the risk of infection, and promotes skin integrity. Procedure: .wash hands thoroughly and apply gloves. Gather necessary supplies.clean gloves.Applying Clean Brief: Remove soiled gloves and dispose of them properly, perform hand hygiene thoroughly and apply new clean gloves.

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 11 (Residents #42 and #110) residents reviewed for respiratory care. -The facility failed to ensure Resident #42's oxygen was administered at the correct setting of 2-3 liters per minute on 06/02/2026.-The facility failed to ensure Resident #110's oxygen was administered at the correct setting of 2-3 liters per minute on 06/03/2026. These failures could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care.Resident #42 Record review of Resident #42's face sheet dated 06/03/26 revealed he was initially admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. Resident #42 had diagnoses which included dementia (a loss of memory, language, and thinking abilities that were severe enough to interfere with daily life), COPD (lung disease that made it hard to breathe), and acute respiratory failure (a sudden life-threatening condition where the respiratory system failed). Record review of Resident #42's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating intact cognition. Further review of the MDS revealed the resident was on oxygen. Record review of Resident #42's care plan initiated on 04/20/25 and revised on 06/02/26 revealed the resident had oxygen via nasal cannula or mask related to respiratory failure, COPD, SOB(shortness of breath), and Hypoxia (the body did not get enough oxygen to function properly). Intervention: follow physician orders for oxygen therapy. Record review of Resident #42's order dated June 2026 revealed Oxygen at 2-3 LPM via nasal cannula as needed for shortness of breath. Monitor O2 sat per shift and as needed for shortness of breath. The order was initiated on 01/17/26 and discontinued on 06/02/26 at 7:53 p.m Record review of Resident #42's order dated June 2026 revealed oxygen at 0.5 LPM via nasal cannula for shortness of breath. Monitor O2 sat per shift. The order was initiated on 06/02/26 at 7:53 p.m. Record review of Resident #42's O2 sat summary for May 2026 revealed the resident's oxygen saturation was 96% with oxygen via nasal cannula. Observation on 06/02/26 at 9:16 a.m. revealed Resident #42 was lying on his back in his bed and had the nasal cannula in his nostrils. The nasal cannula was connected to the oxygen concentrator. The setting on the oxygen concentrator read 0.5 L the observation was before the oxygen order was changed on 06/02/26 at 7:53 p.m. During an interview on 06/02/26 at 9:16 a.m., Resident #42 said he was not having SOB because he had his oxygen. He said a nurse told him the setting on the oxygen concentrator was 1 L, but he could not remember the nurse's name. Resident #42 said he did not change the setting on the concentrator. During an interview on 06/02/26 at 9:22 a.m., RN O said Resident #42's oxygen was set at 0.5 L on the concentrator. She said the oxygen setting on the concentrator should have been between 2 to 3 L. She said Resident #42 stated he did not touch the oxygen setting on the concentrator. RN O said nurses were responsible for making sure the setting on the oxygen concentrator was what the physician prescribed to prevent Resident #42 from having any SOB. She said Resident #42 was not getting the required oxygen. She said she made rounds at least three times during her shift and did not check the setting on the concentrator when she made her initial round during shift change. RN O said she did not know why Resident #42 oxygen was set on 0.5 L. During an interview on 06/04/26 at 8:30 a.m., the DON said if the oxygen was not set on the concentrator as ordered by the physician, RN O did not follow the physician's orders. She said Resident #42 needed oxygen for SOB. The DON said RN O should have called the physician to obtain an order that reflected where Resident #42 wanted the oxygen to be set. She said she was not aware Resident #42 was changing the oxygen setting on the concentrator and, if she had known he was changing the oxygen setting on the concentrator, she would have called the physician and care planned it. She said Resident #42 was receiving some oxygen but was not receiving oxygen as prescribed. She said the nurses should have been monitoring the setting on the concentrator during rounds. She said there was no set time for rounding, but it should have occurred at least every 2 hours. Resident #110Record review of Resident #110's face sheet dated 06/03/2026, reflected he was an [AGE] year-old male originally admitted on [DATE] and last re-admitted on [DATE]. His medical diagnoses included obstructive sleep apnea (this occurs when the throat muscles relax and block the airway), weakness and paralysis following stroke affecting right dominant side, and chronic kidney disease and dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life). Record review of Resident #110's active orders list dated 06/05/2026, reflected he had an order for oxygen @ 2-3 LPM via nasal cannula continuously. Monitor 02 sat with a start date of 05/21/2026 every shift for shortness of breath.Record review of Resident #110's care plan dated 05/06/2026, reflected he had a focus area of oxygen use and required supplemental oxygen via nasal cannula related to SOB with interventions including following physician orders for oxygen therapy delivery, routinely monitoring the resident's oxygen saturation levels, assessing for signs of hypoxia (such as turning blue, confusion, restlessness) and respiratory distress and report to MD as needed.Record review of Resident #110's oxygen readings from 01/03/2026 to 06/04/2026, reflected his readings were within normal range for all dates except for 05/19/2026 when his oxygen reading was at 87% and he was sent to the ER.Observation and interview on 06/03/2026 at 8:23a.m., Resident #110 was in bed and appeared comfortable and not under respiratory distress. Resident #110's oxygenator reading showed he was getting 1.5 L/min. Resident #110 said he did not need anything else. RN I was called into Resident #110's room on 06/03/2026 at 8:43a.m. and RN I read the oxygenator and said it was a little under 2L and turned the knob up to 2L/min. RN I said he had not checked the oxygen level and he was making his way down the hall to Resident #110's room. RN I said the previous shift nurse should have checked the oxygen to make sure it was at the right level. RN I said that residents not getting enough oxygen could negatively affect them and possibly lead to hospitalization. RN I said Resident #110 had previously declined in health and had to get on oxygen and hospice. At the time of the interview with RN I, Resident #110 appeared comfortable and in no distress. Resident #110 said he had no difficulty breathing. Record review of the facility's policy on oxygen last revised 8/2019, it read, Policy: It is the policy of this facility that the facility will provide oxygen therapy by means of various administration devices. Procedures: 1. Review physician's order on the chart for completeness. 5. Assess the resident. Establish baseline respiratory rate and heart rate. 8.Start O2 flow rate at the appropriate flow for administration device.

Based on observations, interviews, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care and in making appointments for 1 of 4 residents (Residents #36) reviewed for dental care. -The facility failed to assist Resident #36 in making their respective follow-up dental appointments. These failures could place residents at risk of oral complications, dental pain, and diminished quality of life. Findings: Record review of Resident #36's face sheet dated 06/05/2026, revealed she was a [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE] with medical diagnoses including Alzheimer's Disease with early onset (a progressive brain disease that cause memory loss), dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life), hypertension (high blood pressure), major depressive disorder (a mental illness characterized by prolonged periods of sadness and feelings of worthlessness), and age-related physical debility (decline in ability). Record review of Resident #36's Comprehensive MDS dated [DATE], revealed she was coded as having no dental concerns, including no obvious or likely cavity or broken natural teeth and no mouth or facial pain, discomfort or difficulty with chewing. Record review of Resident #36's Quarterly MDS dated [DATE], revealed she had a BIMS score of 8, indicating moderate impairment related to thinking and memory. She required substantial assistance with oral hygiene related to dentures and ability to use suitable items to clean teeth. Resident #36 was coded as having no broken or loosely fitting full or partial dentures nor did she have mouth or facial pain, discomfort or difficulty with chewing. Resident #36 had no pain and did not have regular pain medications. Record review of Resident #36's Order Summary dated 06/05/2026 revealed she had an active order for regular texture, regular/thin consistency with an order date of 01/02/2025. Record review of Resident #36's care plan last dated 06/05/2026 revealed she had a focus area of requiring a regular diet with thin liquids for nutritional support and being at risk for unplanned weight loss and nutritional complication dated 06/30/2024 with interventions including assisting resident with eating as indicated, serving diet as ordered and have the DM monitoring and discussing her food preferences. There were no areas documented on oral pain or damaged natural teeth. Record review of Resident #36's most recent dental visit on 12/03/2025 revealed the resident presented for initial exam with a complaint of wanting dentures. Remaining teeth were non-restorable with recommendations to ext. (extract) all remaining teeth and fabrication of CD/CD (complete dentures) to aid in function and mastication (chewing). Resident #36 was documented at being at high risk for caries (cavities) and teeth condition was written as 'poor, asymptomatic; general breakdown. The document wrote that the next actions required by nursing home staff included obtaining signature from responsible party on consent form for extractions. Record review of the dental company's emails revealed the company sent the following email to the SSW:-On 12/08/2025, the company sent an inquiry into Resident #36's applied income. Record review of Resident #36's progress and psychiatric visit notes since December 2025 revealed resident was not documented as having any complaints for oral pain. Record review of the dental company's schedule for the visit on 06/24/2026 revealed Resident #36 was not on the list. Record review of Resident #36's dental insurance information revealed Resident #36 did not have any gaps in dental insurance care. Record review of Resident #36's weights revealed she had no weight loss from 12/10/2025 to 05/08/2026. Record review of Resident #36's meal percentages revealed she ate 75-100% of her meals in the last 30 days from 05/06/2026 to 06/05/2026. Record review of emails related to Resident #36's dental care revealed the Administrator sent an email on 06/05/2026 at 10:28a.m., she said the SSW had no additional documentation for Resident #36's dental care or insurance concerns. Observation and interview on 06/03/2026 at 11:46a.m., Resident #36 was observed during activities in the secured unit with three teeth on her lower right side with white enamel and blackened center when viewed from the top. When asked about her teeth, Resident #36 said that she could not eat hard foods like sausage and some meats, but she could eat softer foods and she got plenty of it and that her teeth only hurt when she ate hard foods. Resident #36 said she ate her breakfast and was getting ready for lunch. Resident #36 said she did not tell her nurse or aides about her food preferences and pain in her teeth. In a later observation and interview on 06/04/2026 at 9:58p.m., Resident #36 was sitting on her bed in her room eating cheese puffs. Resident #36 reiterated that she had no pain now and only had teeth pain when eating hard things like sausages. Interview on 06/03/2026 at 3:13p.m., LVN C said she did not know about Resident #36's teeth and that neither Resident #36 nor CNAs told LVN C about Resident #36's teeth. LVN C said she expected staff to tell her about black teeth. LVN C said she was going to tell the SSW about Resident #36's teeth so she could be placed on a dental list for the next visit by the dental contractor with the facility. In a later interview with LVN C on 06/04/2026 at 10:05a.m., she said staff not informing LVN C of Resident #36's black teeth could have prolonged treatment and that black teeth were a sign of possible infection or could affect the ability to eat. Interview on 06/03/2026 at 3:20p.m., CNA C said that she did not usually work with Resident #36 but knew she was pretty independent with her ADLs. CNA C said that she did not know when she noticed Resident #36's black teeth but that everyone knew about it. Interview with CNA L on 06/04/3026 at 9:23a.m. via phone, CNA L said that Resident #36 required setup only with toothbrush and toothpaste set out and never complained about teeth pain and did not see blackened teeth and that CNA L would report black teeth to Resident #36's nurse. CNA L said black teeth could affect residents by causing infection and other negative outcomes. CNA L could not specify what other negative outcomes. Interview with the Administrator and DON on 06/03/2026 at 7:02p.m., the DON said that black teeth should trigger dental services. The Administrator and DON said they will check if Resident #36 was admitted with dental concerns but that she had never complained about it. In a later interview on 06/04/2026 at 3:41p.m., the Administrator said that if Resident #36 was not able to get her procedures done, she would not be able to get dentures but there was no negative outcome because she was not losing weight and was eating 100% of her meals. Interview with the SSW on 06/04/2026 at 10:52a.m., she said she submitted documents through the dental company portal. Staff would assess pain and let the SSW know. Appointments would depend on when the company was scheduled to come to the facility. The SSW said the process for dental appointments was that after an initial exam, the dental company would make recommendations, and the dentist would notify the resident or resident's RP on the cost. The facility would check the insurance and if the insurance did not cover the recommended procedures, then the facility would let the RP decide if they wanted to proceed with the procedure or not. The SSW was given the initial exam date for Resident #36 was 12/03/2025 and that she would look into Resident #36's history of dental work. The SSW denied anyone complaining about dental pain. The SSW said black teeth should be shared between aides and nurses and herself because it could lead to teeth decay, gingivitis and other oral concerns. The SSW said she would provide the list of residents on active dental services. In a later interview on 06/04/2026 at 12:54p.m., the SSW said she would need to check on Resident #36's dental work as she had not had time to review it. She said that the dental company was solely responsible for communicating any procedures with the family and that the SSW had reviewed the insurance at the time and confirmed that Resident #36 had insurance to complete the procedure. When asked if she was responsible for checking in and ensuring the family received the documentation from the dental company, the SSW responded that it was the dental company's responsibility and that the dental company did not even send documentation to the facility and it was out of the facility's hands. The SSW said she would not know what the family agreed on. In a follow up interview on 06/04/2026 at 2:41p.m., SSW said she was not in charge of appointments and that the dental company would schedule visits and let her know about dates and also if residents refused services. The SSW said she talked to Resident #36's RP recently and said the RP did not mention any concerns with teeth and that he was pretty active and visited Resident #36 weekly. The SSW said she just found out this morning that the dental company had not contacted the family. When asked what could happen if referrals were not followed up on by her, the SSW responded that she wasn't sure how to answer that. Interview with the dental company representative on 06/05/2026 at 11:40a.m., he said that Resident #36 was seen on 12/03/2025 and the company sent the facility her proposed treatment plan on 12/08/2025. The company inquired about Resident #36's applied income to complete the payment portion by email and phone, but no one reached back out so the company could not move forward with the treatment plan. The representative said his supervisor sent the email to several facility staff including the SSW and he was going to ask his supervisor to forward the email. The representative said the company made appointments and always kept the facility in the loop by forwarding information by email to the residents, the RP and facility in case the resident is their own RP. Interview with CNA P on 06/04/2026 at 1:22p.m., CNA P said she was the aide in Resident #36's hall. CNA P said Resident #36 did her own dental care and brushed her own teeth. CNA P said she did not notice black teeth. Interview with Resident #36's FM on 06/04/2026 at 1:45p.m., he said when he talked to a facility staff in December 2025, they did not mention any blackened teeth. The FM said he had issues with Resident #36's dental insurance and was waiting for the facility to update him on Resident #36's insurance status. The FM said he did not know who he talked to about her insurance but that it was a case worker. The FM said that Resident #36 lost her dentures before she transferred to this facility but that even though Resident #36 did not like to use her removable dentures, the facility still should have taken care of her blackened teeth. The FM said he did not receive any messages or phone calls from the dental company. The FM was aware Resident #36 had a hard time eating hard food. Interview with the regional DON on 06/04/2026 at 1:57p.m., she said that from what she was able to find out, Resident #36 had not responded to the dental company's consent form and that Resident #36 never complained of pain and the family did not want to downgrade the diet. The regional DON said even if teeth were decaying, it did not mean that the person was in pain. At her exam on 12/3/2025, Resident #36 denied pain. The regional DON said the dental company did not send copies of the dental consent form to the facility. The regional DON said the dental company would only see her on emergency basis if she complained of pain and that staff would notice if Resident #36 was not eating as much. Interview with the Administrator on 06/04/2026 at 3:41p.m., the Administrator said that the SSW should have followed up to check on the referral for Resident #36. A negative outcome would have been Resident #36 did not get her dentures, but there was no negative outcome since she was not losing weight and eating 100%. Record review of the facility's policy on ancillary services, it read, The facility staff will work to assist and/or coordinate services, such as, but not limited to, the following: Routine dental, vision, audiology and podiatry services. Identify residents who require prompt referral. Examples include but are not limited to: Damaged or broken dentures, hearing aids, glasses, or other assistive devices. Lost dentures, hearing aids, glasses, or other assistive devices .Schedule an appointment and arrange transportation, as needed .Document referrals, coordination efforts, appointments, and resident or representative notifications in the resident's medical record, as applicable.

Based on observation, interview and record review, the facility failed to ensure residents had the right to formulate an advance directive for 4 of 8 Residents (CR#1, Resident #1, Resident #2, Resident #3) reviewed for Advance Directives. - The facility failed to ensure there was a system in place to ensure all residents wishes for advanced directives were implemented and discrepancies regarding DNR wishes were addressed immediately upon admission.- The facility failed to clarify discrepancies in CR #1's wishes of DNR when she admitted on [DATE]. On [DATE] CR #1 was found unresponsive and received CPR from 06:26 AM to 07:04 AM in the facility and until 07:28 AM in the hospital until the POA notified the staff of the DNR wishes and rescue efforts were stopped. CR #1 expired at 07:28 AM. - The facility failed to clarify discrepancies in Resident #1's advances directive upon admission on [DATE] when wishes of DNR were communicated prior to admission. She was a full code from [DATE] to [DATE] and [DATE] to [DATE]. - The facility failed to ensure there was a system in place to ensure all residents wishes for advance directives were implemented and discrepancies regarding DNR wishes were addressed immediately upon admission. An Immediate Jeopardy was identified on [DATE]. The IJ template was provided to the Administrator and DON on [DATE] 02:22 PM. While the immediacy was removed on [DATE] at 01:29 PM, the facility remained out of compliance at a severity level of no actual harm, with a potential for more than minimal harm that was not an immediate jeopardy, and at a scope of widespread due to the facility's need to evaluate the effectiveness of the corrective systems. The failures could affect all residents who have implemented Advance Directives and established their choice not to be resuscitated at risk of receiving CPR against their wishes. Findings included: CR#1 Record review of CR #1's Face Sheet dated [DATE] revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: UTI, history of colon cancer and large intestine, high blood pressure, irregular heartbeat, the presence of a pacemaker and mild cognitive impairment. CR #1 discharged to an acute care hospital on [DATE]. Her Advance Directives were blank. Record review of CR #1's admission Assessment completed on [DATE] signed by RN A revealed, she arrived at the facility on [DATE] at 07:10 PM and the NP was notified of her admission on [DATE] at 07:56 PM, but medication reconciliation was not completed. Family Member #1 was notified of her admission on [DATE] at 07:34 PM. Record review of CR #1's Baseline Care Plan dated [DATE] revealed, Focus: Urinary Incontinence, Bowel Incontinence, Behaviors (resident has episodes of behaviors and is at risk for further increased episodes and injury), Falls (resident is at risk for falls and injuries). Social Services Code Status: Full code. Record review of CR #1's EMR revealed, no admission packet or agreement on record. Family #1 was appointment CR#1's healthcare agent and had the POA was notarized on [DATE]. Record review of CR #1's Hospitalist Service Progress Note dated [DATE] at 02:20 PM revealed, Code Status: DNR. Record review of CR #1's facility provided Hospital Medicine Service Progress Note signed [DATE] at 08:21 AM revealed, Code Status: DNR. Record review of CR #1's facility provided Hospital Medicine Service Progress Note signed [DATE] at 08:03 AM revealed, Code Status: DNR. Record review of CR #1's admission portal Summary Report uploaded [DATE] revealed, during her hospital stay, she demonstrated significant physical deconditioning and impaired cognition, characterized by damage to the small blood vessels in the brain due to reduced blood flow and worsening memory/organization. Advance Directives: Code Status: DNR (Do Not Resuscitate). Living Will: Received. Record review of CR #1's BIMS Assessment Completed [DATE] revealed the resident had moderately impaired condition as indicated by a BIMS score of 12 out of 15. Record review of CR #1's Physicians Orders dated [DATE] revealed, ADC: Full code. The order was discontinued on [DATE]. Record review of CR #1's Physician's Progress Note dated [DATE] at 08:15 AM revealed, code status: Full code. Advance Directives DNR. Record review of CR #1's Change of Condition form dated [DATE] signed by LVN A revealed, Code Status: full code; Assessment: Resident was unresponsive during rounds and shift change and resident was unresponsive to verbal stimuli with no pulse. The NP and Family Member #1 were notified on [DATE]. Record review of CR #1's Progress Notes dated [DATE] at 07:21 AM and signed by LVN A revealed, between 05:30-05:58 AM the resident was rounded on by this nurse and an aide at two separate times. Provided peri care, a brief change and assessed for pain and the need of repositioning. The resident was stable, alert and talking. At 06:20 AM during morning rounds at shift change the oncoming nurse reported to this nurse that the resident was unresponsive and not easily aroused to painful stimuli. No pulse was palpable (felt) and the resident was pale in the face and her skin was warm. Code status confirmed by another nurse on duty that the resident was a full code. CPR was initiated by this nurse after confirmation. The aide called 911 and another nurse assisted with the use of the Ambu bag for breaths in between. During pulse checks there was no pulse. CPR continued. At 06:35 AM EMS arrived and took over compressions. They continued CPR while attempting to start an IV line which was unsuccessful. At 06:45 AM EMS verbally confirmed that there was no blockage in the resident's airway then intubated (tube placed in the throat to help breathing) the resident at bedside and continued to bag. At 06:49 AM the free hand CPR machine was used and the resident still had no pulse. Blood sugar was checked at 06:51 AM by EMS and it was 110. At 07:00 AM EMS left the facility with the resident via stretcher continuing CPR. Family Member #1 was called and no answer. A VM was left for a retuned call. Two minutes later the family member returned the phone call and was notified of the change in condition and she stated, I have noticed that something was wrong with her for a few days now. She was also informed that the resident was sent to the hospital. The DON and NP were notified. Record review of CR #1's ED Hospital Notes dated [DATE] revealed, Medical Decision Making: [AGE] year-old female with cardiac arrest (heart stopped beating) PEA (a form of cardiac arrest where the heart monitor shows an organized rhythm, but the heart muscle does not contract, resulting in no pulse. It is a life-threatening, non-shockable rhythm requiring immediate CPR and identification of underlying causes) on scene, multiple shocks and then recurrent PEA. Greater than 45 minutes total downtime. Following about 10 minutes of CPR in the emergency department, CR #1 did not regain pulses. Next of Kin/POA was contacted who stated CR #1 should be DNR but there was no paperwork on file with the new facility where the patient was currently located. They requested cessation of resuscitative efforts. These efforts were ceased and the patient remained pulseless. Her time of death was 07:28 AM. Disposition: the patient has a disposition of expired. In an interview on [DATE] at 02:35 PM, Family Member #2 said CR #1 wished to be a DNR and her wishes were documented in the records sent to the facility when she was accepted. She said on [DATE], CR #1 was found unresponsive and the facility initiated CPR. Family Member #2 said CPR continued until CR #1 was in the hospital and the family notified them of the residents wishes to be DNR. Family Member #2 said the hospital she discharged from to the facility took care of the DNR paperwork. In an interview of [DATE] at 04:10 PM, Family Member #2 said CR #1 had documents with 2 different code status (full code and DNR) but the facility never reached out to get clarification for the resident's code status. In an interview on [DATE] at 09:14 AM, the Hospital Case Manager said she sent CR #1's clinical records to the facility on [DATE], [DATE] and [DATE] after she received notification that the facility would accept her and could meet the CR #1's needs on [DATE]. The Case Manager would not confirm CR #1's code status and said it was documented in the resident records that were sent to the facility In an interview on [DATE] at 11:13 AM, LVN A said the night of [DATE] was the first day she worked with CR #1. She said the resident was sleepy and didn't want to eat dinner because she was up all night. LVN A said on the night of [DATE] CR #1 was fine, talkative during the night, and when she saw her she was alert. She said when she and the on-coming nurse were performing walking rounds around 06:20 AM on [DATE], CR #1 was found unresponsive. LVN A said after the staff confirmed she was full code in her EMR (banner located in EMR), she initiated CPR. LVN A said a resident's DNR status could be verified through the documents in the miscellaneous tab of the EMR but she did not look in CR #1's miscellaneous tab to verify if there was DNR paperwork. She said facility staff continued CPR until the EMS arrived. She stated she communicated the resident's full code status to the EMS and they continued to perform CPR until the resident discharged from the facility. On [DATE] at 01:37 PM, an attempt was made to contact CR #1's attending physician (MD A), and a message was left. On [DATE] at 02:23 PM, the DON notified surveyors that MD A was unavailable in an email that read [MD A] is not in office I have been told she is out with a family emergency however, the office states that if you want to speak with our medical Director that would be okay Resident #1 Record review of Resident #1's Face Sheet dated [DATE] revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: sepsis (blood infection), UTI, elevated white blood cell count, chest pain, high cholesterol, kidney failure, Parkinsonism (group of diseases with symptoms of tremors), and blood clots. Record review of Resident #1's admission MDS dated [DATE] revealed the resident was severely impaired cognition as indicated by a BIMS score of 3 out 0f 15. Record review of Resident #1's undated Care Plan downloaded [DATE] at 10:00 AM revealed, Focus- FULL CODE: Resident #1/Responsible party have requested a code status of FULL CODE Date Initiated: [DATE] revision on: [DATE]. Interventions/Task- If resident's heart stops, initiate CPR and call 911 for transfer to the hospital; Date Initiated: [DATE]. Record review of Resident #1's OOH- DNR Form dated [DATE] revealed, the form was completed with the signature of the legal guardian, two witnesses and notarized on [DATE]. The facility Medical Director did not sign the form until [DATE]. Record review of Hospital Nephrology Progress Notes dated [DATE] revealed, Code Status: DNR. Record review of Hospital Nephrology Progress Notes dated 0321/26 revealed, Code Status: DNR. Record review of Resident #1's Hospital Transfer Cover Page dated [DATE] revealed Code Status: DNR Record review of Resident #1's Physician's Orders revealed:- [DATE] at 03:17 AM, ADC: Full code; Order type: Advance Directive; Advanced Directive Status: Verified by Medical Record Only. Discontinued on [DATE].- [DATE] ADC: Do Not Resuscitate- DNR- [DATE] ADC: Full Code, Order type: Advance Directive; Advance Directive Status: Verified by Medical Record Only.- [DATE] ADC: Do Not Resuscitate- DNR Record review of Resident #1's Progress Notes revealed,- [DATE] signed by the Social Worker- Call placed to Family Member #3 to verify code status. No answer and was unable to leave a voice message.- [DATE] signed by the Social Worker- Follow up call placed to Family Member #3. The RP wishes for the resident to remain a DNR. There was no documentation prior to [DATE] that addressed the resident's advance directives. In an interview on [DATE] at 11:23 AM, the Administrator said her date of hire was within the last 2 weeks. She said resident admissions started with communication through the admissions portal and when the information was sent to the facility, the DON reviewed the clinical information. The Administrator said she expected the admitting nurse to review the resident's clinical documentation when they arrived, and the review included upcoming appointments and code status (advance directives), and if there were discrepancies in the code status in the records she expected the admitting nurse and the Social Worker to get clarification. In an interview on [DATE] at 11:41 AM, the DON said there was no specific staff responsible for ensuring the resident's admission process included wishes and code status were transcribed or entered accurately. She said it was a multi-staff process but the Social Worker was responsible for entering and verifying a resident's code status during the 72 hour care plan, but normally when a resident is not full code the hospital sends the documentation to the facility. The DON said there was no review of advance directives after the Social Worker entered the information during the 72 hour care plan. The DON was unable to identify who was responsible for ensuring advance directives were accurate and verified before the 72 hour care plan. The DON said she did not review any resident clinicals before or after admissions. She said the Marketer was responsible for clinical review of the residents' charts to ensure the facility could meet their needs . The DON said after she was made aware of concerns regarding CR #1's code status, she did not investigate what happened, and the facility had not performed any audits of resident advance directives She said the marketing team was responsible for verifying the resident's code status prior to admission and if there was a discrepancy the marketing team was responsible for identifying the issue and alerting nursing. The DON said the marketing team was responsible for clinical review of the discharge documents for advance directives. The DON said accurate advance directives were important because it was violation of the resident's rights, and if a resident didn't want to go through CPR, they shouldn't have to. In an interview on [DATE] at 11:57 AM, the Admissions Coordinator said her responsibility during the admissions process was to get the resident's room ready and ensuring the resident had a good stay. She said she was not responsible for reviewing any admissions documentation. In an interview on [DATE] at 12:01 PM, the Social Worker said she confirmed the resident's code status/advance directives during the 72 hour care plan meeting and she did not know who was responsible to ensure a resident's advance directives were respected, or who was responsible for verification of the advance directives before the 72 hour care plan meeting. The Social worker said when she confirmed a resident's advance directive was a DNR, she was expected to facilitate the completion of the OOH-DNR, and ensure the form was signed by the physician. She said if a discrepancy was identified and the facility did not have the OOH-DNR then she was expected to contact the resident, POA, and their family and request the document. The Social Worker said she was unaware of a discrepancy with CR #1's advance directives because she did not perform the clinical review of the resident's admission documentation and never spoke to the resident's POA. The Social Worker said she was scheduled to talk to Family Member #1 on [DATE] but the resident expired on [DATE]. The Social Worker said failure to verify a resident's advance directives placed them at risk of not receiving services in line with what their wishes were. In an interview on [DATE] at 12:27 PM, Family Member #1 said CR #1 admitted to the hospital on [DATE] and 2 days after her admission, the hospital staff had a meeting with the resident and herself to address her advance directives and CR #1 decided she did not want to be resuscitated, so her code status was changed to DNR. She said she was CR #1's POA and she arrived shortly after the ambulance dropped the resident in the facility on [DATE]. She said at admission CR #1 was very confused, yelling that they tried to kill her and rape her in this truck (the ambulance). The resident kept saying people were trying to kill her and beat her so Family Member #1 should not leave her at the facility. Family Member #1 said the facility called her on [DATE] and notified her that CR #1 was found unresponsive, CPR was in progress and emergency services had transported her to the hospital. Family Member #1 stated the family immediately started to call the hospital because CR #1's advance directive was a DNR. She said when she got in touch with the hospital, she notified the doctor that CR #1's advance directive was a DNR, so CPR was stopped and her time of death was called at 07:28 AM. Family Member #1 said she never received an admission packet, and no one ever talked to her or gave her any documentation of their rights or anything else. She said no staff discussed the resident's advance directives or wishes and if they did she would have notified them of her DNR status. In an interview on [DATE] at 12:50 PM, the Admissions Coordinator said she was responsible for the admission packet and it was usually completed after the resident admitted to the facility. She said the packet was provided to the resident or RP via email or presented in person and it as usually completed within 48 hours of admission. The Admissions Coordinator said the packet addressed the resident's wishes, laundry and consent to take pictures. She said she did not go through the admissions packet with the resident or their RP, and she only emailed the packet after the resident admitted to the facility. The Admissions Coordinator said she did not have an admissions packet for CR #1, and Family Member #1 (CR #1's POA) did not receive the admissions packet. She said Family Member #1 was with CR #1 when she arrived with the resident, but she never received the admission packet, there were no communication about the residents rights or anything contained in the packet. The Admissions Coordinator said she intentionally did not send Family Member #1 the admission packet because she had to confirm she was the POA, and the executed POA was provided to the facility with admission documentation that came before and after the resident admitted but she didn't know it was at the time. The Admissions Coordinator said she had no obligation to communicate the contents of the admission packet to the resident or their designee and she did not know the packet contained acknowledgement of a residents advance directives. In an interview on [DATE] at 09:14 AM, Family Member #3 said Resident #1 had wishes to be a DNR for several months before she admitted to the facility, and the facility was made aware of her wishes during admission. He said he provided the OOH- DNR to the facility when she admitted and no facility staff had contacted him in the last 48 hours seeking clarification of Resident #1's advance directives and DNR wishes. Family Member #3 said he was never notified of Resident #1's being a full code. In an interview on [DATE] at 01:48 PM, the Marketer said he only functioned as a liaison between the hospital and the facility. He said the hospital used an admission portal to communicate the resident's clinical information prior to admission. The Marketer said the admission portal combed through the resident's clinical record and generated a summary report that was sent to the facility, and to his knowledge the resident's code status was communicated to the facility through the report. In an interview on [DATE] at 10:10 AM, the NP said when a resident admitted to the facility she expected nursing to review the clinical documentation but most patients admitted with advance directives of full code. She said if there was a discrepancy in which records reflected both full code and a DNR she would expect the provider to be notified and clarification to be made. The NP said she was unaware of any discrepancies with CR #1's code status but failure to clarify discrepancies caused confusion and left the resident with an unknown advance directive. The NP said changes to a resident's code required physician and family notification, and a resident could not be changed from full code to a DNR, or vice versa without notification and approval. The NP said she had not given any approval to change Resident #1's code status from full code to DNR on [DATE], or back to full code on [DATE]. She said failure to send notification prior to changes in advance directives would place residents at risk of not being provided the level of care that was in line with their wishes. The NP said if there were issues with a resident's advance directives they need to call them and let them figure it out. In an interview on [DATE] at 11:27 PM, the Medical Director said when a resident arrived at the facility and discrepancies were identified in the clinical records facility staff must reach out and get clarification. He said nursing staff were expected to notify providers of discrepancies in advance directive so they could work on it. The Medical Director said a resident's advance directive was not only physician driven but required conversations with the resident and/or qualified family member. He said once the facility was notified of a resident's wish to be a DNR, the nurses and providers initiated the appropriate paperwork and got it signed. The Medical Director said failure to identify and clarify discrepancies in a resident's advance directive placed them at risk of death if they were incorrectly documented as a DNR, or conversely a resident received CPR when their wishes were to be a DNR. He said clarification of a resident's DNR advance directives and completion of the appropriate documentation should be done as soon as possible. He said he signed off on Resident #1's OOH-DNR today but was unaware that the facility had the completed form prior to [DATE] and he was notified the facility switched Resident #1's code status to full code on [DATE] but he was not informed about failure to notify the family. In an interview on [DATE] at 12:00 PM, the DON said her date of hire was [DATE]. The DON said when a resident arrived to the facility the admitting nurse was expected to review the clinical packet to ensure accuracy of resident information. The DON stated after the admitting nurse reviewed the chart, the nurse manager reviewed the documentation, if they were in the building, or the next day if they were not in the building when the resident arrived. The DON said once a discrepancy was identified, nursing was expected to reach out to the provider or applicable person for clarification and documented their efforts in the residents chart. She said failure to seek clarification of identified discrepancies including advance directives could result in failure to follow physician's orders or care being provided contrary to the resident's rights. In an interview on [DATE] at 12:00 PM, the Administrator said her date of hire was [DATE]. The Administrator said there was an issue with the admission process regarding advance directives. She said verification of the advance directive was a shared responsibility, and DNR documentation was given to the nursing department who then took care of it. She said Resident #1's OOH-DNR should never have been given to the Admissions Coordinator, and she expected everyone to document all efforts made regarding advance directives but obviously we (DON/Administrator) were not here when the system was put into place. She said there was failure in communication and documentation, and the facility was aware as of yesterday that there was a broken system and they were putting things in place going forward. The Administrator said, there are processes that are broken and they are fixing it. She said there was a failure in the timing of the formulation of residents' advance directives, and when a resident arrived staff should have pulled an order recap to review the admission, but apparently they were not pulling the order recap to review changes to a resident's status. The Administrator said after questions arose from surveyors regarding CR #1's advance directives, the facility completed an audit and identified Resident #1, Resident #2 and Resident #3's advance directives for a DNR could not be confirmed, so they changed them to full code yesterday, [DATE], while they verified their paperwork and consulted their RP. Record review of the facility provided Order Listing Report dated [DATE] at 01:40 PM generated by the DON revealed, Status: Current, Order Status: Active, Order Type: Advance Directive. Resident #1, Resident #2 and Resident #3's Order Summary were ADC: Do not Resuscitate-DNR. Record review of the facility provided Order Listing Report dated [DATE] at 02:24 PM generated by the DON revealed, Status: Current, Order Status: Active, Order Type: Advance Directive. Resident #1, Resident #2 and Resident #3's Order Summary were ADC: Full Code with revision dates of [DATE]. In an interview on [DATE] at 12:00 PM, the Admissions Coordinator said Family Member #3 sent her Resident #1's OOH-DNR so she printed it and handed it to the nurse on [DATE]. She said that was why her advance directives were changed to DNR. The Admissions Director said neither the DON nor Administrator were notified of her communications with Family Member #3 or the change in advance directives. In an interview on [DATE] at 12:00 PM, the Social Worker said the resident's EMR had a tab that indicated the resident's advance directive and she did not know how she was expected to review the resident's documentation/chart to verify their advance directive. Record review of a blank facility TX admission Packet revealed, Advance Directive Acknowledgement- Does the Resident have an existing Advance Directive regarding life-sustaining treatment? Select one of the following: YES. You confirm that the Resident has an existing advance directive and will provide a copy to the Resident's physician and the Facility. You understand that the Facility cannot implement the Advance Directive until it is fully executed and received.Select which documents are currently executed and provide to the Facility: ___ Living Will ___ Healthcare Power of Attorney___ Do-Not-Resuscitate (DNR) Order NO. You confirm that the Resident does not have an existing advance directive andunderstand that you may contact the Facility to discuss this matter further. Even if you do not have an Advance Directive, you have the right to provide the name of one or more people that you want your treating physician to consider appointing your surrogate should you lose the ability to make health care decisions for yourself. In the absence of an Out-of Hospital Do Not Resuscitate Order (OOH-DNR), the undersigned acknowledges that it is the wish of the Resident to receive Cardiopulmonary Resuscitation (CPR). By signing below, the understanding acknowledges and understands that should cardiac arrest occur, the Resident will be considered a FULL CODE and CPR may be performed. You may change your designation at any time. Please contact the Facility to discuss this matter, change your designation, or to complete the necessary documentation. Record review of the undated facility policy titled Admissions Process, Resident Rights, and Timely Completion of admission Packet revealed,Record review of the facility policy Resident Rights revised 04/2024 revealed, Policy- The facility protects and promotes the rights of each resident. The facility staff will uphold the resident's dignity and individuality, providing care that fosters their quality of life in a respectful environment. Procedure: A written copy and oral review of State and Federal Resident Rights are provided to the resident upon admission; The residents will be informed of their rights and responsibilities in a language they can understand. Legal Representative: Should a resident be declared incompetent per state law or be medically incapable of understanding their rights, this policy will apply to the legal representative as indicated. The legal representative supports the resident in: decision-making, accessing medical/ social/or other personal information of the resident, managing financial matters, or receiving notifications.The decisions of a legal representative are treated as the decisions of the resident to the extent required by the court or applicable law, or delegated by the resident. The facility may not extend additional rights to the legal representative that were not delegated by the resident, the court, or applicable law. Record review of the facility policy titled Texas OOH DNR revised 05/2025 revealed, The Facility respects the rights of residents to make advance directives, including the choice to execute a valid Out-of-Hospital Do Not Resuscitate (OOH-DNR) order. The facility will comply with all applicable state laws regarding OOH-DNR orders. This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The Administrator, DON, Regional Clinical Nurse and Director of Operations were notified of the IJ on [DATE] at 02:22 PM and the Administrator was provided with the IJ template. The following Plan of Removal submitted by the facility was accepted on [DATE] at 09:02 PM. Plan of Removal - F578 [DATE]Deficient Practice:The facility failed to have a system in place to clarify discrepancies in residents' advance directives immediately upon admission.Corrective Actions Taken:The Administrator and Director of Nursing (DON) notified the Medical Director of the Immediate Jeopardy on [DATE] during an ad hoc QAPI meeting.Resident #1's code status was immediately corrected on [DATE] to reflect verified wishes following direct confirmation with the POA and physician notification.On [DATE], the Regional Nurse Consultant provided education to the Administrator, Social Worker and DON regarding:Verification of advance directives upon admissionEnsuring emergency procedures align with the resident's code statusThe DON initiated education on [DATE] for licensed nursing staff on:CPR policy and DNR policyVerification of code status upon admission with nursing documentationEnsuring emergency interventions align with resident code statusEducation for newly hired staff will be incorporated into orientation. Staff will not be allowed to provide direct resident care until training has been completed.Education will be completed on [DATE] .The Social Worker and MDS completed a 100% audit of all current residents' code statuses on [DATE] to ensure accuracy and consistency across medical records and physician's orders. 1 resident was identified with an incomplete DNR not signed by the physician but was immediately corrected and verified by POA.Systemic Changes Implemented:All new admissions will be reviewed during the daily clinical morning meeting with the interdisciplinary team (IDT) to:Verify code statusEnsure accurate and consistent documentation, including:Physician's ordersVerified consent from resident/POANursing documentation of confirmationAll new physician's orders will be reviewed in the clinical morning meeting to ensure:Any changes in code status are verified o Supporting documentation is complete and consistent within the medical record No changes were added to the facility policy.No changes to facility clinical admission checklist were noted or added.Monitoring Plan:The Director of Nursing (DON) and/or Unit Managers will conduct daily audits Monday through Friday on new admission, while the Weekend Supervisor will review admissions occurring on Saturdays and Sundays for a period of two weeks and randomly thereafter to ensure that code status is verified and accurately documented. No changes to the policy were needed.Audit findings from the daily new admission audits will be reviewed by the DON and Administrator and discussed during QAPI meetings monthly x3 months.Any identified issues will result in immediate corrective action and staff re-education.Policy Review:The Administrator reviewed the facility policy on CPR, DNR, and Clinical admission checklist on [DATE]. No revisions were required at this

Based on interview and record review the facility failed to inform residents, both orally and in writing in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility for 1 of 8 residents (CR #1) reviewed for resident rights. - The facility failed to provide/communicate to CR#1's and/or her RP the contents of admissions packet which provided the resident's rights, the rules governing resident conduct, their responsibilities during their stay at the facility, and acknowledgement of advance directives when the resident admitted on [DATE]. On [DATE] CR #1 received CPR after she was unresponsive, even though her wishes were DNR. This deficient practice could place residents at risk of not being aware of their rights, responsibilities, and the facility's policies. Findings include: Record review of CR #1's Face Sheet dated [DATE] revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: UTI, history of colon cancer and large intestine, high blood pressure, irregular heartbeat, the presence of a pacemaker and mild cognitive impairment. CR #1 discharged to an acute care hospital on [DATE]. Family Member #1 was documented as Emergency Contact 1 POA Healthcare and Her Advance Directives were blank. Record review of CR #1's admission Assessment completed on [DATE] and signed by RN A revealed, she arrived at the facility on [DATE] at 07:10 PM and the NP was notified of her admission on [DATE] at 07:56 PM, but medication reconciliation was not completed. Family Member #1 was notified of her admission on [DATE] at 07:34 PM. Record review of CR #1's Progress notes dated [DATE] at 09:53 Pm revealed, the resident came to the facility at [07:10 PM] on a stretcher with the assistance of two EMS assist. The resident was AOx2 (the person knows who they are and where they are but does not know the time or situation0. The NP was notified about the arrival of the resident and medication was reconciled. The DON was also notified and the family member was called. The resident was oriented to the room, call light light, bed control and TV. The resident was alert and stable and did not voiced out any concern. Record review of CR #1's BIMS Assessment Completed [DATE] revealed, moderately impaired condition as indicated by a BIMS score of 12 out of 15. Record review of CR #1's EMR revealed no admission packet or agreement on record. In an interview on [DATE] at 11:23 AM, the Administrator said resident rights were communicated through the admissions process and the admissions packet; and the admission Coordinator was responsible for the completion and communication of the contents of the admission packet. In an interview on [DATE] at 11:57 AM the Admissions Coordinator said her responsibilities during the admissions process was to get the resident's room ready and ensure the resident had a good stay. She said she was not responsible for reviewing any documentation. In an interview on [DATE] at 11:41 PM, the DON said the Admissions Coordinator and Marketing were responsible for the completion of admissions packet. She said the admissions packet was sent/communicated prior to the resident arriving at the facility, and the facility tried to get it signed and completed within 72 hours of admission. In an interview on [DATE] at 12:27 PM, Family Member #1 said she was CR #1's POA said she arrived shortly after the ambulance dropped the resident off at the facility. She said on admission CR #1 was very confused, yelling that they tried to kill her and rape her in this truck (the ambulance). Family Member #1 said the resident kept saying people were trying to kill her and beat her so Family Member #1 should not leave her at the facility. Family Member #1 said she never received an admission packet, and no one ever talked to her or gave her any documentation of their rights or anything else. Family Member #1 said the hospital took care of the DNR paperwork. In an interview on [DATE] at 12:50 PM, the Admissions Coordinator said she was responsible for the admission packet, and it was usually completed after the resident admitted . She said the packet was provided to the resident or RP via email or presented in person and it was usually completed within 48 hours of admission. The Admissions Coordinator said the admission packet addressed residents wishes, laundry and consent to take pictures. She said she did not go through the admissions packet with the resident or their RP, and she only emailed the packet after the resident admitted to the facility. The Admissions Coordinator said she did not have an admissions packet for CR #1, and Family Member #1 (CR #1's POA) never received the admissions packet. She said Family Member #1 was with CR #1 when she arrived with the resident, but she never received the admissions packet, there were no communications of the resident's rights or anything contained in the packet. The Admissions Coordinator said she intentionally did not send Family Member #1 the admissions packet because she had to confirm she was the POA, and the executed POA was provided to the facility with admissions documentation that came before and after the resident admitted but she didn't know it was at the time. The Admissions Coordinator said she had no obligation to communicate the contents of the admissions packet to the resident or their designee. She said failure to deliver the admissions packet would leave residents and their families unaware of their rights. In an interview on [DATE] at 11:58 AM, the Administrator said the Admissions Packet functioned as a way to make sure residents were aware of any information they needed while they lived at the facility and their rights. She said the packet contained the residents' rights, advance directive wishes and the resident/designee should be provided the packet before they arrived or at the very least at admission. The Administrator said failure to deliver or communicate the contents of the admissions packet could leave residents unaware of their rights, and the facility would not know the resident's wishes. Record review of a blank facility TX admission Packet revealed, the packet included charges, Resident Rights, and polices that included: state resident rights, federal resident rights, smoking policy notification, and the bed-hold policy notification. The packet contained forms, Resident Preferences, Financial Information, and Acknowledgements: selection of resident preferences, statement of resident rights acknowledgement, notice of privacy practices acknowledgement. The packet also contained, Clinical and Consent Forms: consent to treatment, consent to photograph, video, and Media Use, Pharmacy Services Agreement, Advance Directive Notice and Acknowledgement.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 5 residents (Resident #3) reviewed for quality of care.LVN A and CNA B failed to prevent Resident #3 from an unwitnessed fall while being unsupervised in the memory care unit's dining room. Resident #3 sustained a hematoma to the right side of the forehead, which resulted in hospital treatment.This failure could place residents at risk for harm, pain, and injury. Findings Include:Record Review of Resident #3's face sheet dated 03/21/2026, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #3's diagnoses included Dementia with psychotic disturbance (visual and auditory hallucinations or delusions related to Dementia); difficulty walking not elsewhere classified (general gait impairment or mobility issues); other lack of coordination (non-specific motor control issues or general clumsiness); altered mental status (significant confusion or disorientation with no definitive cause); and, restlessness and agitation (a state of mental tension, inability to relax, or excessive, non-productive activity).Review of Resident #3's Quarterly MDS assessment dated [DATE], indicated the resident had difficulty communicating words or finishing thoughts; sometimes responded adequately to simple, direct communication only; and, had a BIMS score of 00, which indicated severe cognitive impairment. Inattention, and disorganized thinking was present and fluctuated. Presence and frequency of wandering behavior occurred 1 to 3 days. Resident #3 required setup or clean up assistance to walk 10 feet and 50 feet with two turns. Other neurological conditions and non-Alzheimer's dementia noted. Pain assessment interview was not conducted as the resident was rarely or never understood. Noted to have 1 fall without injury since admission or reentry to facility. Record review of Resident #3's comprehensive care plan last reviewed on 12/29/2025, indicated Resident #3 had ADL deficits and required staff to anticipate the resident's needs and provide prompt assistance; provide limited assistance with 1 support person for locomotion on/off unit; provide supervision assistance with 1 support person for walking in room/down corridor; and, to provide PROM during ADL care as needed.Further review of Resident #3's care plan last reviewed on 12/29/2025 indicated the resident had a history of unintentionally walking into objects. Staff interventions included frequent checks on the resident, especially during high-risk times; maintain the resident's safety during increased episodes of wandering; and offering engaging activities to reduce restlessness. The resident had impaired communication and was at risk for further decline and injury. Staff interventions included reducing or removing interfering environmental stimuli, and using communication tools, terms and gestures the resident could understand. The resident also had a history of taking off her footwear.Review of Resident #3's records reflected a progress note by RN A on 3/16/26 at 6:30 PM, indicated Resident #3 had an unwitnessed fall in the dining room. Prior to the fall, the resident was wandering. Vital signs post fall BP 122/76; Pulse 72; Temperature 97.4; Respirations; 17; O2 saturation 97%. DNP was notified and reviewed medications with RN A. RP also notified.Record Review of the SBAR Change of Condition documentation for Resident #3, dated 3/16/2026 at 6:30 PM, RN A noted the resident had an unwitnessed fall in the dining room. Resident was noted to be wandering before the fall. No notable findings after environment surrounding the fall was assessed. Vital signs noted as BP 122/76; Pulse 72; Temperature 97.4; Respirations; 17; O2 saturation 97%. Assessment of range of motion indicated no changes from baseline of right upper and lower extremities or left upper and lower extremities. Resident did not have onset of pain or visible injuries related to the fall. No other significant conditions contributed to the fall. Notifications made to DNP and RP. New orders to send the resident to ER.Review of Resident #3's records revealed a neuro check, dated 03/16/26 at 6:30 PM indicated the following: RN A documented BP 122/76; Pulse 72; Respiration 17; Temperature 97.4; Alert; 0 abnormal eye movements; pupil reactions .3 millimeters; opens eyes spontaneously; no motor deficits; confused conversation. Further review indicated 3/16/26 7:00 PM-3/17/26 resident was at the hospital.Further review of Resident #3's hospital discharge paperwork, dated 3/16/26, indicated the following: Resident's CT scan (noninvasive imaging to create detailed 3D images of bones, soft tissues, and blood vessels, often to diagnose internal injuries), laboratory results, chest X-ray and pelvis X-ray were all reassuring. Additional instructions were to ice the hematoma, which would go away on its own in the next several weeks. Further instructions also included reporting back to the emergency department if the resident developed significant headaches, altered mental status, weakness, unexplained vomiting, or any other cause for concern.Records review of Resident #3's care plan, updated on 03/16/2026, indicated the resident was at risk of falls and injuries related Dementia. The focus was on the resident's fall on 3/16/2026 with a nodule (a small, rounded lump, swelling, or knot of tissue that can form in skin, or other body tissues due to inflammation, infection, or cell accumulation) noted to the right side of forehead. Staff interventions included head-to-toe assessment, notify MD and RP, neuro checks, and send the resident to the ER for evaluation and treatment. Staff interventions also included assisting the resident with proper footwear (non-skid socks).Further review of Resident #3's care plan dated 3/16/2026, reflected an update to the pain focus area indicated the resident was at risk for further episodes of increased pain/discomfort and injury related the hematoma. Interventions included nursing staff administering medications prescribed related to the hematoma; utilize the FACES pain scale to assess the resident's pain level; and, to monitor for effectiveness of pain medication or other interventions, report ineffectiveness to MD.Record review of CNA A's written statement, dated 3/16/2026, reflected the following: CNA A was in a room providing patient care at the time of Resident #3's incident and was not aware of what occurred.Record review of CNA B's written statement dated 3/16/2026, reflected the following: CNA B was charting, turned around and saw Resident #3 on the ground. She wrote she immediately notified the nurse and assisted the nurse with getting the resident up.Record review of the facility interview forms dated 03/16/2026, reflected the following: CNA D reported, to the DON, providing patient care down the hall when she was made aware Resident #3 had a fall.Review of RN A's interview form dated 3/16/2026, reflected the following: RN A reported to the DON, RN A was at the nurses' station charting on the computer when the aide notified RN A was on the floor in the day room. RN A assessed the resident and no apparent injuries were noted immediately. While giving report to the oncoming nurse near the nurses station, RN A noted the resident had swelling and immediately called 911.Review of RN A's interview dated 3/16/26, reflected the following: RN B reported to the DON, RN B was making rounds down the hall and was made aware of Resident's #1's fall when she RN B returned to the nurses station.Unsuccessful attempts were made on 3/21/26 at 9:51 AM and 3/22/26 at 10:18 AM to interview Resident #3's RP.Observation of Resident #3 on 3/21/26 at 2:12 PM, the surveyor followed Resident #3 to the dining room. Resident #3 ambulated independently; however, every few steps and when stopping, Resident #3 experienced loss of balance lasting about 2 - 3 seconds. The surveyor attempted to engage Resident #3. Resident #3 appeared to hear the surveyor but did not respond and continued to walk in the opposite direction. The surveyor requested nursing assistance to assess Resident #3. Resident #3 had visible discoloration on the right side of her face, including the area above the eyebrow, below the eye, and extending toward the nose. The discoloration was yellow and purple. Resident #3 did not allow LVN C to assist longer than about 15 seconds, moved staff's hands away, and continued walking down the corridor.During an interview on 3/21/26 at 2:12 PM, LVN C said Resident #3 never sat still including during meals, and did not communicate verbally or make needs known. She said if Resident #3 was in pain, she might cry, and staff had to rely on nonverbal indicators such as crying or grimacing to identify changes in condition, requiring continuous direct observation to ensure Resident #3's safety. LVN C said residents in the memory care unit were expected to be supervised at all times and staff were required to communicate with one another when leaving an area, including for breaks or other tasks, to ensure continuous monitoring and that another staff member was aware and observing residents. She said when seated at the nurses' station, full visibility of the dining room was not maintained without turning her head, and this position did not allow for continuous direct observation of all residents.On 3/21/26 at 5:15 PM, CNA A said the incident occurred toward the end of the shift on 3/17/26 at approximately 6:30 PM. She said Resident #3 was in the dining room prior to the incident. She said Resident #3 walked around continuously, did not stay seated, and was not oriented to her surroundings. She said Resident #3 did not communicate verbally and could not make her needs known. She said Resident #3 required staff to watch her while walking. She said she placed Resident #3 on the couch in the dining area and left to provide care to another resident. She said she did not notify other staff she was leaving the area because staff were present near the nurses' station and did not need to provide a handoff of supervision.On 3/21/26 at 5:28 PM, CNA B said the incident occurred toward the end of the shift. She said Resident #3 walked around constantly, did not sit unless eating or sleeping, and did not communicate verbally. She said she was at the nurses' station completing documentation at the time of the incident and was not directly observing Resident #3. She said she did not see or hear the fall and was unaware of the exact whereabouts of other staff at the time. She said Resident #3 was on the floor in the dining room in a sort of seated position on her bottom. She said she was not sure how long Resident #3 had been on the floor. She said she had been charting for about 5 minutes before she saw resident #3 on the floor. She said the last time she saw Resident #3, she was walking around in the dining room. She said she and the LVN A, who was sitting at the nurse's station, immediately went to Resident #3, and the nurse completed an assessment, including vital signs. She said she and LVN A moved Resident #3 to the couch after the nurse said this was okay. She said Resident #3 immediately got back up and continued walking. She said she remained near Resident #3 and monitored her after the initial assessment while the nurse returned to the nurses' station. She said she and the nurse later observed swelling forming on Resident #3's forehead at the same time. She said the nurse immediately called 911 and made additional notifications.On 3/22/26 at 11:22 AM, LVN A said the incident occurred on 3/17/26 at approximately 6:30 PM while Resident #3 was in the dining room. She said Resident #3 was not oriented, did not remain seated, and continuously walked, including during meals. She said she was seated at the nurses' station documenting and could only see a portion of the dining room from that position. She said she was notified by CNA B, Resident #3 was on the floor. She said both she and CNA B immediately responded and assessed Resident #3, including a head-to-toe assessment and vital signs, and observed no visible injuries at that time. She said she contacted the DNP after the initial assessment. She said Resident #3 was moved to the couch and then immediately began walking again. She said CNA B remained with and monitored Resident #3 after the initial assessment. She said maybe 5 - 10 minutes later she observed a bump forming on Resident #3's head. She said she and CNA B noticed the knot at the same time. She said she immediately called 911 due to the head injury and contacted the DNP and DON to report the change. She said she documented her assessments and notes related to the incident.On 3/22/26 at 1:00 PM, the ADON said residents in the memory care unit were at risk for injury due to behaviors and mobility. He said staff were expected to have their eyes on residents at all times and communicate with one another to ensure supervision was maintained to prevent falls and injuries. He said the situation was handled appropriately once LVN C found Resident #3 and the injury was identified.On 3/22/26 at 1:37 PM, the DON said Resident #3 was not oriented, could not communicate her needs, and wandered continuously. She said Resident #3 required monitoring at all times. She said staff were expected to ensure someone always had eyes on all the memory care residents, including Resident #3. She said staff were also trained and expected to ensure supervision coverage was verbally passed on to another staff before leaving an area where residents were present. She said staff positioned at the nurses' station might not be able to see the entire dining room and would not be able to see Resident #3 on the floor. She said lack of supervision placed residents at risk for injury, failure to identify changes in condition, and other adverse outcomes. She said once LVN A notified her of the resident's hematoma, emergency services had already been contacted, she notified the administrator and EMS arrived at the facility within minutes.On 3/22/26 at 3:42 PM, the Administrator said Resident #3 required constant supervision due to inability to ensure her own safety and continuous wandering. She said residents in memory care were at increased risk for falls and injury without supervision. She said staff were expected to maintain direct visual observation at all times and communicate with each other on passing on supervision responsibilities to keep the residents safe. She said the incident might have been preventable if appropriate supervision was maintained. She said staff reported that once Resident #3 was found on the floor, the nurse assessed Resident #3 and notifications were made, and once the hematoma was identified, 911 was called and Resident #3 was sent out. She said the staff acted appropriately once the change in condition was identified.On 3/27/26 at 12:28 PM, the DNP said she was notified of Resident #3's unwitnessed fall and was informed Resident #3's vital signs were within normal limits. She said she instructed staff to monitor Resident #3 and notify her of any changes in condition. She said she was later notified that Resident #3 developed a hematoma and was being sent out to the hospital. She said the discoloration observed was related to the hematoma and consistent with the injury. She said the facility staff acted appropriately in notifying her and sending Resident #3 out once the hematoma was identified. She said she was not willing to provide a statement regarding potential risk and did not provide hypothetical risk statements.Review of the facility's policy titled Dementia Care indicated Resident who display symptoms or are diagnosed with dementia should receive the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being.The facility provides treatment and services that include, but are not limited to:.necessary person-centered care and services that reflect the resident's goals.while maximizing their dignity, autonomy, privacy, socialization, independence choice, and safety.Staff providing care to residents with dementia.will have competencies and skills to support the resident with dementia through the implementation individualized approaches to care that are directed toward understanding, preventing, relieving, and/or accommodating a resident's distress of loss of abilities.Review of the facility's policy titled Fall Management revised 07/2025 indicated The facility will provide a safe environment for all residents by implementing a fall management program. The program includes.individualized care plans.Develop an individualized fall prevention plan for each resident identified at risk. Examples of interventions: Environmental modifications.non-slip footwear; supervision during high risk activities e.g.ambulation.Review of the facility's policy titled Standards of Care revised 10/2023 indicated All care provided will comply with current guidelines, best practices, and Federal/State regulations.Safety measures will be in place to prevent accidents and injuries, including fall preventions strategies.All staff members are responsible for adhering this policy and for providing care that meets these standards. The Administrator will oversee the implementation and compliance with this policy.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 10 residents (Resident #2) reviewed for quality of care.The facility failed to ensure proper care and monitoring of an indwelling urinary catheter, which resulted in Resident #2's penis slit increasing from 0.3 cm in length by 0.1 cm in width to 1.5 cm in length by 0.5 cm in width, and the color of the slit area was beefy red and slightly bleeding.2. The facility failed to ensure proper care and monitoring of Resident #2's indwelling urinary catheter, which resulted in urine draining onto the resident's incontinent brief.These failures could have placed residents at risk for pain, infection, injury, and hospitalization.Record review of Resident #2's face sheet dated 03/26/26 reflected a [AGE] year-old male originally admitted on [DATE] and re-admitted on [DATE] with medical diagnoses of hypertension (high blood pressure), pressure ulcer of sacral region, stage 3 (is a deep, crater-like wound where the skin had broken down through all layers, revealing the fatty tissue underneath but not muscle, tendon, or bone), obstructive and reflux uropathy (obstructive uropathy is a condition where urine flow is blocked, causing a damming effect that can damage the kidneys, while reflux uropathy is a condition where urine flowed backward (the wrong way) in the urinary tract, also potentially damaging the kidneys), pressure ulcer of other site (stage 3).Record review of Resident #1's annual MDS assessment dated [DATE] revealed his BIMS score was 07, indicating severe cognitive impairment. He required total assistance with toileting. He was incontinent of bladder and bowel and had an indwelling catheter.Record review of Resident #2's care plan dated 04/18/2025 revealed Resident #2 had a suprapubic foley catheter and was at risk for increased UTIs and skin breakdown related to neurogenic bladder and obstructive uropathy. Interventions included: follow physician orders for catheter insertion, changes, and maintenance; monitor site for signs/symptoms of infection or skin breakdown and report to MD; monitor urine for odor, color, sediment, and amount, and report abnormalities to MD.Record review of Resident #2's order summary for March 2026 revealed orders to monitor for potential complications of indwelling urinary catheter use such as redness, irritation, signs/symptoms of infection, obstruction, urethral erosion, bladder spasms, hematuria, or leakage around the catheter every shift, with a start date of 12/08/25.Record review of Resident #2's MAR for March 2026 revealed monitoring for potential complications of indwelling urinary catheter use such as redness, irritation, signs/symptoms of infection, obstruction, urethral erosion, bladder spasms, hematuria, or leakage around the catheter dated 12/08/25 showed the nurse signed off that there were no issues with the foley and skin area.Record review of Resident #2's order summary report for March 2026 revealed a urethral indwelling urinary catheter: (20) Fr with (5) cc normal saline balloon using a closed drainage system, to be changed monthly and as needed related to infection and inflammation, and changed as needed if plugged or out, with an order date of 03/24/26.Record review of Resident #2's MAR for March 2026 revealed the urethral indwelling urinary catheter: (20) Fr with (5) cc normal saline balloon using a closed drainage system, to be changed monthly and as needed related to infection and inflammatory reaction due to indwelling urethral catheter, and changed as needed if plugged or out, was transcribed on 03/26/26.Record review of Resident #2's MAR for March 2026 revealed an order to verify the catheter securement device was present, intact, and properly attached every shift, with an order date of 03/06/2026.Record review of statement of deficiencies dated 1/9/26 revealed Observation and interview of Resident #12's [Resident #2] incontinent and foley care on 01/07/2026 at 10:32 am with CNA AA and CNA BB, there was no leg strap or Statlock (stabilization device for a foley catheter) to secure the catheter. There was small redness to the top side of the penis near a slit. Resident #12 did not verbalize he was in pain or displayed any facial grimacing while staff cleaned indwelling catheter. The slit was measured by the ADON RN and was 0.3 cm in length and 0.1 cm in width. CNA AA and CNA BB said they had not seen the slit on the resident's penis before.During an observation and interview during foley care for Resident #2, provided by CNA C and CNA S on 03/25/26 from 11:29 a.m. to 12:10 p.m., revealed Resident #2's penis was slit from the meatus to the shaft below the penis head. The color of the slit was beefy red and there was fresh blood. When CNA C wiped the penis three times with wipes, the wipes had a substantial amount of blood. Resident #2's incontinent brief was saturated with urine, the wet indicator was not visible, and the wound dressing was wet and non-adhesive. The foley bag tubing did not have urine but had smears of sediment, and the foley bag contained about 200 mL of cloudy urine with a significant amount of sediment. CNA S told CNA C to call LVN M. LVN M came into Resident #2's room and observed the resident. The surveyor asked LVN M what he observed. He stated the resident's penis was slit from the meatus toward the shaft, was red, and had minimal bleeding. The surveyor asked LVN M to measure the slit. He stated he would return and left the room while CNA C and CNA S continued providing incontinent care. LVN M returned and stated he had called the NP and received an order to apply ointment. The surveyor then asked him to call the DON. The DON came and observed the site, and LVN M measured the slit and stated it measured 1.5 cm by 0.5 cm. LVN M stated he observed the incontinent brief was saturated with urine and the wound dressing near the buttock was very wet and not adhering, while the second dressing was soaked but not completely.During an interview on 03/26/26 at 9:06 a.m., LVN M stated he was Resident #2's nurse and had made rounds twice but did not notice the foley was leaking or assess Resident #2's penis. He stated the aide or nurse could provide foley care. He stated during his floor orientation about 5 weeks ago, he was told Resident #2 had a slit on his penis and he saw it, but it was not as large as it was the previous day and was not bleeding. He stated he was told it was regular wear and tear from the foley. He stated the NP gave a one-time order for A&D ointment to be applied on the slit on Resident #2's penis the previous day. He stated he was not aware the foley was leaking until he saw the incontinent brief soaked and the tubing contained sediment with no urine. He also observed sediment in the foley bag. He stated multiple factors could cause the foley to leak. He did not respond when asked what could cause leakage or when to obtain an order to flush. He stated leakage meant the foley was not functioning properly and could cause skin breakdown.During a telephone interview on 03/26/26 at 10:56 a.m., the NP stated the facility had not informed her that the slit had increased in size since the survey. She stated the foley could leak if the size was smaller than the meatus or if the balloon was not properly inflated. She stated the facility had not notified her of leakage with the ordered Fr size or whether it was properly inflated. She stated if sediment was present, the facility would follow standing orders or obtain an order to flush. She stated if she had been notified the slit was worsening, she would have assessed Resident #2. She stated LVN M did not call her yesterday and she did not give an order for ointment. She stated she was in the facility today and was not informed. She stated prolonged foley use could cause a slit.During an interview on 03/26/26 at 1:54 p.m., CNA C stated she was Resident #2's aide the previous day and had not changed him prior to providing incontinent care for with the surveyor. She stated she did not regularly work with him but worked 2-3 days per week. She stated the slit was slightly larger than before but had not previously been bleeding. She stated the brief was very wet, and the wet indicator was not visible due to leakage, which could cause breakdown or infection.During an interview on 03/26/26 at 2:38 p.m., RA S stated the foley was leaking onto the brief, which was soaked, and the wet indicator had faded. She stated the penis had a slit larger than the previous week with bright red blood. She stated irritation could occur from the foley during incontinent care or reposition and she would report to the charge nurse if she observed any changes.During an interview on 03/26/26 at 2:48 p.m., the ADON stated he measured the slit and it was previously small with no bleeding, drainage, or redness. He stated the NP and wound care NP assessed it and considered it part of the resident's anatomy due to foley use. He stated he saw Resident #2 slit on his penis three weeks prior, and it was smaller. He stated if there had been bleeding or drainage, he would have notified the physician. He stated LVN M should have monitored and reported changes. He stated improper turning could pull the foley and worsen the slit. He stated sediment could block the foley and cause leakage, leading to skin breakdown if unrecognized.During an interview on 03/26/26 at 4:09 p.m., the DON stated the penile area was normal in color with a slit and she did not observe blood because staff had cleaned the area. She stated she saw a small slit. She stated she did not know the brief was wet. She observed sediment and noted a history of UTIs. She stated sediment can be normal but must be reported. She stated only the bag was changed. She stated the NP did not express concern, but was unsure of timing. She stated the meatus could bleed due to foley use and contractures. She stated the balloon could leak or deflate and prolonged moisture could cause breakdown.During an interview on 03/26/26 at 4:18 p.m., the Corporate Nurse stated a deflated balloon or sediment could cause leakage. She stated LVN M should notify the physician if clogging occurred. She was not aware of the worsening slit. She stated the physician previously indicated the slit was due to chronic foley use. She stated irritation could occur if the foley was pulled, although a stat lock was present.Record review of the facility's policy on catheter care revised 02/2024 stated in part: to ensure proper hygiene, minimize infection risk, and maintain resident comfort during catheter care. Exposure of Catheter Site: Male Resident: If uncircumcised, retract the foreskin and hold the penis just below the glans. Maintain this position throughout the procedure.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 2 of 3 (Resident #1 and Resident #3) residents reviewed for comprehensive assessments.1. The facility failed to ensure that Resident #1's care plan included the physician ordered hand splint interventions for his hand contractures, and the implementation of the device.2. The facility failed to implement the care plan interventions for Resident #3's persistent wandering when she had an unwitnessed fall and sustained a hematoma to the right side of the forehead, which resulted in hospital treatment.This deficient practice could place residents at risk of not receiving proper care and services.Findings included:Resident #1Record review of Resident #1's face sheet dated 03/26/26 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease (a progressive brain disorder that slowly destroys memory and eventually the ability to carry out simple tasks), parkinsonism (a nervous system disorder), stroke, muscle weakness, and need for assistance with personal care.Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 out of 15, indicating he had moderately impaired cognition. Further review revealed the resident was dependent on staff for ADL care. Resident #1 had impairment to the upper extremity on one side.Record review of Resident #1's care plan revision dated 01/08/26 revealed Resident #1 had contractures and was at risk for skin breakdown, increased pain to affected areas, and further worsening of contracted areas as evidenced by contractures to bilateral hands. Interventions included keeping contractured areas clean and dry, providing PROM (donot force contractured areas), monitoring for increased pain/stiffness, and providing medications/treatments as ordered.Record review of Resident #1's March physician orders revealed an order for an RNA program 6x/week x 6 months that might have included: L resting hand splint; passive-to-active-assisted ROM exercises to BUEs to maintain ROM in BUEs or prevent further complications; and stretching to each wrist and hand to prevent further contractures, ordered 03/26/26.During an observation and interview on 03/25/26 at 3:09 p.m., it was revealed Resident #1 had contractures on both hands and there was no splint or carrot in his hands. Resident #1 said the nurse had not applied any carrot or rolled-up towel to his hands that day. Resident #1 stated that the staff applied the carrot or hand roll to his hands when they wanted, and he could not complain because they were the ones providing care for him since he could not do anything for himself.During an interview on 03/25/26 at 3:29 p.m., RN B said he was Resident #1's nurse for that day and he came to work at 7:00 a.m He stated he had not seen any carrot on his left hand, but he was supposed to have a carrot in his hand. RN B said the ADON had told him to apply the carrots for Resident #1's hands as soon as therapy brought the carrots to him. RN B said if Resident #1 did not have any preventative rolls or carrots in his hands, the contractures would worsen. RN B said the aide or restorative aides were supposed to apply carrots for Resident #1's hands.During an interview on 03/25/26 at 4:24 p.m., CNA T said she was Resident #1's CNA for the morning shift, and Resident #1 did not have any carrot in his hand during that morning shift. She said the restorative aide was responsible for applying the carrot to the resident's hands. CNA T said if the carrots were not applied to the resident's hands, the contractures could get worse.During an interview on 03/25/26 at 4:28 p.m., RA S said Resident #1 was supposed to have carrots in each hand. RA S said it was the responsibility of the restorative aides and the CNAs to apply carrots on Resident #1. She said Resident #1's hands could get worse if the staff did not apply the carrots as ordered. RA S said if there were no carrots, then they could use towels. She said carrots should be applied to Resident #1's hands for four hours, then removed for a two-hour break with hand massage before the carrots would be reapplied until the next day. She said the other restorative aide had applied the carrots, and she would have taken them off for a two-hour break. RA S said she went to Resident #1's room to reapply the carrots, but there were no carrots in his room, and she checked the resident's drawers as well. She said a staff member brought two carrots and gave them to her, and she applied the carrots on Resident #1's hands.During an interview on 03/25/26 at 4:55 p.m., the DON said she would look into the care plan regarding the care for Resident #1 because carrots were not on his care plan. She said the restorative aides did not document on the POC and they were still charting on paper. The surveyor requested the paper charting, and the DON said she was still putting it together.During an interview on 03/26/26 at 1:54 p.m., CNA C said she had applied a carrot on Resident #1's left hand close to the window, and she took the carrot off after four hours and placed it in his drawer. She said she would tell Resident #1's aide that she had applied the carrot on his hand the previous day. However, she did not see Resident #1's aide and did not tell the aide. CNA C said she documented care on the POC in the computer. She said Resident #1's hand could become more contracted if the carrot was not applied to the resident's hands. CNA C said it was on Resident #1's POC to apply carrots on Resident #1's hands.During an interview on 03/26/26 at 3:20 p.m., the ADON said the restorative aides were supposed to apply the carrots on Resident #1's hands, and he did not know if there was an order for the carrots or if it was in the resident's care plan. The ADON said the therapy department was in charge of training the restorative aides. He said Resident #1's contractures would get worse if therapy did not apply the carrots on Resident #1's hands.During an interview on 03/27/26 at 8:50 a.m., the MDS Coordinator said the DON and therapy worked together after therapy to place a resident in a restorative program, and there should have been an order for restorative care for contractures. She said the DON would notify her, and she would update the care plan with the order, which would include the interventions. She said if Resident #1 needed carrots for his contracted hands, and they were not applied, the contractures could worsen. The MDS Coordinator said she was called after hours the previous day while she was at home and was notified that the facility would be reviewing all residents with contractures, and she was updating the contracture care area for Resident #1's care plan.During an interview on 03/27/26 at 11:36 a.m., the DON said the carrot was a nursing intervention, and they could not find where it was documented or signed off by the staff that they had provided the care for Resident #1. The DON said it was a broken system, and they were going to reassess all residents with contractures. She said she had a physical therapist in the building at that time, and the therapist was evaluating all the residents with contractures. Resident #3Record Review of Resident #3's face sheet dated 03/21/2026, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #3's diagnoses included Dementia with psychotic disturbance (visual and auditory hallucinations or delusions related to Dementia); difficulty walking not elsewhere classified (general gait impairment or mobility issues); other lack of coordination (non-specific motor control issues or general clumsiness); altered mental status (significant confusion or disorientation with no definitive cause); and, restlessness and agitation (a state of mental tension, inability to relax, or excessive, non-productive activity).Review of Resident #3's Quarterly MDS dated [DATE], indicated the resident had difficulty communicating words or finishing thoughts; sometimes responded adequately to simple, direct communication only; and, had a BIMS score of 00. Inattention, and disorganized thinking was present and fluctuated. Presence and frequency of wandering behavior occurred 1 to 3 days. Resident #3 required setup or clean up assistance to walk 10 feet and 50 feet with two turns. Other neurological conditions and non-Alzheimer's dementia noted. Pain assessment interview not to be conducted as the resident was rarely or never understood. Noted to have 1 fall without injury since admission or reentry to facility. Record review of the comprehensive care plan last reviewed on 12/29/2025, indicated Resident #3 had ADL deficits and required staff to anticipate the resident's needs and provide prompt assistance; provide limited assistance with 1 support person for locomotion on/off unit; provide supervision assistance with 1 support person for walking in room/down corridor; and, to provide PROM during ADL care as needed.Further review of the care plan last reviewed on 12/29/2025 indicated the resident had a history of unintentionally walking into objects. Staff interventions included frequent checks on the resident, especially during high-risk times; maintain the resident's safety during increased episodes of wandering; and offering engaging activities to reduce restlessness. The resident had impaired communication and was at risk for further decline and injury. Staff interventions included reducing or removing interfering environmental stimuli, and using communication tools, terms and gestures the resident could understand. The resident also had a history of taking off her footwear.Review of Resident #3's records reflected a progress note by RN A on 3/16/26 at 6:30 PM, indicated Resident #3 had an unwitnessed fall in the dining room. Prior to the fall, the resident was wandering. Vital signs post fall BP 122/76; Pulse 72; Temperature 97.4; Respirations; 17; O2 saturation 97%. DNP was notified and reviewed medications with RN A. RP also notified.Record Review of the SBAR Change of Condition documentation for Resident #3, dated 3/16/2026 at 6:30 PM, RN A noted the resident had an unwitnessed fall in the dining room. Resident was noted to be wandering before the fall. No notable findings after environment surrounding the fall was assessed. Vital signs noted as BP 122/76; Pulse 72; Temperature 97.4; Respirations; 17; O2 saturation 97%. Assessment of range of motion indicated no changes from baseline of right upper and lower extremities or left upper and lower extremities. Resident did not have onset of pain or visible injuries related to the fall. No other significant conditions contributed to the fall. Notifications made to DNP and RP. New orders to send the resident to ER.Observation of resident #3 on 3/21/26 at 2:12 PM, revealed the surveyor followed Resident #3 to the dining room. Resident #3 ambulated independently; however, every few steps and when stopping, Resident #3 experienced loss of balance lasting about 2 - 3 seconds. The surveyor attempted to engage Resident #3. Resident #3 appeared to hear the surveyor but did not respond and continued to walk in the opposite direction. The surveyor requested nursing assistance to assess Resident #3. Resident #3 had visible discoloration on the right side of the face, including the area above the eyebrow, below the eye, and extending toward the nose. The discoloration was yellow and purple. Resident #3 did not allow LVN C to assist any longer than about 15 seconds, moved staff hands away, and continued walking down the corridor.During an interview on 3/21/26 at 5:15 PM, CNA A said Resident #3 was nonverbal, not oriented, continuously walked, and did not remain seated. She said Resident #3 required staff to watch her while walking due to fall risk. She said she was trained on Resident #3's care plan and understood supervision was required.On 3/21/26 at 5:28 PM, CNA B said Resident #3 walked constantly, did not sit still, and did not communicate verbally. She said she documented in the point-of-care system to track Resident #3's needs but was unsure whether Resident #3's care plan specifically included supervision interventions.On 3/22/26 at 11:22 AM, LVN A said Resident #3 continuously moved and walked around. She said Resident #3 did not remain seated. She said staff accessed Resident #3's care needs through the care plan and the point of care (POC) used by CNAs. She said there were no specific interventions addressing Resident #3's constant movement other than general supervision and her non-skid socks. She said following the incident, she assessed Resident #3, notified the DNP of the unwitnessed fall, and again regarding the hematoma, and Resident #3 was sent to the hospital.On 3/22/26 at 1:00 PM, the ADON said staff were expected to follow care plans to ensure residents received necessary care and that failure to follow care-planned interventions placed residents at risk for harm and failure to receive required services.On 3/22/26 at 1:37 PM, the DON said Resident #3 was care planned for supervision due to wandering and fall risk. She said the MDS Coordinator worked with the nursing department to create and update resident care plans. She said ultimately, the MDS Coordinator was responsible for ensuring care plans were accurate. She said staff were trained to use care plans. She said aides documented the care they provided in the same system that outlined resident care. She said failure to follow care-planned interventions placed residents at risk for injury and failure to identify changes in condition. She said lack of care plans being individualized could lead to lack of appropriate care of a resident. She said as far as she knew, Resident #3's care planned interventions were appropriate for the resident.On 3/22/26 at 2:31 PM, CNA A said sometimes Resident #3 seemed like she could be on 1:1 supervision because she walked so much.An observation in the memory care unit on 3/22/26 at 2:18 PM, revealed Resident #3 was observed wandering up and down the hallway and spinning in a circle several times. 1 staff stood in the middle of the hall with the wandering residents in their line of sight. Resident #3 was wearing non-skid socks.On 3/22/26 at 2:43 PM, the MDS Coordinator said staff were expected to be familiar with care plans and had daily access to them. She said failure to follow care-planned interventions could result in residents not receiving necessary services. She said Resident #3's care plan was updated after the incident on 3/16/26 to include Resident #3 wearing non-skid socks. She said the care planned interventions for Resident #3 were appropriate.On 3/22/26 at 3:42 PM, the Administrator said Resident #3 was care planned for supervision at the time of the incident on 03/16/26, and required monitoring due to behaviors and fall risk. She said failure to follow the care plan resulted in residents not receiving necessary care and increased the risk of preventable incidents. She said the incident might have been preventable if the care plan had been followed. She said she would have to review the care plan again to determine whether the resident's care planned interventions were appropriate regarding walking and supervision.On 3/27/26 at 12:28 PM, the DNP said she was notified of Resident #3's condition following the fall and later notified of the hematoma with discoloration. She said the discoloration was related to the hematoma and consistent with the injury. She said she instructed staff to send Resident #3 to the hospital immediately. She said she was not willing to provide a statement regarding potential risk and did not provide hypothetical risk statements.Record review of the facility's policy titled Care Plan Revisions revised May 2022 read in part, .The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents within the facility.Guidelines #2e. Care plans would be modified as needed by the MDS Coordinator or other designated staff member.#2f. The Unit Manager or other designated staff member would conduct an audit on all residents experiencing a change in status, at the time the change in status was identified, to ensure care plans had been updated to reflect current resident needs.Review of the facility's policy titled Standards of Care revised 10/2023 indicated All care provided will comply with current guidelines, best practices, and Federal/State regulations.Safety measures will be in place to prevent accidents and injuries, including fall preventions strategies.All staff members are responsible for adhering this policy and for providing care that meets these standards. The Administrator will oversee the implementation and compliance with this policy.Review of the facility's policy titled Dementia Care indicated Resident who display symptoms or are diagnosed with dementia should receive the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being.The facility provides treatment and services that include, but are not limited to:.necessary person-centered care and services that reflect the resident's goals.while maximizing their dignity, autonomy, privacy, socialization, independence choice, and safety.Staff providing care to residents with dementia.will have competencies and skills to support the resident with dementia through the implementation individualized approaches to care that are directed toward understanding, preventing, relieving, and/or accommodating a resident's distress of loss of abilities.Review of the facility's policy titled Fall Management revised 07/2025 indicated The facility will provide a safe environment for all residents by implementing a fall management program. The program includes.individualized care plans.Develop an individualized fall prevention plan for each resident identified at risk. Examples of interventions: Environmental modifications.non-slip footwear; supervision during high risk activities e.g.ambulation.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 10 residents (Resident #12) reviewed for incontinent care. 1. CNA AA failed to ensure Resident #12's indwelling Foley catheter tubing was below the bladder while assisting LVN CC during pressure ulcer treatment on 01/7/26. 2.The facility failed to ensure Resident #12's indwelling catheter was secured on 1/7/26. Resident #12 had a slit on his penis measuring 0.3 cm length by 0.1 cm width that was identified by the Surveyor on 1/7/26. These failures could place residents at risk for pain, infection, injury, and hospitalization.Findings included: Record review of Resident #12's face sheet dated 1/7/26 reflected a [AGE] year-old male originally admitted on [DATE] and was re-admitted on [DATE] with medical diagnoses of Pneumonia (is a lung infection that inflames the air sacs ( alveoli), causing them to fill with fluid or pus, which makes it hard to breathe) unspecified organism, acute respiratory failure with hypoxia (low oxygen in the body), essential (primary) hypertension (high blood pressure) schizophrenia (is a serious, long-term brain disorder that causes people to interpret reality in an abnormal way, making it difficult to distinguish between what is real and what is imaginary), pressure ulcer of sacral region, stage 3 (is a deep, crater-like wound where the skin has broken down through all layers, revealing the fatty tissue underneath but not muscle, tendon or bone) other malaise, obstructive and reflux uropathy (obstructive uropathy is a condition where urine flow is blocked, causing a damming effect that can damage the kidneys, while reflux uropathy is a condition where urine flow backward (the wrong way) in the urinary tract, also potentially damaging the kidneys, muscle weakness (generalized), pressure ulcer of other site, (stage 3), type 2 diabetes mellitus without complications, type 2 diabetes mellitus with other specified hemiplegia and hemiparesis (weakness on one side of your body) following cerebral infarction (Stroke) affecting right dominant side, functional quadriplegia (a complete inability to move due to severe disability or frailty caused by another condition without physical injury or damage to the spinal cord), vitamin d deficiency, malignant neoplasm (Cancerous tumor, an abnormal growth of cells that divides uncontrollably, invades surrounding healthy tissue, and can spread (metastasize) to distant parts of the body, unspecified kidney, except renal pelvis infection and inflammatory reaction due to indwelling urethral catheter (a common type of thin, flexible tube that a doctor or nurse puts into the bladder to continuously drain and collect urine acute respiratory failure (is when your lungs suddenly can't do their job of getting oxygen into your blood and removing carbon dioxide). Record review of Resident #12's Comprehensive MDS dated [DATE], revealed his BIMS score was 10, indicating moderate cognitive impairment. He required total assistance with toileting. He was continent for bladder and incontinent of bowel. He had an indwelling catheter. Record review of Resident #12's care plan dated 04/18/2025, interventions were to follow physician orders for catheter insertion, changes, and maintenance. Monitor site for signs and symptoms of infection or skin breakdown - report any noted to MD. Notify the Physician of any adverse findings/changes. Record review of Resident #12's order summary dated 1/7/26 revealed he had orders for: use catheter securing device to reduce excessive tension on the tubing and facilitate urine flow. Rotate site of securement daily. (order date 10/10/25). Monitor for potential complications of indwelling urinary catheter use such as redness, irritation, s/s of infection, obstruction, urethral erosion. (start date 12/8/2025). Record review of Resident #12's skin assessments dated 12/10/2025, 12/18/2025, 12/25/2025, and 01/01/2026 did not address the slit on the penis. Record review of care plan dated 10/10/25 reflected Resident #12 was on Antibiotic: Meropenem Intravenous Solution Reconstituted 1 GM (Meropenem) Use 1 gram intravenously every 8 hours for UTI for 2 WEEKS Observation and interview of Resident #12's incontinent and foley care on 01/07/2026 at 10:32 am with CNA AA and CNA BB, there was no leg strap or Statlock (stabilization device for a foley catheter) to secure the catheter. There was small redness to the top side of the penis near a slit. Resident #12 did not verbalize he was in pain or displayed any facial grimacing while staff cleaned indwelling catheter. The slit was measured by the ADON RN and was 0.3 cm in length and 0.1 cm in width. CNA AA and CNA BB said they had not seen the slit on the resident's penis before. Interview with the interim treatment nurse, LVN CC, on 01/07/2026 at 10:57 am, she stated she was not aware of the slit on Resident #12's penis. LVN CC stated this was her first time working with Resident #12. While performing pressure ulcer treatment to Resident #12's sacral area, LVN CC handed the indwelling catheter tubing to CNA AA and it was placed on the bed with cloudy urine along the tubing while performing treatment to sacral area. The tubing was not below Resident #12's bladder. Interview with LVN CC on 01/07/26 at 11:05 am, regarding having the indwelling catheter placed on the bed while performing pressure ulcer treatment, she said she was very sorry, it should be below the resident's bladder. Interview with ADON RN on 01/07/2026 at 11:10 am he stated he was not aware of the slit on Resident #12's penis. He said he had not checked if Resident #12's Statlock was in place because he was just called in to work. He said he would normally check placement every shift. Attempted to contact the treatment nurse LVN DD on 01/07/2026 at 2:33 pm and left a voicemail message. The call was not returned. Interview with DON on 01/07/2025 at 4:05 pm she stated she was not made aware of Resident #12 having a slit on the penis. Now that she has been made aware, the facility staff immediately conducted audits of every resident and started an in-service on Statlocks and foley care. DON stated that it could cause tension and tear on the penis if the Statlock is not in place. The expectation is all nurse aides with notify the nurse to place the Statlock in the right position. DON said F/C should be hung below Resident #12's bladder and this is to prevent back flow of urine to the bladder and could result in Resident #12 acquiring a UTI. DON said she would be monitoring the CNAs randomly now. DON said she does have monthly in-services on F/C and incontinent care. Interview with Resident #12's MD she said she was notified on 1/7/26 of the slit to Resident #12's penis. She said she expected the skin to be protected by using the Statlock to anchor the foley and prevent injury. Interview with Resident #12's NP she said she was notified of Resident #12's slit to the penis on 1/8/26. She said it was not normal for the resident to have a slit to the penis but said the penile area looked good and was not infected. Interview with CNA AA, CNA JJ, CNA KK and CNA ZZ on 01/08/26 at 9:43 AM and at different times regarding recent in-services, CNA's said they had in-services on securing F/C, checking for any skin change, slits, PPE, and notify the nurse. Interview with LVN AA and LVN ZZ on 01/09/26 at 10:45 AM, they said they had in-services to monitor and document F/C every Statlocks each shift and head to toe assessments done each shift and notify ADON and the doctor. Record review of the facility's policy for Catheter Care revised 2/2024: Indwelling, straight, reflected . Catheter Management . Kinks: Ensure the catheter tubing remains free from any kinks that might obstruct urine flow. Securement: Rotate the catheter securement device regularly, and change it when it becomes visibly soiled to prevent skin breakdown or irritationPositioning: ensure the catheter bag is positioned below the level of the bladder to allow for proper drainage and avoid reflux of urine.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 (Resident #54) residents reviewed for comprehensive assessments.The facility failed to ensure that Resident #54's care plan documented interventions for hand contractures.This deficient practice could place residents at risk of not receiving proper care and services. Findings Included:Record review of Resident #54's face sheet dated 01/07/2026 revealed a [AGE] year-old admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease (a progressive brain disorder that slowly destroys memory and eventually the ability to carry out simple tasks), parkinsonism (a nervous system disorder), stroke, muscle weakness and need for assistance with personal care.Record review of Resident #54's quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 out of 15 indicating he had moderately impaired cognition. He had impairment to the upper extremity one side and impairment on both sides of the lower extremities.Record review of Resident #54's physician orders revealed an order for Baclofen 10mg tablets, start date was 07/20/2025.Record review of Resident #54's January 2026 MAR revealed he was receiving Baclofen 10mg every 8 hours for muscle spasms.Record review of Resident #54's follow-up progress note written by the MD on 12/08/2025 revealed past medical history included bilateral wrist contractures. The physical exam included musculoskeletal - contractures bilateral upper extremities, left wrist severely contracted, greater than right wrist. Further review revealed the assessment and plan included to continue Baclofen 10mg three times daily for management of muscle spasms and contractures.Record review of Resident #54's care plan downloaded from the electronic health record on 01/07/2026 at 9:28 AM revealed a care plan that was last reviewed on 12/15/2025. Focus - Resident #54 had ADL self-care deficits and was at risk for further decline and ADL functioning and injury. Interventions included: provide PROM (passive range of motion) during ADL cares as needed by RCS (resident care staff). The date initiated was 10/24/2025. The care plan did not specifically address interventions for hand contractures including administration of Baclofen for contractures as ordered by the MD.Observation on 01/06/2026 at 10:30 AM, Resident #54's left hand was severely contracted, and arm was bent at the elbow. Resident #54's right hand was also bent at the elbow. The resident was able to open and close the right hand upon command. Both hands did not have palm protectors or hand braces.In an interview on 01/09/2026 at 1:10 PM, the MDS nurse was asked how Resident #54's hand contractures were addressed in the care plan. The MDS nurse stated she was aware of the resident's hand contractures and that interventions should be included in the care plan. The MDS nurse then stated that she updated Resident #54's care plan to address contractures on 01/08/2026.In an interview on 01/09/2026 at 2:25 PM, the DON stated the nursing team was responsible for updating the care plan. The DON stated the charge nurse, MDS nurse and even the DON can update the care plan. The DON stated the purpose of the care plan was to provide information on how to care for residents, so all staff know how to meet the residents' needs. The DON stated Resident #54's contractures should be in the care plan and did not know why his care plan was not updated prior to 01/08/2026.

Based on observation, record review, and interviews, the facility failed to ensure that each resident received adequate supervision to prevent accidents for 2 of 8 residents (Resident #60 and Resident #134) reviewed.The facility failed to ensure adequate supervision to prevent accidents for Resident #60 and Resident #134 when they were smoking outside without staff supervision.This failure placed the residents at risk for burns, injury, and fire hazards.Findings included:Record review of Resident #60's undated face sheet revealed he is a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE]. His diagnoses were lack of coordination, muscle weakness, falls, difficulty in walking, schizoaffective disorder (hallucinations and delusions), dementia, and transient ischemic attack (a temporary blockage of blood flow to the brain).Record review of Resident #60's MDS annual assessment dated [DATE] revealed a BIMS score of 10 out of 15 which indicated moderate cognitive impairment and the resident may need support with decision-making or understanding instructions.Record review of Resident #60's Smoking assessment dated [DATE] revealed resident was to not wear a smoking apron, but was educated on the following: designated smoking area, designated smoking times, staff will store smoking materials, residents may not smoke outside of designated smoking times or designated smoking areas, and noncompliance with smoking policies and procedures may lead to involuntary/immediate discharge. The IDT determination was that the resident was safe to smoke with supervision.Record review of Resident #60's Care Plan dated 12/29/2025 revealed he has the potential for injury related to being a smoker. The interventions put into place indicated that staff members will store and distribute the residents' smoking materials, safe smoking will occur during safe smoking times and in the designated smoking areas, routinely complete safe smoking assessments to assess for safe smoking, supervision required, and any assistive devices needed.Record review of Resident #134's undated face sheet revealed he was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE]. His diagnoses were respiratory failure, muscle weakness, dementia, cognitive communication deficit, repeated falls, lack of coordination, and presbyopia (loss of eyes ability to focus on nearby objects).Record review of Resident #134's Smoking assessment dated [DATE] revealed resident was to not wear a smoking apron, but was educated on the following: designated smoking area, designated smoking times, staff will store smoking materials, residents may not smoke outside of designated smoking times or designated smoking areas, and noncompliance with smoking policies and procedures may lead to involuntary/immediate discharge. The IDT determination was that the resident was safe to smoke with supervision.Record review of Resident #134's Care Plan dated 01/06/2026 revealed resident was a tobacco smoker and refused to give his cigarettes to staff. The interventions put into place were staff to perform smoking assessments according to facility policy and explain where designated smoking areas were and smoking times.During an observation on 01/06/2026, at 12:49 pm two residents were observed smoking outside, unsupervised. Residents were observed sharing 1 cigarette, putting it out, and came back into the building. The residents identified were Resident #60 and Resident #134. Both residents refused to be interviewed.In an interview with LVN T on 01/06/2026 at 12:51 pm she stated she was only monitoring the residents in the dining room, which was beside the facility's designated smoking area. LVN T denied seeing the residents outside smoking and unsure of how residents would have smoking supplies, as it was normally locked in the Activities Coordinator's office. The risk of the residents smoking unsupervised could result in the residents burning themselves.In an interview with ADMN on 01/06/2026 at 12:5 7pm ADMN stated the facility staff were assigned to supervise smokers by the department throughout the day. ADMN stated they have two residents who do what they want to do, and they searched the residents' rooms prior and found cigarettes and lighters, which they refused to give to staff. Smoking paraphernalia was locked in a box in the Activity Director's office, which only staff have access to. Staff were trained to use the fire extinguisher and fire blanket, should there be a fire while smoking. The risk of residents smoking unsupervised was the residents burning themselves.Record review of Electronic Healthcare Records on 01/07/2026 at 9:04 am revealed Resident #60 and Resident #134 have been discharged from the facility on 01/06/2026.In an interview with AD H on 01/07/2026 at 11:07 am stated the designated times for smoking were 8:30am, 11am, and she is unsure of the rest, but it is posted on the wall by the designated smoking area. She is responsible for locking all smoking supplies for each resident who is a smoker. At times the resident's family will ask her to purchase resident cigarettes, and she will. The lighter is provided by the facility to ensure the safety of the resident when lighting the cigarette, which she does or any staff that is designated for that smoking time. Residents are to not be left unsupervised when smoking as it is a risk of the residents having a fall, burning themselves, or someone else. She stated she does not know any residents that have separate allotted smoking times outside of the times already allotted for the residents. The reason for having allotted smoking times is to ensure the residents will be supervised by staff and if anything changes it will come from the ADMN or DON.In an interview with HSK D on 01/08/2026 at 1:35 pm stated her allotted smoking time is 1:30 pm when she's working and no residents are to have any smoking supplies. She has not witnessed any residents smoking unsupervised, if she did, she would notify the Administrator and stay with the residents to ensure they are safe. All smoking supplies are kept in a lock box in the activities director's room. She is trained to use the fire extinguisher if there is a fire during the smoking times. The risk of the residents being unsupervised while smoking could be dangerous because it could cause a fire.Record review Staff Smoking Schedule on 01/09/2026 at 7:30 am revealed the allotted smoking times are 8am (Laundry Staff), 11am (Activities Director), 1:30pm (Housekeeping Staff), 4pm (Floor Technician), and 6pm (Maintenance Staff). The schedule also displays staff that are assigned when others may be out.In interview with FT P on 01/09/2026 at 8:29 am stated his allotted smoking time to supervise residents while smoking outside is 4 pm. He does walk around the smoking area to ensure the right residents are outside smoking and he is trained to know what to do in case of a fire. He keeps all the smoking materials with him and lights the cigarette for the resident. If he witnessed a resident outside smoking with no supervision, he would stay with the resident while requesting a nurse to come, as no resident should be outside smoking without supervision. All smoking materials are left in the activity director's office, locked. The risk of a resident smoking unsupervised could cause harm by burning themselves.In interview with LR M on 01/09/2026 at 8:35 am she stated her allotted smoking time to supervise residents while smoking outside is 8 am. When outside with smoking residents, she is verifying the correct residents are outside by the folders in the smoking lock box. In the morning, she only has four residents that she is monitoring while smoking. In case of a fire, she shas been trained to use the fire blanket and the fire extinguisher. All the supplies were kept with her, and they do assist the residents with lighting the cigarette because they cannot have a lighter. The risk of the residents smoking unsupervised is being burned or hurting someone outside.In an interview with LVN K on 01/09/2026 at 10:18am she stated she does complete the smoking assessments for the residents, which is completed quarterly. The reason for Resident #60 and Resident #134 being discharged was due to violating the smoking policy. Any resident that is a smoker has been assessed and cannot be left unsupervised, as that is their policy for the safety of the residents. Both residents identified outside smoking were safe smokers and the only time the assessment will change between the quarters is if the residents develop the shakes or they are unable to hold the cigarette on their own. At that time, residents will need to wear a smoking apron to prevent any ashes from burning the resident. The risk of a resident smoking unsupervised could result in burning themselves or someone else.Record review of the facilities Safe Smoking policy dated 03/2024 read. We are committed to providing a safe, healthy, and comfortable environment for all residents, staff, and visitors. Our policy is designed to ensure residents are aware of their privilege when it comes to smoking but also following guidelines in which smoking may occur in our setting. This policy applies to facilities that permit smoking (including the use of e-cigarettes/vape pens).The facility may permit smoking for certain individuals at designated times in designated areas based upon the findings of the resident's Smoking - Safety Screen. The Smoking Policy Notification is outlined in the admission Agreement.Staff members maintain all smoking materials as appropriate for the resident. Staff members will distribute smoking materials to residents at designated smoking times in the designated smoking area.Residents who require supervision while smoking will be supervised by an employee throughout the designated smoke break.

Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #10) of 2 residents reviewed for enteral nutrition. The facility failed to always provide the abdominal binder as a supportive device per physician orders to help prevent dislodgment of Resident #10's G-tube (Gastrostomy feeding tube). These failures could place residents with G-tubes at risk of injuries, hospitalization, and death. Record review of Resident #10's face sheet dated 01/08/2026 revealed a [AGE] year-old admitted to the facility on [DATE] and initially admitted on [DATE]. Her diagnoses included dementia, severe malnutrition, , , gastrostomy status (the presence of a G-tube which is a hollow device inserted through the abdominal wall to create a passageway into the stomach to provide long-term access for delivering nutrition), and adult failure to thrive. Record review of Resident #10's quarterly MDS dated [DATE] revealed a BIMS score of 00 out of 15 indicating severe cognitive impairment. Resident #10 had no impairment to upper and lower extremities. Resident #10 was dependent on staff assistance for all ADLs. She had a feeding tube for nutritional approaches.Record review of Resident #10's care plan last reviewed on 01/06/2026 revealed: Focus - Resident #10 requires the use of a feeding tube for nutrition and is at risk of nutritional complications. Goal - Resident #10's feeding tube will remain patent (clear and open for use) and resident will receive nutrition as ordered without evidence of aspiration, dehydration or nutritional compromise. Interventions included: ABD (abdominal) binder at all times. Focus - Resident #10 requires tube feeding r/t dysphagia (difficulty with swallowing). Interventions included - monitor/document s/sx of aspiration, fever, tube dislodgement Record review of Resident #10's physician orders revealed an order dated 10/14/2025 at 9:56AM for the device: abdominal binder - every shift for monitor placement: skin check donning/doffing for bathing/showers (check skin when removing and replacing the binder when bathing the resident).Record review of Resident #10's change of condition progress note dated 10/14/2025 at 11:18 AM and written by RN F revealed the resident's G-tube was found to be dislodged and the hospice nurse was notified. Further review of the progress note revealed a 16-French foley catheter (a flexible tube used for urinary drainage) was inserted into the stoma (a surgical opening created in the abdomen for placement of a g-tube) and balloon (the flexible drainage tube has a balloon inflated to maintain the position of the tube) was inflated to maintain tract patency (the passage of the stoma being clear and unobstructed). Continued review of the progress note revealed the resident was subsequently transferred to the hospital for further evaluation and management. Record review of Resident #10's progress note dated 10/14/2025 at 2:06 PM and written by the MDS nurse revealed the resident returned and a G-tube was in place. Observation on 01/09/2026 at 8:00 AM, revealed Resident #10 was receiving patient care at the time by the hospice aide.Observation on 01/09/2026 at 9:40 AM, revealed LVN CC pulled back the covers over Resident #10 to view the G-tube site. The resident did not have an abdominal binder on. The resident was observed moving her arms and hands freely without restrictions.Attempted interview of Resident #10 on 01/09/2026 at 9:40 AM, revealed did not answer when asked if she was in any pain. Resident #10 was alert, pleasant, cooperative, smiled at those around her and did not appear in distress.In an interview on 01/09/2026 at 12:00 PM, LVN AA stated he was taking care of Resident #10 and stated he received a report in the morning that the ABD binder was put into laundry because it became wet. LVN AA stated Resident #10 should always have the binder on and that without it there is a chance she could pull The g-tubeout. LVN AA stated he was unsure, but she may have a history of G-tube dislodgement but was less likely to pull at it because she is less active. LVN AA stated if dislodged, the risk is that the resident would have to leave the facility to get it replaced as this is not done at the bedside. LVN AA stated the binder is probably dry now and that he will make sure the clean/dry binder is on the resident. LVN AA was asked why she had only one binder and he did not say why but stated he had been monitoring her every hour.In an interview on 01/09/2026 at 2:20PM, the DON stated the nurses were responsible to follow orders for ABD binder if the physician places the order. The DON stated nurses and aides can place the binder on the resident and that if the ABD binder becomes soiled, she would expect it to be put into the wash and for nursing to get a clean one from laundry or central supply. The DON state the ABD binder should always be on Resident #10 due to her history of pulling out G-tubes. The DON stated the risk to the resident was complete dislodgement, trauma to the stoma site, the stoma could close, and the resident would have to be sent out to get it replaced. If the ABD binder is not on the resident, she expected nursing staff to closely monitor and maybe place something in front of the abdomen in the time being to deter resident from handling the tubing until the ABD binder is replaced.Record review of the facility policy and procedure for Enteral Feedings, revised on 09/2023 read in part: The facility will provide adequate care for residents with enteral feeding tubes to prevent complications. Types - Gastrostomy Tube, Jejunostomy Tube.

Based on observation, interview and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of one residents reviewed for Tracheotomy care (Resident #1) The facility failed to ensure LVN AA used sterile technique and checked oxygen saturation before and during tracheostomy suctioning for Resident #1 on 01/09/26. These failures placed residents with tracheostomy requiring suctioning at risk for respiratory infections, hospitalizations, and a decline in their quality of life. Findings included:Record review of Resident #1's face sheet revealed she was a [AGE] year-old female who was originally admitted on [DATE] and was readmitted [DATE]. Her medical diagnoses included tracheostomy status (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck), sepsis (a life- threatening medical emergency where the body's extreme, over-the-top reaction to an infection damages its own tissues and organ), unspecified organism, other muscle spasm, essential (primary) hypertension (high blood pressure), anxiety disorder (a mental health condition characterized by persistent excessive fear and worry) and unspecified, metabolic encephalopathy ( a brain dysfunction caused by a chemical imbalance or metabolic problem in the body not a direct injury or confusion or memory loss and persistent vegetative state, other speech and language deficits following nontraumatic intracerebral hemorrhage (stroke). Record review of Resident #1's quarterly MDS dated [DATE] revealed the BIMS was blank indicating the resident was rarely or never understood. Further review revealed the staff assessed Resident #1 on mental status and found he had short-term, long-term and memory/recall ability problems. Further review revealed that Resident #1 was dependent on staff for care, which means the resident does none of the effort to complete the activity. Record review of Resident #1's Physician Orders reviewed 05/05/2023 revealed the following: 1. Tracheostomy Care every shift and PRN. Clean or change inner cannula when needed Shiley (flexible trach tube) 4.5 x7 days2.Tracheostomy site dressing change every DAY and PRN if soiled.3. Suction tracheostomy tube as needed to clear airway. Document results in Progress notes4. Trach suctioning Q shift and PRN5. Oxygen at 4-6L/min via Tracheostomy Record review of Resident #1's Care plan revised 10/24/2025 revealed resident was care-planned for: 1. Resident #1 has a Tracheostomy r/t respiratory failure-Interventions: Suction as necessary, use Universal Precautions as appropriate Interview and observation of Resident #1 on 01/06/2026 at 7:30am revealed the resident was observed lying in bed with the head at a 30-degree angle. She was unable to answer yes or no to all questions asked by the surveyor. Resident #1's oxygen concentrator read 5L/min via trach mask. Observation of Resident #1 on 01/09/2026 at 10:30am, revealed resident was observed lying in bed with the head at a 30-degree angle. Resident #1's oxygen concentrator read 5L/min. The resident had foam coming out of her mouth but did not appear to be in distress. Observation on 01/09/2026 at 10:30 AM revealed Resident #1 was in bed with dry crusted phlegm to side of the mouth. LVN AA washed hands, donned cleaned gloves, opened the sterile suction kit, doffed the dirty gloves without washing hands, donned the sterile gloves from the suction kit, picked up the sterile suction catheter, then picked up the connecting suction tube to the suction machine at Resident#1's bedside. LVN AA then connected it to sterile tubing and was using both hands then removed the oxygen neck mask, then suctioned. LVN AA did not check oxygen saturation before and during suctioning. LVN AA then washed hands. At 10:42AM, LVN AA opened the trach kit, donned sterile gloves, picked up the drape and placed it on the bed side table, then picked up the inner cannula on the bedside in the drape, picked up 4x4 gauzes and placed them in the drape, then picked up a normal saline bottle with the sterile gloves. Using sterile gloves, LVN AA undid the neck mask and took out the inner cannula and replaced the new cannula. LVN AA did not change the gloves when going from a dirty field to sterile field. LVN AA checked oxygen saturation after tracheostomy care. In an interview with LVN AA on 1/9/26 at 10:56AM about the trach care, he said he did a great. He said he did forget to maintain a dominant hand and was trained that changing the inner cannula was aseptic technique. He said he forgot to check oxygen saturation before starting the suction. He said he had in-service on tracheostomy about 2 months ago. In an interview with the Respiratory Therapist on 01/09/26 at 11:15 AM, she confirmed that changing the inner cannula was aseptic technique, and she was following the facility technique, and the suctioning was a sterile technique. She said LVN AA should have a dominant hand and should not use both hands during suctioning, and not performing suctioning in a sterile technique could result in infection and death. She said she does tracheostomy in-service any time the facility has a resident with a tracheostomy. In an interview on 01/09/2026 at 12:45 PM, the DON stated sterile technique should be used throughout tracheostomy care and not suctioning tracheostomy with sterile technique could result in infection or cardiac arrest. Record review of the facility policies and procedures Tracheostomy care, revised 9/2025 reflected:Policy: The facility will ensure that tracheostomy care is performed aseptically for cleaning of the tracheostomy tube and stoma site, to prevent plugging of the tracheostomy tube, to prevent airway obstruction, to prevent infection of trach site, and to maintain a patent airway for suctioning. Equipment: Procedure . 10. Open trach care kit. 11. Aseptically DON sterile gloves. 16. With a non-dominant hand, pick up new inner cannula and with the dominant hand, replace inner cannula.21. Note: Monitor O2 saturation throughout procedure.

Based on interview and record review, the facility failed to ensure medical records were kept in accordance with professional standards and practices and were complete and accurately documented for 1 of 5 residents (Resident #125) reviewed for accuracy of records. The facility failed to ensure Resident #125's bath or shower was documented as given on 1/1/26, 1/3/26 and 1/6/26 in her electronic chart.These failures could place residents at risk for improper care due to inaccurate records. Findings included: Record review of Resident #125's admission Record dated 1/9/26 revealed a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE]. Her diagnoses included encephalopathy (damage or disease that affects the brain), schizoaffective disorder depressive type (a mental health condition that is marked by a mix of schizophrenia symptoms such as hallucinations and delusions, and mood disorder symptoms), Alzheimer's disease with early onset, and morbid obesity.Record review of Resident #125's 5-day MDS assessment dated [DATE] revealed a BIMS score of 11 out of 15 which indicated moderate cognitive impairment. She was dependent on staff for showering/bathing.Record review of Resident #125's care plan dated 12/29/25 indicated her ADL functions were extensive to total assistance with 2 staff members (total assistance requires hands on help throughout the entire task, significant assistance: the individual can perform some parts of the task but requires substantial help from a caregiver). Interventions were to set-up, assist, give shower, shave, oral, hair, nail care per schedule and PRN.Record review of Resident #125's undated electronic POC (the point in time when staff deliver healthcare products and services to patients at the time of care) response history revealed her bathing schedule was Tuesday, Thursday, and Saturday on the 7 a.m. - 7 p.m. shift. N/A was documented by CNA I for showers on 1/3/26 and 1/6/26. CNA B marked N/A for a shower on 1/1/26. (N/A indicated not applicable). There was no documentation on the electronic chart to indicate Resident #125 had a shower or bed bath on those days.Record review on 1/7/26 of Resident #125's paper shower sheets for January 2026 revealed one shower was documented on 1/3/26. The shower sheet was signed and dated by CNA H. It did not indicate the cleansing activity or expected resident grooming received.In an interview on 1/7/26 at 10:42 a.m. Resident #125 said the staff did not pay attention to her and sometimes did not give her a shower. She said she never turned down a shower, and her last shower was last week.In an interview on 1/7/26 at 4:00 pm CNA H said Resident #125 was total care with showers (total assistance requires hands on help throughout the entire task). She said her shower days were Tuesday, Thursday, and Saturday during the day shift. She said she last showered Resident #125 on Saturday 1/3/26. She said she also gave her a bed bath on Thursday 1/1/26 but forgot to document it. In an interview on 1/7/26 at 4:15 pm CNA I said she gave Resident #125 a bed bath on Tuesday 1/6/26 but forgot to document it on the shower sheet. She said the resident gets her baths.In an interview on 1/7/26 at 4:30 p.m. CNA I said she must have clicked the wrong button while documenting Resident #125's showers on the POC.In an interview on 1/8/26 at 3:00 p.m. the DON said staff needed to document the shower/bath to show that the care was done. She said she conducted in-services with the staff on general documentation and said if the care was not documented it was not done. She said she monitored the shower documentation through spot checks. In an interview on 1/9/26 at 2:16 p.m. the Administrator said she expected documentation to be complete to ensure residents received the proper care needed. Record review of the facility's Clinical Documentation policy dated 11/2025 read in part, .The facility maintains accurate, timely, and resident-centered clinical documentation within Electronic Medical Records (EMR) to reflect care provided in accordance with physician orders and the resident's plan of care. Documentation supports continuity of care, clinical decision-making, and communication among the interdisciplinary team. Routine care is documented through assigned tasks.Procedure: CNAs document care in Point of Care (POC) within Electronic Medical Records (EMR). Paper documentation is used only during approved downtime and entered into Electronic Medical Records once systems are restored. General Documentation Expectations: Documentation should be: Completed as close to the time of care as possible, Accurate and reflective of care provided.

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 to promote healing and prevent infection, for 1 of 7 residents (CR #1) reviewed for wound care. The facility failed to follow wound care orders for CR#1's sacral wound on 11/07/24, 11/12/24, 11/16/24, 11/23/24, 11/24/24, and 11/27/24. CR#1 was transferred to the hospital after family intervention and was diagnosed with a stage 4 pressure injury (full-thickness skin and tissue loss, exposing muscle, tendon, or bone) with infection and severe sepsis. The noncompliance was identified as past non-compliance. The past non-compliance IJ began on 11/28/24 and ended on 2/20/25. The facility corrected the non-compliance before the survey began. This failure could place residents at risk of deterioration of wound, increased infection, decreased quality of life, and hospitalization. Findings included: 1.Record review of CR#1's Face Sheet (undated) revealed, a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses which included Non-ST elevation Myocardial infarction (heart attack that occurs when blood supply to the heart was reduced, causing damage), Acute respiratory failure with hypoxia (lungs failed to adequately oxygenate the blood), Chronic Obstructive Pulmonary Disease (airway obstruction and chronic inflammation of the lungs), Diabetes Mellitus (chronic metabolic disease characterized by high blood sugar levels), and End Stage Renal Disease (kidney failure). Record review of CR#1's admission MDS assessment dated [DATE] indicated a BIMS summary score of 05, which indicated severe cognitive impairment. The resident did not have pressure ulcers as a diagnosis on the entrance MDS. However, there was an indication for a pressure reducing device for her bed. Record review of CR#1's Comprehensive Care Plan, dated 10/03/24, indicated that CR#1 was at risk for pressure wounds related to alteration in skin integrity and pressure ulcer formation. The goal was to be free from alteration in skin integrity/formation of pressure wounds over the next 90 days. CR#1's interventions included assisting with toileting as indicated and performing weekly skin checks. Record review of CR #1 physician's orders on 11/05/24 indicated sacrum: cleanse site with normal saline, wound sacrum cleanser pat dry, skin prep, apply hydrocolloid sheet 3x weekly (Tuesday, Thursday, and Saturday) and prn. That order was discontinued, and a new sacrum wound care order was started on 11/21/24. The new order was for sacrum wound: cleanse site with Vashe pat dry, apply Santyl ointment (Nickel Thick) as topical, cover with calcium alginate as a primary dressing, and cover with bordered gauze daily and PRN every day. Record review of CR #1's treatment administration record for November 2024 revealed wound care was not performed as ordered on 11/07/24, 11/12/24, 11/16/24, 11/23/24, 11/24/24, and 11/27/24. Record review of CR #1's weekly wound evaluation summary dated 11/01/2024 revealed a new sacral opening. Record review of CR #1's weekly wound evaluation summary dated 11/05/2024 revealed wound to the sacrum which measured 3x2x0.1cm Record review of CR#1's wound care notes on 11/18/24 by NP F revealed that CR#1's chronic sacral wound was measured at 3.4x7x0 cm. Record review of CR#1's wound care notes on 11/25/24 by NP F revealed that CR#1's chronic sacral wound continued to be unstageable but deteriorating and measured at 5x5x0. Record review of nursing notes dated 11/28/24 revealed CR#1's family member notified EMS to have resident CR#1 transferred from the facility to the hospital due to the condition of CR#1's wound. Record review of local hospital's medical records revealed that CR #1 was brought to the ED on 11/28/24 at 8:34 AM from a nursing facility with a sacral wound. After assessment, the resident was admitted to the hospital with stage 4 pressure injury and severe sepsis (life threatening condition where one or more body's organ is damaged from the inflammatory response). Wound cultures were collected and revealed positive for Escherichia. Coli (bacteria found in the intestines). Attempted to interview with the previous wound care nurse on 03/19/25 at 1:39 PM, but she no longer worked for the facility. During an Interview on 03/20/25 at 12:51 PM with contracted Dialysis RN, she said CR #1 had fluid overload and was on dialysis Monday-Friday. She said CR #1 was alert and oriented with some confusion. She said the resident developed a sacral wound; therefore, they would turn her to her side so she would be off the wound while in dialysis. During an interview on 03/20/2025 at 1:00 PM with the ADON, (who started at the facility on 09/23/24), she said CR#1's family would come to the facility regularly. She said the staff would notify the family member of any changes. She said the resident was in the Geri-chair most of the day and out of the bed per the family's request. She said her expectation was for the staff to follow MD orders. She said the risk of not following MD orders was a concern and that staff should always follow the orders. She said the staff conducted in-services on following MD orders recently but could not to provide a date. The ADON said the risk of not following MD orders could worsen the condition/diagnoses or wound. During an interview on 03/20/2025 at 3:24 PM with the DON, she said CR#1 was admitted to the facility without pressure ulcers but developed a pressure wound while at the facility. She said the resident was being treated as ordered, but the staff did not document her treatment. The DON said she could not confirm wound care was perfomed due to insufficient documentation. She said the wound care nurse who performed the treatment was terminated and no longer work at the facility. The DON said there was a new wound care nurse. She said she expected the staff to follow MD orders and document all treatments . The DON said the risk of not performing wound care as ordered could lead to deterioration of the wound. Attempted to interview wound care Nurse Practitioner F on 03/20/25 at 3:51 PM, but she no longer worked for the wound care company. During an interview on 03/20/25 at 4:09 PM, the current wound care nurse, Nurse Practitioner L said Nurse Practitioner F assessed and provided treatment to CR#1, who no longer work for the company. Nurse Practitioner L said her expectation was that the nursing staff followed MD orders. She said some residents were placed on hydrocolloid, which can last up to 7 days; however, the staff should not deviate from the orders. She said if the order said to provide treatment every 3 days, the staff should follow that order. The Wound Care Nurse Practitioner L said the risk of not following the MD's orders was deterioration of the wound. During an interview on 03/20/25 at 5:13 PM with LVN T, wound care nurse, (who started at the facility on 2/24/25), she said her expectation was for staff to follow MD orders for wound care. She said the wound care doctor comes to the facility once a week, and if there were a change or deterioration to the wound, she would assess the wound to include measurements and notify the charge nurse and wound care MD. She said she conducted an in-service on skin assessments last week. She said she educated the CNAs on what to look for on the resident's skin. She said the risk of not following the physician's orders was the wound/ulcer could worsen. During an interview on 03/20/25 at 5:45 PM with the administrator, she said her expectation was the staff follow MD orders. She said she was unaware of what could happen if the staff did not cleanse the wound as ordered by the MD. During an interview on 04/07/25 at 2:12PM, CR#1's family member said she called EMS because CR#1's wound was large and had an odor. She said when she arrived at the local hospital the doctor admitted CR#1 her aunt because she was septic. She said she had E. Coli in her wound. She said after acquiring the wound and becoming septic, CR#1 was never the same. CR#1's family member said they had to perform colostomy (surgical procedure that creates an opening in the abdomen to allow stool to pass out the body) on 12/12/24, and she was discharged to another nursing facility on 12/14/24. During an interview on 04/07/25 at 4:48 PM, the Chief Medical Officer for the wound care company said NP F no longer worked there. She said, based on the photos, CR #1 had a chronic unstageable sacral wound. She said the wound had not significantly changed between the initial visit on 11/18/24, measuring 23.8 cm, and the 2nd visit on 11/25/24, measuring 25cm. She said the interventions, including the dressing that was ordered, were appropriate for wound care. She said the resident had significant comorbidities and was incontinent to bowel and bladder, which could also deteriorate the wound quickly. The chief medical officer said the resident was declining, and based on the appearance of the wound, this skin failure was a phenomenon that was recognized in residents with a terminal condition. During an interview on 04/07/25 at 5:01 PM, LVN M said nurses perform weekly skin assessment on the residents. She said the nurses were responsible for providing wound care if the wound care nurses were unavailable. She said the staff was in-serviced last week on wound care. She said the risk of not performing wound care could lead to further breakdown of the skin or worsen the wound. During an interview on 04/07/25 at 5:36 PM, RN O said nurses perform wound care when the wound care nurse was not available. She said they also have a wound care MD that comes once a week to provide care. RN O said they perform skin assessments on every new admission and conduct weekly skin assessments. She said a wound consult was requested for every resident with a wound, and the MD was contacted if there was a change in the wound. RN O said the last in-service on wound care was conducted last week. She said the risk of not providing wound care was infection. Attempted telephone interview with Dr. T on 04/08/25 at 12:54 PM, left a voicemail message. During an observation of Resident #2's wound care on 04/09/25 at 2:40 PM, the wound care nurse sanitized hands and applied PPE (personal protective equipment), including gown and gloves. She cleaned the bedside table and applied barrier to bedside table. She doffed gloves and washed her hands. She donned gloves, cleaned the unstageable sacral wound with wet gauze, and patted it dry. The wound care nurse doffed gloves, washed her hands, and donned new gloves. She applied Medihoney, calcium alginate, and dressing as ordered. She doffed her gown and gloves and washed her hands. She repositioned the resident to her right side and removed discarded items. During an interview on 04/09/25 at 2:51 PM, RN S said she does wound care as needed. She said she noticed an increase in training in January and February by the wound care nurse. She said she cannot remember the date of her last wound care training. She said in training, the staff was educated on change of condition (odor, increase drainage, increase pain, and increase temperature) and the notification process. She said when providing wound care, the staff should document changes in the wound and notify the MD, RP, and DON. She said staff should reposition residents every 2 hours and change wet and soiled briefs frequently to prevent skin breakdown. Review of the facility's policy titled Wound Evaluation, with a revision date of 06/ 2019, read in part . Procedures: 2. Document all treatments performed and resident response in Point Click Care. 6. Evaluation results are communicated to the members of the interdisciplinary care team through documentation, care plan meetings, and care planning . The noncompliance was identified as past non-compliance. The IJ began on 11/28/24 and ended on 02/20/25. The facility corrected the non-compliance and implemented the following interventions prior to the surveyors entering the facility on 03/18/25: -Record review of QA meetings, with facility clinical staff and regional nursing staff, regarding facility skin system and wound care on 12/06/24, 12/20/24, 01/10/25 and 02/07/25. -Record review of Wwound care nurses were terminated on 12/17/24 and 12/23/24. -Record review of skin sweeps conducted 12/23/24 through 12/31/24. Results indicated no other residents were found to have new or worsening wounds. -Record review of QA Nurse and DON followed-up on all wound care audits and skin assessments. -Outside Wound Care physician rounded on all residents on 02/06/25-02/07/25. -Interviews with staff they who stated they have been in-serviced to report any changes or anything different for the resident. - Record review of in-services and re-education provided to facility staff on 01/06/25, 01/14/25, 01/15/25, 02/05/25, and 02/14/25. Topics included: Wound care; change in conditioning; incontinent care and repositioning for residents with wounds. -Observations during annual recertification 03/18/25-03/20/25 revealed no concerns.

Based on observation, interview, and record review the facility failed to ensure resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 2 out of 2 residents (Resident #1 and CR #2) reviewed for adequate supervision. Facility failed to perform timely intervention after multiple reports of closet door malfunctioning. The closet door fell on Resident #1 on 07/22/23 resulting to hospitalization . The noncompliance was identified as Past Non Compliant. The IJ began on 7/22/23 and ended on 7/25/23. The facility corrected the non compliance by removing the doors prior to surveyor entrance. This deficiency exposed residents living in the facility to safety hazard. Findings included: Record review of Resident #1's face sheet revealed Resident #1 was a [AGE] year-old female. She was admitted to the facility on [DATE], her initial admission was 09/28/2017. She was diagnosed with osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases), pain, dementia, disorder of bladder, diarrhea, Major depressive disorder, abnormality of gait and mobility, fall, cataract, muscle weakness, and hypertension. Review of Resident #1's MDS (Minimum Data Set) dated July 31, 2023, section G0110 revealed resident required one-person physical assist with bed mobility, walk in room, walk in corridor, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. Section I0020 revealed Resident #1 had a medically complex condition Record review of Resident #1's care plan dated 07//12//2023 revealed: 1. Focus: Resident #1 has dementia Goal: Resident #1 will be safe in her environment . 2. Focus: ADL self-care Goal: Resident #1will have no further decline in ADL or injury . Intervention: anticipate needs and provide prompt assistance with the following - Walk in room [ROOM NUMBER]:1 - Walk in corridor 1:1 - Locomotion on unit 1:1 - Locomotion off unit 1:1 - Dressing 1:1 - Personal hygiene 1:1 3. Focus: Resident #1 is at risk for fall and injuries Goal: Resident #1 will be free from falls and injuries . Record review of progress note revealed the following: - On 07/22/2023 at 08:10pm At 7.50 pm Patient fall on the floor in her room attempting getting something in the closets , patient found on the floor face up and the closet door was on top of her, scream help me nurse rush into the room for help, 911 was called paramedics arrived at 08:00pm to access her Blood Pressure was elevated 179/91, Temperature 97.8 Pulse-90, SPO2 98 Pain scale 9 on the scale of 1-10 scale, patient was alert and oriented going to the ER was crying for pain. - On 07/23/2023 at 03:33am Patient returned from the ER at 0200 with the daughter accompany her in the room with 2 new prescription prn cyclobenzaprine 5mg PO and ondansetron 4mg PO prn, presently in her room sleeping vital signs stable daughter sitting by the side of her bed BP 124/70, T 97.2, P 74, R18, SPO2 98 ibuprofen 600mg ever 8 hours given for pain immediately she came back. presently in her bed sleeping. - On 07/23/2023 at 12:41pm Patient vital signs and neurological check completed. Upon check, patient vitals signs are low and neurological signs are abnormal. Daughter requested resident be sent back to the hospital for further evaluation. Pupils dilated, motor weakness noted, withdrawals to external stimulus, confused orientation, slurred speech. Body aches and weakness. Symptoms in relation to fall last evening on night shift. Record review of hospital record revealed Resident #1 was diagnosed with Nausea and Vomiting. Diagnostic CT (Computerized Tomography) scan revealed No CT evidence of acute intracranial abnormality. Physician note revealed Resident #1 likely had concussion, On 08/23/2023 at 2:23pm in an observation of Resident #1 in her room, resident was in bed and sleeping. Family Member 1 was at the bedside, she stated after her mom was back from the hospital on the next day (07/24/2023), the resident (CR#2) across her mom's (Resident #1) room stated that he (CR#2) had complained about the closet door to the therapist (Occupational Therapist A) few days before her mom had the accident, but they (facility) did not do anything about it. Resident's Family member 1 stated CR #2 told her that the Occupational Therapist A took pictures of the closet door of his room when he (CR#2) told him (Occupational Therapist A). Resident Family member 1 stated when she made attempt to get the pictures, Occupational Therapist A stated he did not have picture. On 08/23/2023 at 3:11pm in an interview with CR #2 (Former resident of the facility) via phone, he said about more than a month ago when he first noticed the closet door of his room came off, he stated his family member (Family Member 2) moved the closet door couple of times to one side so he (CR#2) won't have to move them when he needed to use the closet, he said Family Member 3 also helped to move the door too. CR #2 said the Occupational Therapist A who was helping him with therapy saw the closet door at that time and took picture of the closet door, CR #2 stated the Occupational Therapist A stated he was going to show the picture to the management. CR #2 stated but it seemed like the Occupational Therapist A was scared because he later denied that he did not have any picture again. CR #2 stated there was nothing done to address the issue. He stated he first experienced the issue of closet door malfunctioning in his room before the incident of Resident #1 happened (he could not recall exact date). He stated his closet door did not completely come off, but it was disconnected from the frame on one side. On 08/23/2023 at 4:07pm in an interview with Occupational Therapy A, he stated he had been working at the facility for about 4 years. He said CR #2 told him around July that the closet door was faulty. Occupational Therapist A stated he could not recall specific date, but he said it was few days after CR #2 came back from the hospital, he said resident (CR#2) was hospitalized on [DATE] and came back about 3 days after. He said he did not see the closet door, neither did he take any picture. He stated he told the former Administrator, he stated he did not recall the exact date when CR #2 told him, but he told the Administrator (the former Administrator) about it. He stated right now the maintenance had removed all the barn-style doors from the closet. On 08/23/2023 at 4:47pm in an interview with the DON who had been working at the facility for two months, she said she did not know what happened to Resident #1's door, and she (DON) was not in the building at the time of the incident. She stated that immediately the incident happened, all the closet doors were removed for safety reason. She stated prior to that incident, she did not hear of any closet door coming off or having fault. On 08/23/2023 at 5:15pm in an interview with the New Administrator, She Said she was not there in the facility when the Resident #1 fell with the closet door on top of her. She said she did hear about it at the time she started working at the facility about 4 weeks ago. The New Administrator said the closet doors were removed ever before she started working at the facility. On 08/23/2023 at 5:42pm in an interview over the phone with Former Administrator, she said she did not hear about any incident about closet door faulty before the Resident #1's incident happened. She said she was the interim Administrator, and she was only at the facility for a month (the end of June to the end of July). She said they took off the barn door of all the closets for safety. She said she knew that the organization was in the process of remodeling of some of the rooms and that will be up to them to decide what to do with the closets. On 08/23/2023 at 6:03pm in an interview via the phone with the Former Maintenance Staff, he said before the incident of Resident #1's closet door fell off on her, he said a resident and another family member told him that the door fell down and hit the family member's foot. He stated the room was in the new hallway that was just built. He stated he did not recall the name of the resident and the exact date, but he heard a complaint about the closet doors in the past which he told the Administrator (former Administrator), the general contractor and the Regional Staff. On 08/23/2023 at 6:55pm in a phone interview with the Regional Staff, he said he did not remember any maintenance staff telling him about closet door malfunctioning. He said he was notified after the Resident #1 fell and the closet doors were removed. He stated he had no idea who notified him at that time, he said he got notified about it anyway. On 08/30/2023 at 4:02pm in an interview with Nurse A who was the nurse taking care of Resident #1 the day Resident #1 fell . She said the resident screamed for help and they all rushed to the room. Nurse A reported that the resident stated she was trying to pick something in the closet and when she was losing her balance, she grabbed the closet door then the closet door came off and she fell with the closet door. Nurse said resident was crying in pain and pain medication was administered. Nurse A stated Resident #1 was sent to the hospital immediately, but she was back from the hospital within 24-hours in the morning - she stated the incident occurred during the night shift and she was sent to hospital that night, but resident came back in the morning. Nurse said the resident was sent back to hospital the same day she came back because she was having abnormal vital sign, altered mental status and nausea/ vomiting as a result of the fall. On 09/05/2023 at 6:28pm in an interview with Former medication Aide, she stated the closet doors of the new hallway appeared fragile, she said it was not firm like the closet door of other old rooms. She stated she did not hear complaints from any residents but with the look of the closet door hanging on a rail, she said it appeared fragile. On 09/05/2023 at 6:38pm in an interview with family member 2, he stated he came to the facility up to three times a week to visit CR #2, and he was in the building about three to four weeks while the CR #2 was admitted there. He stated they got a lot of things going on at one time there at the facility, he said there was no hot water for almost a month, he said but they got the hot water fixed. He stated every time he came to the facility, he had seen the closet door of CR#2's room in a pretty bad condition. He said it was loose on the top part. He stated complaint was made to the staffs there, but nothing was done for a very long time. On 09/05/2023 at 6:43pm in an interview with the Family member 3, the son of CR #2, he stated the closet door of his father's room was coming off track multiple times. He said the closet door came off track many times and he put it back couple of times too, he said there were multiple times the door was off track He stated every time he would point out the closet door to the staffs - he said he did not know their names, he said I point it out to whoever comes in there, but they said it was the maintenance job. Facility did not have policy on Physical Environment. The noncompliance was identified as Past Non Compliant. The IJ began on 7/22/23 and ended on 7/25/23. The facility corrected the non compliance by removing the doors prior to surveyor entrance. On 9/13/23 at 1:14 p.m., facility administrator was notified of past non compliance IJ. A plaln of removal was not requested. An IJ template was provided to the administrator via email.

Based on observation, interview and record review, the facility failed to ensure the resident's right to be free from neglect for 2 of 13 residents (Resident #1 and Resident #2) reviewed for neglect. -The facility failed to provide adequate supervision for Resident #1 to prevent harm from suicidal ideations and self-injurious behaviors that resulted in him swallowing a battery, having a plan to swallow razors, and being hospitalized . -The facility failed to adequately educate staff on caring for residents with diagnosis of suicidal ideations and self-harming behaviors. -The facility failed to care plan and put additional services in place for Resident #1 when he admitted to the facility with suicidal ideations and having multiple suicide attempts on 2/6/23 and readmitted on [DATE] after swallowing another battery. -The facility failed to initiate safety interventions when Resident #1 expressed suicidal ideations, requested to go to the hospital and was found with scissors and razors after he continuously requested medicine for his chronic pain and leaking ileostomy bag and resulted in an actual suicide attempt on 06/17/2023. -The facility failed to notify the NP that Resident #1 had a diagnosis of suicidal ideations, and that Resident #1 was found with a box with scissors and razors inside. -The facility failed to consistently change Resident #1 and Resident #2's ileostomy bag resulting in leaking of stool, burning skin and hospitalization . An Immediate Jeopardy (IJ) was identified on 07/01/23. The IJ template was provided to the facility on [DATE] at 2:45 p.m. While the IJ was removed on 07/05/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not an Immediate Jeopardy because all staff had not been trained on caring for residents with suicidal ideations, neglect, ordering pain medications timely, changing ileostomy bags, and care planning for suicidal ideations. These failures placed residents who have a diagnosis of suicidal ideations at risk of not being properly monitored, not having their immediate needs being met and possibly resulting in hospitalization or death. Findings include: Resident #1 Record review of Resident #1's face sheet dated 6/28/23 revealed a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of being initially admitting to the facility with suicidal ideations, systemic inflammatory response syndrome (SIRS) of Non-Infectious origin without acute organ dysfunction (exaggerated defense response of the body), cerebral palsy (disorder that affects a persons ability to maintain balance and posture), sepsis due to enterococcus, fistula of intestine (abnormal opening or intestine that allows the contents to leak to another part of the body), idiopathic peripheral autonomic neuropathy (damage of the peripheral [NAME] where cause can not be deermined), intervertebral disc degeneration, lumbar region, residual schizophrenia, scoliosis, bipolar disorder, colostomy status, major depressive disorder, and anxiety. Record review of Resident #1's Care Plan dated 6/26/23 revealed resident complains of increased pain/discomfort and is at risk for further episodes of increased pain/discomfort and injury. Goal: Resident 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. Interventions: Allow to verbalize feelings of pain/discomfort . Resident #1 has a Colostomy due to Medical Condition. Goal: Resident #1 will have no complications from ostomy site over the next 90 days. Intervention: Monitor site for swelling, pain, redness, etc.Apply Nystatin powder to Colostomy Site. Resident #1 has a diagnosis of depression with Goal: have fewer or no episodes of depression and will voice feelings about self over the next 90 days. Interventions/Tasks: Allow [Resident #1] to verbalize feelings of depression. Give medications per order-monitor labs - report abnormalities to MD. Resident #1 has a behavior problem of not waiting on staff to change his colostomy will call the police 911. Intervention: Anticipate and meet [Resident #1's] needs. Resident #1 call 911 due to meds not here. Interventions/Tasks: If reasonable, discuss [Resident #1's] behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. Further Record review of Resident #1's Care Plan dated 6/26/23 revealed he was not care planned for suicidal ideations when he admitted to the facility with the diagnosis on 2/6/23. Record review of Resident #1's Quarterly MDS dated [DATE] revealed his BIMS Summary Score was 15 indicating he was cognitively intact. Resident #1's functional status revealed walking in room and corridor did not occur, supervision with set up help only for locomotion on and off the unit and eating. Resident #1 required limited assistance with one person assisting for transfer, toilet use, and personal hygiene and he needed extensive assistance with one person physically assisting him for dressing. Record review of Resident #1's Physician Orders dated 6/30/23 revealed: Discontinue Oxycontin 20 mg ER when 30 mg tablet has arrived. One time only for 3 days dated 6/28/23 and ended 7/1/23. Oxycodone HCL Oral tablet 10 mg give 1 tablet by mouth every 4 hours related to systemic inflammatory response syndrome of non-infectious origin without acute organ dysfunction dated 4/11/23. Oxycontin Oral tablet ER 12 Hour Abuse-Deterrent 30 mg give 1 tablet orally every 12 hours for chronic pain. Oxycontin Oral Tablet ER 12 Hour Abuse-Deterrent 20 mg Give 1 tablet orally every 12 hours for chronic pain. Nystatin External Powder 100000 UNIT/GM (Nystatin (Topical)) Apply to colostomy topically three times a day for colostomy site irritated dated 04/04/23. Zinc Oxide External Ointment 20 % (Zinc Oxide (Topical)) Apply to colostomy site topically four times a day for colostomy site irritated dated 02/16/23. Record review of Resident #1's Medication Administration Record for 6/1-6/30/23 revealed: Colostomy Observation every shift Monitor Resident's colostomy. Ensure Colostomy is intact, free from s/s of infection and functioning properly. The box was blank on 6/6/23 at 6 p.m. Colostomy: Empty every shift Licensed Nurse will monitor colostomy and ensure it is emptied every shift and as needed. The box was blank on 6/6/23 at 6 p.m. Observation: Behaviors. Target Behaviors : withdrawn, crying, lack of appetite every shift Monitor Resident for Presence of Behaviors withdrawn, crying, lack of appetite. Document Yes or No to whether Behaviors were Observed. Notify MD as needed for Behaviors. The box was blank on 6/6/23 at 6 p.m. 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 for pain observation. The box was blank on 6/6/23 at 6 p.m. Skin: Protective skin barrier ointment after each incontinent episode and PRN every shift. The box was blank on 6/6/23 at 6 p.m. Nystatin External Powder 100000 UNIT/GM (Nystatin (Topical)) Apply to colostomy topically three times a day for colostomy site irritated. The box was blank on 6/6/23 at 6 p.m. Zinc Oxide External Ointment 20 % (Zinc Oxide (Topical)) Apply to colostomy site topically four times a day for colostomy site irritated. The box was blank on 6/6/23 at 9 p.m. Oxycodone HCL Oral Tablet 10 mg. The box was blank on 6/6/23 at 6 p.m. Oxycontin Oral Tablet ER 12 Hour (Oxycodone HCl). The box was blank on 6/6/23, 6/10/23, and 6/11/23 at 9 p.m. Further review of the MAR revealed no documentation to indicate Resident #1 was out of the facility on the days the MAR was blank. Record review of Resident #1's Controlled Drug Administration Record Tablet for Oxycodone IR 10 mg oral date issued 5/3/23 revealed: 6/16/23 at 9 a.m. 6/16/23 at 1 p.m. 6/16/23 at 5 p.m. 6/16/23 at 8 p.m. 6/17/23 at 1 a.m. 6/17/23 at 5 a.m. 6/17/23 at 9 a.m. 6/17/23 at 1 p.m. 6/17/23 at 5 p.m. the last dose was administered and there were 0 tablets left. Record review of Resident #1's progress note dated 6/6/23 at 2:30 a.m. by LVN E revealed, Resident is currently stable .PRN Oxycodone HCl oral tablet 10 mg administered at 7:32 p.m. and 1:32 a.m. respectively due to burning pain on skin. Record review of Resident #1's progress note dated 6/8/23 at 4:06 p.m. by LVN D revealed Resident #1 alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's progress note dated 6/9/23 at 4:56 a.m. by LVN A revealed Resident #1 alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's progress notes dated 6/11/23 at 5:54 a.m. by LVN C revealed Resident #1 called 911 because his colostomy was not change prompt, at the time of his call the nurse/writer was on break, colostomy was changed .[Resident #1] alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's Progress note dated 6/13/23 at 11:07 p.m. by LVN A revealed Confirmed new order from [Doctor] to discontinue patient PRN oxycodone HCL Oral Tablet 10 mg (Oxycodone HCL) every 4 hours. [Resident #1] started on scheduled oxycodone HCl Oral tablet 10 mg (Oxycodone HCl) every 4 hours for his pain management. Resident #1 remains oxycodone HCl oral tablet ER 20 mg (Oxycodone HCl) twice daily. Resident #1 made aware of new changes with his pain medications. Record review of Resident #1's Follow up with Physician dated 6/13/23 at 12 a.m. revealed Past Medical History: Borderline personality disorder, cerebral palsy, depressive disorder, difficult intravenous access, PTSD, self-injury behavior, schizophrenia, chronic enterocutaneous fistula, right ureteropelvic junction renal stone with intermittent obstruction .Social History: .History of multiple suicide attempts via self-mutilating behavior and ingestion of various objects .History of Present Illness: This is a [AGE] year old while male with a past history of significant for PTSD/bipolar disorder with multiple suicide attempts with self-injurious behavior and ingestion of various objects, cerebral palsy, scoliosis, and a chronic enterocutaneous fistula 2/2 self-inflicted stab wound on his abdominal wall that required exploratory laparotomy x2 and excision of infected abdominal wall mesh (11/28/20), extensive adhesiolysis, and partial small bowel resection complicated by chronic draining wound .Patient states that his chronic abdominal pain is now becoming uncontrolled. He states that he is at his wits end and expressing a desire to go back to the hospital. His colostomy continues to leak stool creating a red rash around the site. He still refuses fentanyl patch saying that he doesn't like the way it makes him feel. He is requesting to have the oxy schedule and seeing if that helps. He has appt with surgery on 6/20/23. He also mentions that he is feeling more depressed but not suicidal. Record review of Resident #1's Progress note dated 6/17/23 at 10:15 p.m. by LVN A revealed NP notified that pharmacy only send patient Oxycontin 20 mg. [Resident #1] wasn't happy and was yelling that this can't be happening. NP stated that she did notified Doctor that pharmacy did not deliver [Resident #1] Oxycontin IR 10 mg. NP said she haven't gotten a response from the Doctor yet. [Resident #1] was made aware and did reassure him that we're working on it. Record review of Resident #1's SBAR (Change of Condition) dated 6/18/23 at 12:31 a.m. by LVN A revealed: [Resident #1] complaining of extreme pain to his stomach. [Resident #1] requested to be sent out to the hospital. NP notified .[Resident #1] requested to be sent out to the hospital because he can't take it anymore because of his pain. Nurse caught [Resident #1] holding some tools in his hand. Nurse took away from patient holding 4 disposable shaving razors, a small scissors and a plastic water cover from the kitchen while he was sitting up. NP notified and approved to send him out. Patient was yelling out loud, disturbing the peace of other residents'. Cursing out loud by using different offensive words that are derogatory. Unable to calm patient down. Patient went out via 911 at 11:47 p.m. Record review of Resident #1's Local Hospital Record dated 6/23/23 revealed Pouch was leaking on arrival. Pouch was last changed on 6/19/23 wound ostomy continence note. Changed pouch. Applied marathon liquid skin protectant to peristomal, raw, denuded openings. Applied 1 piece pouch with convex barrier ostomy ring. Good seal achieved. Record review of Resident #1's Progress notes dated 6/25/23 at 7:53 p.m. by LVN B revealed Received [AGE] year-old patient in the building via EMS Stretcher 2 men crew Awake Alert and Oriented x3, with medical history of cerebral palsy, depression, scoliosis, abdominal stab wound post colostomy that been leaking for the past 4 years and known history of drug seeking behavior just discharged from [local hospital]. Upon arrival patient continue to demand for the pain medication on the same spot and called another 911 that he is going back to hospital if nobody gave him immediate attention, medication confirm and verified with the doctor, presently eyes closed in the room continue to monitor throughout the night. Record review of Resident #1's Local Hospital Record Discharge Summary dated 6/25/23 at 7:50 p.m. revealed, Reason for Visit: pain issues complained of abdomen pain from his colostomy, chronic. Takes oxycodone for pain. Nursing facility does not have his short acting oxycodone 10 mg which he gets every 4 hours only long acting 20 mg dose which he received at 9 p.m. tonight. States his colostomy bag is always leaking .His abdominal wall cellulitis may also be irritant dermatitis from the feces. He was started back on his chronic pain medications. Patient initially did not want to return to his facility. He then notified me that he swallowed a battery. Psychiatry was consulted and Cymbalta was increased to 80 mg daily. X-ray of the abdomen was completed that showed metallic cylindrical object in the left upper quadrant. Chest x-ray showed 2 cm focal opacity however he does have a skin tag in that region. GI was consulted and proceeded with EGD on 6/22 and was unable to retrieve foreign body. He was also noted to have elevated liver enzymes may be due to Cymbalta. He was continued on Cymbalta due to benefits of medication. Surgery was consulted. CT abdomen pelvis was completed that showed cylindrical metallic density within the small bowel loop in the lower mid abdomen with moderate stool burden. He was unable to pass battery. GI proceeded with colonoscopy and was able to retrieve the battery. He was restarted on regular diet which he tolerated well .Impression: Ingested foreign body-AAA battery battery-successfully removed by ileoscopy through ileostomy. Record review of Resident #1's Psychological Services Progress Note dated 6/27/23 revealed: Symptoms: (Symptoms that were focused on in this session) Psychological: depression, Physical: Physical decline, Functional/Behavioral challenges: Adjustment difficulty (illness/decline/Loss, Stressors/Changes in Mental Status: Declining health .Results of Psychotherapy: Functional improvement noted .Identified- external emotional triggers, Disposition/Rationale for continued treatment: Symptoms require more attention. In an observation and interview with Resident #1 at the facility on 6/28/23 at 1:20 p.m. revealed Resident #1 rolling around the hallway in his wheelchair. Resident #1 stated he ate a battery and he explained he had an ileostomy bag, and it was leaking. He stated it leaked all the time no matter what the facility did. Resident #1 stated he had it for 4 years and he had trouble with the facility getting ostomy bags all the time and he had trouble with them getting his PRN pain meds to him. Resident #1 stated he had several talks with Administration about these incidents asking them to tighten this up (his pain medication and ostomy bags). Resident #1 stated he spoke with Doctor's in the hospital to make things better and they said there was nothing they could do. He stated before he went to the hospital on 6/17/23, he found out his medicine (oxycodone 10 mg) had lapsed, and he told the nurse to send him to the hospital. He said he had discussions with them several times and LVN A said no they will just send him right back. Resident #1 stated with the state of mind he was in, he thought he would just do something that he had to go. He stated he was in a lot in pain with the ileostomy leaking and it burned his skin and he also had cerebral palsy and scoliosis. Resident #1 stated the state of mind he was in, he said to himself he would do what he had to do to get out of the facility. Resident #1 stated since this incident he spoke with the psych specialist at the facility and she was getting him medication for anxiety and she said if a scenario happened again and the facility ran out of meds then he (Resident #1) would tell the staff he wants to go to the hospital and he did not feel safe. Resident #1 stated since that issue happened the facility had a new unit manager and she stayed on top of the meds, and he stated he was staying on top of the meds also. Observation of Resident #1's ileostomy bag revealed it was leaking onto his brief and his skin. Resident #1 stated he felt that the facility neglected him, and he did not mean to snitch on anyone, but it is what it is. Resident #1 stated he could not remember the Nurses name. Resident #1 stated the staff said they could not make the ileostomy bag stop leaking. Resident #1 stated the ileostomy was not leaking as bad as it was yesterday. He said, the ileostomy bag leaked a lot and that was an understatement and it had burned him in the past where he had to go to the hospital. Resident #1 stated the last time he went to the hospital for the ileostomy burning his skin was a few months ago. In an interview and record review on 6/28/23 at 1:40 p.m. with Unit Manager A, she stated Resident #1 getsfrustrated about his pain meds when the facility does not get them right when they were due. Unit Manager A stated, Resident #1 was asking about his pain meds closer to 6 p.m. on 6/17/23 and he asked for the pain meds and the med aide was in another room and he got frustrated. Unit Manager A stated Oxycodone 10 mg was PRN, but they made it routine a few days before he went out. Unit Manager A stated Resident #1 went out on 6/17/23 and came back on 6/25/23. Record review of Resident #1's narcotic count sheet with Unit Manager A revealed Resident #1 did run out of Oxycontin ER 20 mg on 6/17/23 at 9 p.m. She stated he ran out of meds on 6/17/23 so no meds were given. Unit Manager A did call the local pharmacy on 6/28/23 at 2:13 p.m. and they stated Resident #1's Oxycontin ER 20 mg was delivered on 6/17/23 at 6:45 p.m. with 14 tablets. Unit Manager A stated Resident #1 ran out of Oxycodone 10mg. Record review of Resident #1's narcotic count sheet with Unit Manager A revealed the last Oxycodone 10 mg tablet was given on 6/17/23 and he had 0 pills left. Unit Manager A stated the local pharmacy stated oxycodone 10 mg was delivered on 6/18/23 at 6:32 p.m. Unit Manager A stated Resident #1 missed 1 dose of oxycodone 10 mg on 6/17/23 for 9 p.m. In an interview on 6/28/23 at 2:20 p.m. with the DON she stated thought Resident #1 called 911 on 6/17/23 and they showed up at the building. The DON stated he had not told them that he swallowed the battery. In an interview on 6/29/23 at 1:18 p.m. with LVN A she stated the Doctor messed up. She stated she got report from shift changeon 6/17/23 saying the Nurse got in touch with NP because Resident #1 ran out of meds, and they contacted the Doctor to call the medication in. LVN A stated she received report saying Unit Manager A took care of that, but the pharmacy only brought the oxycodone 20 mg and not the oxycodone 10 mg. LVN A stated the pharmacist said on 6/17/23 Resident #1 ran out of Oxycodone 10 mg and would need a new prescription. LVN A stated she got in touch with the NP and asked the NP to have the Doctor to contact LVN A. LVN A stated Resident #1 was suicidal and if he did not get his medicine, he would start doing things. She stated the Doctor did not respond back and he was supposed to call in those dosages. LVN A stated the meds came in the next day on 6/18/23. LVN A stated on 6/17/23 Resident #1 was screaming, and she realized Resident #1 was trying to cause harm to himself. She stated she told NP that Resident #1 said call 911 and the NP said call 911 . LVN A stated Resident #1 was holding some scissors and razors on 6/17/23 and she removed it from him and she continued to try to get the oxycodone 10 mg by contacting the NP. She stated she called 911 and said he was complaining of pain. LVN A stated Resident #1 was really angry and upset. He said it happened all the time that the facility ran out of his medication. LVN A stated Resident #1 was scheduled to get Oxycodone 20 mg twice a day and she went to his room saying it was his night meds 20mg for 10p.m. LVN A stated she told Resident #1 they did not have the 10 mg because they ran out of the 10 mg and was waiting for the pharmacy. She stated Resident #1 started yelling and raging screaming out of control. LVN A stated Resident #1 just got his oxycodone 20 mg long-acting meds at 9 p.m. and he started screaming and raging at 9p.m. She stated she had to leave Resident #1 to call the NP and he started yelling god dammit and saying things like he was going to harm himself. LVN A stated Resident #1 was mad the previous days because he was out of his medicine. LVN A stated Resident #1 was holding items in his hand, scissors and razors that could harm him. LVN A stated Resident #1 said he was going to harm himself. She stated Resident #1 was holding a pair of scissors, 4 disposable razors, a plastic lid from a plastic cup and he keep saying he was going to hurt himself. LVN A stated she was already aware of Resident #1's history and she took the items from him (Resident #1) and brought it to the Nurse station then she called 911 (Unknown time). LVN A stated 911 came and he told 911 he had a colostomy that was excoriated, and the stomach contents leaked out and he told 911 he was having stomach pain, the facility had been out of his meds for a few days, and he could not take it anymore and he did not want to be at the facility. She stated Resident #1 could not bear the pain and he was insisting to go to the hospital and NP said go ahead and send the resident. LVN A stated she did not know anything about a battery. She stated the only thing Resident #1 was holding in his hand were the scissors and razors and she took them away from him and called 911. LVN A stated she did not trust Resident #1. LVN A stated she did not call anyone to assist her with Resident #1 because the CNA was busy working and Resident #1 was sitting in the wheelchair crying, yelling and screaming god dammit LVN A stated the Doctor did not call in both dosages and they were supposed to call when they had 7 pills in the blister pack. LVN A stated Resident #1 had a history of trying to harm himself. LVN A stated the facility had an adequate supply for ileostomy bags and the only issue was about pain meds for Resident #1. In an interview on 6/29/23 at 1:53 p.m. with Resident #1, he stated prior to him swallowing the battery he had several conversations about having enough ostomy supplies because before the new Unit Manager got there, supplies was an issue. He stated he was having problems getting his prn pain meds when he needed, and he had several conversations with the previous Management (Administrator B). Resident #1 stated before he went to the hospital, he had gone days without his pain medication. He stated on 6/17/23, that evening he took his last prn dose of pain meds oxycodone 10 mg, and they said by the time it was time to get it again, the meds would be at the facility, and he said great. Resident #1 stated the medicine did not come in and they only brought the scheduled pain meds (oxycodone 20 mg) and he had asked for his pain meds (oxycodone 10 mg) and LVN A said the pharmacy only brought in the scheduled pain meds (oxycodone 20 mg). Resident #1 stated it was Saturday night and the next day was Sunday and if they run out on a Saturday you do not get meds until Monday. Resident #1 stated the med aide that day on 6/17/23 said it was his last dose at 5:30 to 6 p.m. and they said his meds should be in by the time the next dose was due. He stated he told the late-night nurse (LVN A) he was out of here (the facility) and that he was going to the hospital where they could take care of him. Resident #1 stated LVN A said let her give him (Resident #1) the scheduled dose and she said she would get a hold of the Doctor and he should let her see what she could do. Resident #1 stated the ostomy supply kept running out, there was the issue with getting prn meds and them running out of pain medication. He said, he had it and he blew up. Resident #1 stated he spoke with Unit Manager A before and he tried to solve the issue. Resident #1 stated it was a little after 9 p.m. on 6/17/23 when LVN A took the scissors from him at 9:45 to 10 p.m. when she saw them in his hand, and he said nothing nothing. Resident #1 stated in the box was razors, scissors and he had hidden batteries in his pocket. Resident #1 stated it was after 9 p.m. when she gave the scheduled meds, and she was having trouble getting hold of the Doctor. Resident #1 stated he told LVN A he wanted to get out of the facility, and she said if you just go for pain meds, they will give you one dose and send him right back. Resident #1 stated he had already told LVN A that he wanted to leave going to the hospital right after 9p.m. He stated LVN A took the scissors and razors, and after she (LVN A) left out of his room at around 9:45 to 10 p.m., Resident #1 shut his room door and swallowed the battery that he got from the TV remote. He stated he went out of his room after he swallowed the battery and continued to blow up and said he did not feel safe at the facility and wanted to go to the hospital, and he was leaving. Resident #1 said LVN A said let her call the Doctor and they sent him out to the hospital. Resident #1 stated LVN A allowed a couple of hours to go by and he was by himself in his room. He stated he stayed in the hallway for a while and LVN A told him to calm down and that he was waking people up, but by this time his ostomy bag was leaking, his skin was burning, and he was hurting. Resident #1 stated he was sent to the hospital in a mess with feces on him and his ostomy bag was still leaking. Resident #1 stated he never told LVN A he swallowed a battery; he told the hospital 24 to 48 hours after he had gotten to the hospital that he swallowed the battery, and they rushed him to emergency. Resident #1 stated when he went into the hallway he stayed until 911 got there. In an interview on 6/29/23 at 2:46 p.m. with the DON she stated if a resident was suicidal the facility would put them on one-on-one observation and call the doctor to let them know. The DON stated the facility would call the psychiatrist and let them know as well so they can come and evaluate the resident. The DON stated she was not sure how the pharmacy in the company operates because she just started working at the facility on 5/22/23 as interim. The DON stated the staff should not leave the resident who was trying to commit suicide by themselves, and she would stay there and get the Doctor on the phone. The DON stated that was why she said if someone was suicidal, they need to be one on one observation. The DON stated she did not know what to say about the battery because the facility did not know he swallowed a battery until he came back from the hospital. The DON stated she understood that you do not turn your back on someone who is suicidal, but where there is a will there is a way, they will swallow even in your presence. In an interview on 6/29/23 at 2:57 p.m. with the Administrator, she stated she did not know what to say about the battery. In an interview on 6/29/23 at 3:00 p.m. with Unit Manager A, she stated the residents were not allowed to have razors and that the residents do not have access to razors, and they were in the supply room. Unit Manager A stated Resident #1 asked for razors today, 6/29/23 to shave himself with and she told him no and the facility would shave him. In an interview on 6/30/23 at 12:54 p.m. with the Medical Director, he stated the nursing home staffhad been aware that Resident #1 was admitted with suicide ideations, and he had been followed by psychiatry and psychology in May 2023. The Medical Director stated Resident #1 denied that the resident made any outcries that he wanted to harm himself since being admitted at the facility. The Medical Director stated he did not know why Resident #1 had scissors or razors. The Medical Director stated he did not have his pain medicine because it was running low, and they were waiting for the attending physician to send in a refill. The Medical Director stated he was not aware the medication was completely out. The Medical Director stated an ileostomy bag was for hygiene and cleanliness, but sometimes due to the person's body or the way they were it may be difficult to keep the bag adhered. The Medical Director stated they want the bag to stay adhered for cleanliness, but if the stool leakage occurs and it was left unattended it could burn the skin. In an interview on 6/30/23 at 1:35 p.m. with the DON she stated she was told Resident #1 was sent to the hospital on 6/17/23. The DON stated if a patient needs to go to the hospital it needs to be from the Doctor or NP and If a resident said they wanted to go to the hospital they have to let the Dr know what's going on and they have to give the okay to send the resident out. The DON stated if the resident was admitted into the facility that means they were not on suicidal watch. She stated the moment the resident was admitted to the facility unless they voice out, they were suicidal they have to ask them what their plan was, then follow the steps of what they need to do. The DON stated it the resident had a diagnosis, there was nothing they would do if they were not voicing that they would hurt themselves. She stated although because the resident have the history of suicidal ideations, they would get psych services involved. The DON stated Resident #1 was not care planned for suicidal ideations and she stated she could not answer why, and she would have to get the MDS Coordinator to see why. The DON stated she did not know how Resident #1 got the scissors and razors. She stated when Resident #1 returned from the hospital on 6/25/23; they did a head-to-toe assessment and documented to make sure there were no new issues. The DON stated if the hospital deemed Resident #1 competent and okay to come back to the facility, then they go by the recommendations of what the hospital asked them to do. The DON stated if the hospital said they need psych services, the facility would follow the recommendations the hospital gave them. The DON stated she did not know why they were running out of medications. The DON stated the facility had a pharmacy and the Nurses have to call the pharmacy to replenish the medication. The DON stated every pharmacy was different, with this pharmacy they need to call them within 3 days if the resident was running

Based on observation, interview and record review, the facility failed to implement their written policies and procedures to prohibit neglect for 2 of 13 residents (Resident #1 and Resident #2) reviewed for neglect. - The facility failed to implement their policy on Neglect to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness for Resident #1 and Resident #2 and when Resident #1 was admitted to the facility with suicidal ideations and multiple suicide attempts on 2/6/23 and then readmitted to the facility on [DATE] and did not receive comprehensive services to prevent further destructive behaviors. -The facility failed to care plan and put additional services in place for Resident #1 when he admitted to the facility with suicidal ideations and having multiple suicide attempts on 2/6/23 and readmitted on [DATE] after swallowing another battery. -The facility failed to initiate safety interventions when Resident #1 expressed suicidal ideations, requested to go to the hospital and was found with scissors and razors after he continuously requested medicine for his chronic pain and leaking ileostomy bag and resulted in an actual suicide attempt on 06/17/2023. -The facility failed to notify the NP that Resident #1 had a diagnosis of suicidal ideations, and that Resident #1 was found with a box with scissors and razors inside. -The facility failed to consistently change Resident #1 and Resident #2's ileostomy bag resulting in leaking of stool, burning skin and hospitalization . An Immediate Jeopardy (IJ) was identified on 07/01/23. The IJ template was provided to the facility on [DATE] at 2:45 p.m. While the IJ was removed on 07/05/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not an Immediate Jeopardy because all staff had not been trained on caring for residents with suicidal ideations, neglect, ordering pain medications timely, changing ileostomy bags, and care planning for suicidal ideations. These failures placed residents who have a diagnosis of suicidal ideations at risk of not being properly monitored, not having their immediate needs being met and possibly resulting in hospitalization or death. Findings include: Record review of the Facility's Policy on Abuse, Neglect, & Exploitation Prevention Policy & Procedure revised 9/10/2020 revealed, Our facility prohibits the abuse, mistreatment, neglect, and/or exploitation of residents. We believe that all residents have the right to be free from such actions by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving our community .Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Resident #1 Record review of Resident #1's face sheet dated 6/28/23 revealed a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of being initially admitting to the facility with suicidal ideations, systemic inflammatory response syndrome (SIRS) of Non-Infectious origin without acute organ dysfunction (exaggerated defense response of the body), cerebral palsy (disorder that affects a persons ability to maintain balance and posture), sepsis due to enterococcus, fistula of intestine (abnormal opening or intestine that allows the contents to leak to another part of the body), idiopathic peripheral autonomic neuropathy (damage of the peripheral [NAME] where cause can not be deermined), intervertebral disc degeneration, lumbar region, residual schizophrenia, scoliosis, bipolar disorder, colostomy status, major depressive disorder, and anxiety. Record review of Resident #1's Care Plan dated 6/26/23 revealed resident complains of increased pain/discomfort and is at risk for further episodes of increased pain/discomfort and injury. Goal: Resident 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. Interventions: Allow to verbalize feelings of pain/discomfort . Resident #1 has a Colostomy due to Medical Condition. Goal: Resident #1 will have no complications from ostomy site over the next 90 days. Intervention: Monitor site for swelling, pain, redness, etc.Apply Nystatin powder to Colostomy Site. Resident #1 has a diagnosis of depression with Goal: have fewer or no episodes of depression and will voice feelings about self over the next 90 days. Interventions/Tasks: Allow [Resident #1] to verbalize feelings of depression. Give medications per order-monitor labs - report abnormalities to MD. Resident #1 has a behavior problem of not waiting on staff to change his colostomy will call the police 911. Intervention: Anticipate and meet [Resident #1's] needs. Resident #1 call 911 due to meds not here. Interventions/Tasks: If reasonable, discuss [Resident #1's] behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. Further Record review of Resident #1's Care Plan dated 6/26/23 revealed he was not care planned for suicidal ideations when he admitted to the facility with the diagnosis on 2/6/23. Record review of Resident #1's Quarterly MDS dated [DATE] revealed his BIMS Summary Score was 15 indicating he was cognitively intact. Resident #1's functional status revealed walking in room and corridor did not occur, supervision with set up help only for locomotion on and off the unit and eating. Resident #1 required limited assistance with one person assisting for transfer, toilet use, and personal hygiene and he needed extensive assistance with one person physically assisting him for dressing. Record review of Resident #1's Physician Orders dated 6/30/23 revealed: Discontinue Oxycontin 20 mg ER when 30 mg tablet has arrived. One time only for 3 days dated 6/28/23 and ended 7/1/23. Oxycodone HCL Oral tablet 10 mg give 1 tablet by mouth every 4 hours related to systemic inflammatory response syndrome of non-infectious origin without acute organ dysfunction dated 4/11/23. Oxycontin Oral tablet ER 12 Hour Abuse-Deterrent 30 mg give 1 tablet orally every 12 hours for chronic pain. Oxycontin Oral Tablet ER 12 Hour Abuse-Deterrent 20 mg Give 1 tablet orally every 12 hours for chronic pain. Nystatin External Powder 100000 UNIT/GM (Nystatin (Topical)) Apply to colostomy topically three times a day for colostomy site irritated dated 04/04/23. Zinc Oxide External Ointment 20 % (Zinc Oxide (Topical)) Apply to colostomy site topically four times a day for colostomy site irritated dated 02/16/23. Record review of Resident #1's Medication Administration Record for 6/1-6/30/23 revealed: Colostomy Observation every shift Monitor Resident's colostomy. Ensure Colostomy is intact, free from s/s of infection and functioning properly. The box was blank on 6/6/23 at 6 p.m. Colostomy: Empty every shift Licensed Nurse will monitor colostomy and ensure it is emptied every shift and as needed. The box was blank on 6/6/23 at 6 p.m. Observation: Behaviors. Target Behaviors : withdrawn, crying, lack of appetite every shift Monitor Resident for Presence of Behaviors withdrawn, crying, lack of appetite. Document Yes or No to whether Behaviors were Observed. Notify MD as needed for Behaviors. The box was blank on 6/6/23 at 6 p.m. 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 for pain observation. The box was blank on 6/6/23 at 6 p.m. Skin: Protective skin barrier ointment after each incontinent episode and PRN every shift. The box was blank on 6/6/23 at 6 p.m. Nystatin External Powder 100000 UNIT/GM (Nystatin (Topical)) Apply to colostomy topically three times a day for colostomy site irritated. The box was blank on 6/6/23 at 6 p.m. Zinc Oxide External Ointment 20 % (Zinc Oxide (Topical)) Apply to colostomy site topically four times a day for colostomy site irritated. The box was blank on 6/6/23 at 9 p.m. Oxycodone HCL Oral Tablet 10 mg. The box was blank on 6/6/23 at 6 p.m. Oxycontin Oral Tablet ER 12 Hour (Oxycodone HCl). The box was blank on 6/6/23, 6/10/23, and 6/11/23 at 9 p.m. Further review of the MAR revealed no documentation to indicate Resident #1 was out of the facility on the days the MAR was blank. Record review of Resident #1's Controlled Drug Administration Record Tablet for Oxycodone IR 10 mg oral date issued 5/3/23 revealed: 6/16/23 at 9 a.m. 6/16/23 at 1 p.m. 6/16/23 at 5 p.m. 6/16/23 at 8 p.m. 6/17/23 at 1 a.m. 6/17/23 at 5 a.m. 6/17/23 at 9 a.m. 6/17/23 at 1 p.m. 6/17/23 at 5 p.m. the last dose was administered and there were 0 tablets left. Record review of Resident #1's progress note dated 6/6/23 at 2:30 a.m. by LVN E revealed, Resident is currently stable .PRN Oxycodone HCl oral tablet 10 mg administered at 7:32 p.m. and 1:32 a.m. respectively due to burning pain on skin. Record review of Resident #1's progress note dated 6/8/23 at 4:06 p.m. by LVN D revealed Resident #1 alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's progress note dated 6/9/23 at 4:56 a.m. by LVN A revealed Resident #1 alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's progress notes dated 6/11/23 at 5:54 a.m. by LVN C revealed Resident #1 called 911 because his colostomy was not change prompt, at the time of his call the nurse/writer was on break, colostomy was changed .[Resident #1] alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's Progress note dated 6/13/23 at 11:07 p.m. by LVN A revealed Confirmed new order from [Doctor] to discontinue patient PRN oxycodone HCL Oral Tablet 10 mg (Oxycodone HCL) every 4 hours. [Resident #1] started on scheduled oxycodone HCl Oral tablet 10 mg (Oxycodone HCl) every 4 hours for his pain management. Resident #1 remains oxycodone HCl oral tablet ER 20 mg (Oxycodone HCl) twice daily. Resident #1 made aware of new changes with his pain medications. Record review of Resident #1's Follow up with Physician dated 6/13/23 at 12 a.m. revealed Past Medical History: Borderline personality disorder, cerebral palsy, depressive disorder, difficult intravenous access, PTSD, self-injury behavior, schizophrenia, chronic enterocutaneous fistula, right ureteropelvic junction renal stone with intermittent obstruction .Social History: .History of multiple suicide attempts via self-mutilating behavior and ingestion of various objects .History of Present Illness: This is a [AGE] year old while male with a past history of significant for PTSD/bipolar disorder with multiple suicide attempts with self-injurious behavior and ingestion of various objects, cerebral palsy, scoliosis, and a chronic enterocutaneous fistula 2/2 self-inflicted stab wound on his abdominal wall that required exploratory laparotomy x2 and excision of infected abdominal wall mesh (11/28/20), extensive adhesiolysis, and partial small bowel resection complicated by chronic draining wound .Patient states that his chronic abdominal pain is now becoming uncontrolled. He states that he is at his wits end and expressing a desire to go back to the hospital. His colostomy continues to leak stool creating a red rash around the site. He still refuses fentanyl patch saying that he doesn't like the way it makes him feel. He is requesting to have the oxy schedule and seeing if that helps. He has appt with surgery on 6/20/23. He also mentions that he is feeling more depressed but not suicidal. Record review of Resident #1's Progress note dated 6/17/23 at 10:15 p.m. by LVN A revealed NP notified that pharmacy only send patient Oxycontin 20 mg. [Resident #1] wasn't happy and was yelling that this can't be happening. NP stated that she did notified Doctor that pharmacy did not deliver [Resident #1] Oxycontin IR 10 mg. NP said she haven't gotten a response from the Doctor yet. [Resident #1] was made aware and did reassure him that we're working on it. Record review of Resident #1's SBAR (Change of Condition) dated 6/18/23 at 12:31 a.m. by LVN A revealed: [Resident #1] complaining of extreme pain to his stomach. [Resident #1] requested to be sent out to the hospital. NP notified .[Resident #1] requested to be sent out to the hospital because he can't take it anymore because of his pain. Nurse caught [Resident #1] holding some tools in his hand. Nurse took away from patient holding 4 disposable shaving razors, a small scissors and a plastic water cover from the kitchen while he was sitting up. NP notified and approved to send him out. Patient was yelling out loud, disturbing the peace of other residents'. Cursing out loud by using different offensive words that are derogatory. Unable to calm patient down. Patient went out via 911 at 11:47 p.m. Record review of Resident #1's Local Hospital Record dated 6/23/23 revealed Pouch was leaking on arrival. Pouch was last changed on 6/19/23 wound ostomy continence note. Changed pouch. Applied marathon liquid skin protectant to peristomal, raw, denuded openings. Applied 1 piece pouch with convex barrier ostomy ring. Good seal achieved. Record review of Resident #1's Progress notes dated 6/25/23 at 7:53 p.m. by LVN B revealed Received [AGE] year-old patient in the building via EMS Stretcher 2 men crew Awake Alert and Oriented x3, with medical history of cerebral palsy, depression, scoliosis, abdominal stab wound post colostomy that been leaking for the past 4 years and known history of drug seeking behavior just discharged from [local hospital]. Upon arrival patient continue to demand for the pain medication on the same spot and called another 911 that he is going back to hospital if nobody gave him immediate attention, medication confirm and verified with the doctor, presently eyes closed in the room continue to monitor throughout the night. Record review of Resident #1's Local Hospital Record Discharge Summary dated 6/25/23 at 7:50 p.m. revealed, Reason for Visit: pain issues complained of abdomen pain from his colostomy, chronic. Takes oxycodone for pain. Nursing facility does not have his short acting oxycodone 10 mg which he gets every 4 hours only long acting 20 mg dose which he received at 9 p.m. tonight. States his colostomy bag is always leaking .His abdominal wall cellulitis may also be irritant dermatitis from the feces. He was started back on his chronic pain medications. Patient initially did not want to return to his facility. He then notified me that he swallowed a battery. Psychiatry was consulted and Cymbalta was increased to 80 mg daily. X-ray of the abdomen was completed that showed metallic cylindrical object in the left upper quadrant. Chest x-ray showed 2 cm focal opacity however he does have a skin tag in that region. GI was consulted and proceeded with EGD on 6/22 and was unable to retrieve foreign body. He was also noted to have elevated liver enzymes may be due to Cymbalta. He was continued on Cymbalta due to benefits of medication. Surgery was consulted. CT abdomen pelvis was completed that showed cylindrical metallic density within the small bowel loop in the lower mid abdomen with moderate stool burden. He was unable to pass battery. GI proceeded with colonoscopy and was able to retrieve the battery. He was restarted on regular diet which he tolerated well .Impression: Ingested foreign body-AAA battery battery-successfully removed by ileoscopy through ileostomy. Record review of Resident #1's Psychological Services Progress Note dated 6/27/23 revealed: Symptoms: (Symptoms that were focused on in this session) Psychological: depression, Physical: Physical decline, Functional/Behavioral challenges: Adjustment difficulty (illness/decline/Loss, Stressors/Changes in Mental Status: Declining health .Results of Psychotherapy: Functional improvement noted .Identified- external emotional triggers, Disposition/Rationale for continued treatment: Symptoms require more attention. In an observation and interview with Resident #1 at the facility on 6/28/23 at 1:20 p.m. revealed Resident #1 rolling around the hallway in his wheelchair. Resident #1 stated he ate a battery and he explained he had an ileostomy bag, and it was leaking. He stated it leaked all the time no matter what the facility did. Resident #1 stated he had it for 4 years and he had trouble with the facility getting ostomy bags all the time and he had trouble with them getting his PRN pain meds to him. Resident #1 stated he had several talks with Administration about these incidents asking them to tighten this up (his pain medication and ostomy bags). Resident #1 stated he spoke with Doctor's in the hospital to make things better and they said there was nothing they could do. He stated before he went to the hospital on 6/17/23, he found out his medicine (oxycodone 10 mg) had lapsed, and he told the nurse to send him to the hospital. He said he had discussions with them several times and LVN A said no they will just send him right back. Resident #1 stated with the state of mind he was in, he thought he would just do something that he had to go. He stated he was in a lot in pain with the ileostomy leaking and it burned his skin and he also had cerebral palsy and scoliosis. Resident #1 stated the state of mind he was in, he said to himself he would do what he had to do to get out of the facility. Resident #1 stated since this incident he spoke with the psych specialist at the facility and she was getting him medication for anxiety and she said if a scenario happened again and the facility ran out of meds then he (Resident #1) would tell the staff he wants to go to the hospital and he did not feel safe. Resident #1 stated since that issue happened the facility had a new unit manager and she stayed on top of the meds, and he stated he was staying on top of the meds also. Observation of Resident #1's ileostomy bag revealed it was leaking onto his brief and his skin. Resident #1 stated he felt that the facility neglected him, and he did not mean to snitch on anyone, but it is what it is. Resident #1 stated he could not remember the Nurses name. Resident #1 stated the staff said they could not make the ileostomy bag stop leaking. Resident #1 stated the ileostomy was not leaking as bad as it was yesterday. He said, the ileostomy bag leaked a lot and that was an understatement and it had burned him in the past where he had to go to the hospital. Resident #1 stated the last time he went to the hospital for the ileostomy burning his skin was a few months ago. In an interview and record review on 6/28/23 at 1:40 p.m. with Unit Manager A, she stated Resident #1 getsfrustrated about his pain meds when the facility does not get them right when they were due. Unit Manager A stated, Resident #1 was asking about his pain meds closer to 6 p.m. on 6/17/23 and he asked for the pain meds and the med aide was in another room and he got frustrated. Unit Manager A stated Oxycodone 10 mg was PRN, but they made it routine a few days before he went out. Unit Manager A stated Resident #1 went out on 6/17/23 and came back on 6/25/23. Record review of Resident #1's narcotic count sheet with Unit Manager A revealed Resident #1 did run out of Oxycontin ER 20 mg on 6/17/23 at 9 p.m. She stated he ran out of meds on 6/17/23 so no meds were given. Unit Manager A did call the local pharmacy on 6/28/23 at 2:13 p.m. and they stated Resident #1's Oxycontin ER 20 mg was delivered on 6/17/23 at 6:45 p.m. with 14 tablets. Unit Manager A stated Resident #1 ran out of Oxycodone 10mg. Record review of Resident #1's narcotic count sheet with Unit Manager A revealed the last Oxycodone 10 mg tablet was given on 6/17/23 and he had 0 pills left. Unit Manager A stated the local pharmacy stated oxycodone 10 mg was delivered on 6/18/23 at 6:32 p.m. Unit Manager A stated Resident #1 missed 1 dose of oxycodone 10 mg on 6/17/23 for 9 p.m. In an interview on 6/28/23 at 2:20 p.m. with the DON she stated thought Resident #1 called 911 on 6/17/23 and they showed up at the building. The DON stated he had not told them that he swallowed the battery. In an interview on 6/29/23 at 1:18 p.m. with LVN A she stated the Doctor messed up. She stated she got report from shift changeon 6/17/23 saying the Nurse got in touch with NP because Resident #1 ran out of meds, and they contacted the Doctor to call the medication in. LVN A stated she received report saying Unit Manager A took care of that, but the pharmacy only brought the oxycodone 20 mg and not the oxycodone 10 mg. LVN A stated the pharmacist said on 6/17/23 Resident #1 ran out of Oxycodone 10 mg and would need a new prescription. LVN A stated she got in touch with the NP and asked the NP to have the Doctor to contact LVN A. LVN A stated Resident #1 was suicidal and if he did not get his medicine, he would start doing things. She stated the Doctor did not respond back and he was supposed to call in those dosages. LVN A stated the meds came in the next day on 6/18/23. LVN A stated on 6/17/23 Resident #1 was screaming, and she realized Resident #1 was trying to cause harm to himself. She stated she told NP that Resident #1 said call 911 and the NP said call 911 . LVN A stated Resident #1 was holding some scissors and razors on 6/17/23 and she removed it from him and she continued to try to get the oxycodone 10 mg by contacting the NP. She stated she called 911 and said he was complaining of pain. LVN A stated Resident #1 was really angry and upset. He said it happened all the time that the facility ran out of his medication. LVN A stated Resident #1 was scheduled to get Oxycodone 20 mg twice a day and she went to his room saying it was his night meds 20mg for 10p.m. LVN A stated she told Resident #1 they did not have the 10 mg because they ran out of the 10 mg and was waiting for the pharmacy. She stated Resident #1 started yelling and raging screaming out of control. LVN A stated Resident #1 just got his oxycodone 20 mg long-acting meds at 9 p.m. and he started screaming and raging at 9p.m. She stated she had to leave Resident #1 to call the NP and he started yelling god dammit and saying things like he was going to harm himself. LVN A stated Resident #1 was mad the previous days because he was out of his medicine. LVN A stated Resident #1 was holding items in his hand, scissors and razors that could harm him. LVN A stated Resident #1 said he was going to harm himself. She stated Resident #1 was holding a pair of scissors, 4 disposable razors, a plastic lid from a plastic cup and he keep saying he was going to hurt himself. LVN A stated she was already aware of Resident #1's history and she took the items from him (Resident #1) and brought it to the Nurse station then she called 911 (Unknown time). LVN A stated 911 came and he told 911 he had a colostomy that was excoriated, and the stomach contents leaked out and he told 911 he was having stomach pain, the facility had been out of his meds for a few days, and he could not take it anymore and he did not want to be at the facility. She stated Resident #1 could not bear the pain and he was insisting to go to the hospital and NP said go ahead and send the resident. LVN A stated she did not know anything about a battery. She stated the only thing Resident #1 was holding in his hand were the scissors and razors and she took them away from him and called 911. LVN A stated she did not trust Resident #1. LVN A stated she did not call anyone to assist her with Resident #1 because the CNA was busy working and Resident #1 was sitting in the wheelchair crying, yelling and screaming god dammit LVN A stated the Doctor did not call in both dosages and they were supposed to call when they had 7 pills in the blister pack. LVN A stated Resident #1 had a history of trying to harm himself. LVN A stated the facility had an adequate supply for ileostomy bags and the only issue was about pain meds for Resident #1. In an interview on 6/29/23 at 1:53 p.m. with Resident #1, he stated prior to him swallowing the battery he had several conversations about having enough ostomy supplies because before the new Unit Manager got there, supplies was an issue. He stated he was having problems getting his prn pain meds when he needed, and he had several conversations with the previous Management (Administrator B). Resident #1 stated before he went to the hospital, he had gone days without his pain medication. He stated on 6/17/23, that evening he took his last prn dose of pain meds oxycodone 10 mg, and they said by the time it was time to get it again, the meds would be at the facility, and he said great. Resident #1 stated the medicine did not come in and they only brought the scheduled pain meds (oxycodone 20 mg) and he had asked for his pain meds (oxycodone 10 mg) and LVN A said the pharmacy only brought in the scheduled pain meds (oxycodone 20 mg). Resident #1 stated it was Saturday night and the next day was Sunday and if they run out on a Saturday you do not get meds until Monday. Resident #1 stated the med aide that day on 6/17/23 said it was his last dose at 5:30 to 6 p.m. and they said his meds should be in by the time the next dose was due. He stated he told the late-night nurse (LVN A) he was out of here (the facility) and that he was going to the hospital where they could take care of him. Resident #1 stated LVN A said let her give him (Resident #1) the scheduled dose and she said she would get a hold of the Doctor and he should let her see what she could do. Resident #1 stated the ostomy supply kept running out, there was the issue with getting prn meds and them running out of pain medication. He said, he had it and he blew up. Resident #1 stated he spoke with Unit Manager A before and he tried to solve the issue. Resident #1 stated it was a little after 9 p.m. on 6/17/23 when LVN A took the scissors from him at 9:45 to 10 p.m. when she saw them in his hand, and he said nothing nothing. Resident #1 stated in the box was razors, scissors and he had hidden batteries in his pocket. Resident #1 stated it was after 9 p.m. when she gave the scheduled meds, and she was having trouble getting hold of the Doctor. Resident #1 stated he told LVN A he wanted to get out of the facility, and she said if you just go for pain meds, they will give you one dose and send him right back. Resident #1 stated he had already told LVN A that he wanted to leave going to the hospital right after 9p.m. He stated LVN A took the scissors and razors, and after she (LVN A) left out of his room at around 9:45 to 10 p.m., Resident #1 shut his room door and swallowed the battery that he got from the TV remote. He stated he went out of his room after he swallowed the battery and continued to blow up and said he did not feel safe at the facility and wanted to go to the hospital, and he was leaving. Resident #1 said LVN A said let her call the Doctor and they sent him out to the hospital. Resident #1 stated LVN A allowed a couple of hours to go by and he was by himself in his room. He stated he stayed in the hallway for a while and LVN A told him to calm down and that he was waking people up, but by this time his ostomy bag was leaking, his skin was burning, and he was hurting. Resident #1 stated he was sent to the hospital in a mess with feces on him and his ostomy bag was still leaking. Resident #1 stated he never told LVN A he swallowed a battery; he told the hospital 24 to 48 hours after he had gotten to the hospital that he swallowed the battery, and they rushed him to emergency. Resident #1 stated when he went into the hallway he stayed until 911 got there. In an interview on 6/29/23 at 2:46 p.m. with the DON she stated if a resident was suicidal the facility would put them on one-on-one observation and call the doctor to let them know. The DON stated the facility would call the psychiatrist and let them know as well so they can come and evaluate the resident. The DON stated she was not sure how the pharmacy in the company operates because she just started working at the facility on 5/22/23 as interim. The DON stated the staff should not leave the resident who was trying to commit suicide by themselves, and she would stay there and get the Doctor on the phone. The DON stated that was why she said if someone was suicidal, they need to be one on one observation. The DON stated she did not know what to say about the battery because the facility did not know he swallowed a battery until he came back from the hospital. The DON stated she understood that you do not turn your back on someone who is suicidal, but where there is a will there is a way, they will swallow even in your presence. In an interview on 6/29/23 at 2:57 p.m. with the Administrator, she stated she did not know what to say about the battery. In an interview on 6/29/23 at 3:00 p.m. with Unit Manager A, she stated the residents were not allowed to have razors and that the residents do not have access to razors, and they were in the supply room. Unit Manager A stated Resident #1 asked for razors today, 6/29/23 to shave himself with and she told him no and the facility would shave him. In an interview on 6/30/23 at 12:54 p.m. with the Medical Director, he stated the nursing home staffhad been aware that Resident #1 was admitted with suicide ideations, and he had been followed by psychiatry and psychology in May 2023. The Medical Director stated Resident #1 denied that the resident made any outcries that he wanted to harm himself since being admitted at the facility. The Medical Director stated he did not know why Resident #1 had scissors or razors. The Medical Director stated he did not have his pain medicine because it was running low, and they were waiting for the attending physician to send in a refill. The Medical Director stated he was not aware the medication was completely out. The Medical Director stated an ileostomy bag was for hygiene and cleanliness, but sometimes due to the person's body or the way they were it may be difficult to keep the bag adhered. The Medical Director stated they want the bag to stay adhered for cleanliness, but if the stool leakage occurs and it was left unattended it could burn the skin. In an interview on 6/30/23 at 1:35 p.m. with the DON she stated she was told Resident #1 was sent to the hospital on 6/17/23. The DON stated if a patient needs to go to the hospital it needs to be from the Doctor or NP and If a resident said they wanted to go to the hospital they have to let the Dr know what's going on and they have to give the okay to send the resident out. The DON stated if the resident was admitted into the facility that means they were not on suicidal watch. She stated the moment the resident was admitted to the facility unless they voice out, they were suicidal they have to ask them what their plan was, then follow the steps of what they need to do. The DON stated it the resident had a diagnosis, there was nothing they would do if they were not voicing that they would hurt themselves. She stated although because the resident have the history of suicidal ideations, they would get psych services involved. The DON stated Resident #1 was not care planned for suicidal ideations and she stated she could not answer why, and she would have to get the MDS Coordinator to see why. The DON stated she did not know how Resident #1 got the scissors and razors. She stated when Resident #1 returned from the hospital on 6/25/23; they did a head-to-toe assessment and documented

Based on observation, interview, and record review the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment plan of care for 1 of 13 residents (Resident #1) reviewed for comprehensive care plan in that The Facility failed to care plan for Resident #1 having suicidal ideations upon admission to the facility on [DATE] and again when he returned on 6/25/23 from the hospital after having swallowing a battery was not care planned or monitored for suicidal ideations. An Immediate Jeopardy (IJ) was identified on 07/01/23 at 2:45 p.m. While the IJ was lowered on 07/05/23, the facility remained out of compliance at a severity level of actual harm that is not an Immediate Jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal. This failure placed residents who have a diagnosis of suicidal ideations at risk of not being properly monitored, not having their immediate needs being met and possibly resulting in hospitalization or death. Findings include: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the diagnosis of systemic inflammatory response syndrome (SIRS) of Non-Infectious origin without acute organ dysfunction, cerebral palsy, sepsis due to enterococcus, fistula of intestine, idiopathic peripheral autonomic neuropathy, intervertebral disc degeneration, lumbar region, residual schizophrenia, scoliosis, bipolar disorder, colostomy status, major depressive disorder, anxiety, and initially admitted to the facility with suicidal ideations. Record review of Resident #1's Care Plan dated 6/26/23 revealed resident complains of increased pain/discomfort and is at risk for further episodes of increased pain/discomfort and injury. Goal: Resident 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. Interventions: Allow to verbalize feelings of pain/discomfort . Resident #1 has a Colostomy due to Medical Condition. Goal: Resident #1 will have no complications from ostomy site over the next 90 days. Intervention: Monitor site for swelling, pain, redness, etc .Apply Nystatin powder to Colostomy Site. Resident #1 has a diagnosis of depression with Goal: have fewer or no episodes of depression and will voice feelings about self over the next 90 days. Interventions/Tasks: Allow [Resident #1] to verbalize feelings of depression. Give medications per order-monitor labs - report abnormalities to MD. Resident #1 has a behavior problem of not waiting on staff to change his colostomy will call the police 911. Intervention: Anticipate and meet [Resident #1's] needs. Resident #1 call 911 due to meds not here. Interventions/Tasks: If reasonable, discuss [Resident #1's] behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. Record review of Resident #1's Care Plan revealed he was not care planned for suicidal ideations when he admitted to the facility with the diagnosis on 2/6/23. Record review of Resident #1's Quarterly MDS dated [DATE] revealed Cognitive Pattern BIMS Summary Score was 15 indicating cognitively intact. Resident #1's functional status revealed walking in room and corridor did not occur, supervision with set up help only for locomotion on and off the unit, and eating. Resident #1 required limited assistance with one person assisting for transfer, toilet use, and personal hygiene and he needed extensive assistance with one person physically assisting him for dressing. Record review of Resident #1's Physician Orders dated 6/30/23 revealed: Discontinue Oxycontin 20 mg ER when 30 mg tablet has arrived. One time only for 3 days dated 6/28/23 and ended 7/1/23. Oxycodone HCL Oral tablet 10 mg give 1 tablet by mouth every 4 hours related to systemic inflammatory response syndrome of non-infectious origin without acute organ dysfunction dated 4/11/23. Oxycontin Oral tablet ER 12 Hour Abuse-Deterrent 30 mg give 1 tablet orally every 12 hours for chronic pain. Oxycontin Oral Tablet ER 12 Hour Abuse-Deterrent 20 mg Give 1 tablet orally every 12 hours for chronic pain. Record review of Resident #1's Controlled Drug Administration Record Tablet for Oxycodone IR 10 mg oral date issued 5/3/23 revealed: 6/16/23 at 9 a.m. 6/16/23 at 1 p.m. 6/16/23 at 5 p.m. 6/16/23 at 8 p.m. 6/17/23 at 1 a.m. 6/17/23 at 5 a.m. 6/17/23 at 9 a.m. 6/17/23 at 1 p.m. 6/17/23 at 5 p.m. the last dose was administered and there were 0 tablets left. Record review of Resident #1's SBAR (Change of Condition) dated 6/18/23 at 12:31 a.m. by LVN A revealed: [Resident #1] complaining of extreme pain to his stomach. [Resident #1] requested to be sent out to the hospital. NP notified .[Resident #1] requested to be sent out to the hospital because he can't take it anymore because of his pain. Nurse caught [Resident #1] holding some tools in his hand. Nurse took away from patient holding 4 disposable shaving razors, a small scissors and a plastic water cover from the kitchen while he was sitting up. NP notified and approved to send him out. Patient was yelling out loud, disturbing the peace of other residents'. Cursing out loud by using different offensive words that are derogatory. Unable to calm patient down. Patient went out via 911 at 11:47 p.m. Record review of Resident #1's Progress notes dated 6/25/23 at 7:53 p.m. by LVN B revealed Received [AGE] year-old patient in the building via EMS Stretcher 2 men crew Awake Alert and Oriented x3, with medical history of cerebral palsy, depression, scoliosis, abdominal stab wound post colostomy that been leaking for the past 4 years and known history of drug seeking behavior just discharged from [local hospital]. Upon arrival patient continue to demand for the pain medication on the same spot and called another 911 that he is going back to hospital if nobody gave him immediate attention, medication confirm and verified with the doctor, presently eyes closed in the room continue to monitor throughout the night. Record review of Resident #1's Progress note dated 6/17/23 at 10:15 p.m. by LVN A revealed NP notified that pharmacy only send patient Oxycontin 20 mg. [Resident #1] wasn't happy and was yelling that this can't be happening. NP stated that she did notified Doctor that pharmacy did not deliver [Resident #1] Oxycontin IR 10 mg. NP said she haven't gotten a response from the Doctor yet. [Resident #1] was made aware and did reassure him that we're working on it. Record review of Resident #1's Progress note dated 6/13/23 at 11:07 p.m. by LVN A revealed Confirmed new order from [Doctor] to discontinue patient PRN oxycodone HCL Oral Tablet 10 mg (Oxycodone HCL) every 4 hours. [Resident #1] started on scheduled oxycodone HCl Oral tablet 10 mg (Oxycodone HCl) every 4 hours for his pain management. Resident #1 remains oxycodone HCl oral tablet ER 20 mg (Oxycodone HCl) twice daily. Resident #1 made aware of new changes with his pain medications. Record review of Resident #1's Follow up with Physician dated 6/13/23 at 12 a.m. revealed Past Medical History: Borderline personality disorder, cerebral palsy, depressive disorder, difficult intravenous access, PTSD, self injury behavior, schizophrenia, chronic enterocutaneous fistula, right ureteropelvic junction renal stone with intermittent obstruction .Social History: .History of multiple suicide attempts via self-mutilating behavior and ingestion of various objects .History of Present Illness: This is a 43-yeaar old while male with a past history of significant for PTSD/bipolar disorder with multiple suicide attempts with self injurious behavior and ingestion of various objects, cerebral palsy, scoliosis, and a chronic enterocutaneous fistula 2/2 self-inflicted stab wound on his abdominal wall that required exploratory laparotomy x2 and excision of infected abdominal wall mesh (11/28/20), extensive adhesiolysis, and partial small bowel resection complicated by chronic draining wound .Patient states that his chronic abdominal pain is now becoming uncontrolled. He states that he is at his wits end and expressing a desire to go back to the hospital. His colostomy continues to leak stool creating a red rash around the site. He still refuses fentanyl patch saying that he doesn't like the way it makes him feel. He is requesting to have the oxy schedule and seeing if that helps. He has appt with surgery on 6/20/23. He also mentions that he is feeling more depressed but not suicidal. Record review of Resident #1's progress notes dated 6/11/23 at 5:54 a.m. by LVN C revealed Resident #1 called 911 because his colostomy was not change prompt, at the time of his call the nurse/writer was on break, colostomy was changed .[Resident #1] alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's progress note dated 6/9/23 at 4:56 a.m. by LVN A revealed Resident #1 alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's progress note dated 6/8/23 at 4:06 p.m. by LVN D revealed Resident #1 alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's progress note dated 6/6/23 at 2:30 a.m. by LVN E revealed, Resident is currently stable .PRN Oxycodone HCl oral tablet 10 mg administered at 7:32 p.m. and 1:32 a.m. respectively due to burning pain on skin. Record review of Resident #1's Local Hospital Record Discharge Summary dated 6/25/23 at 7:50 p.m. revealed, Reason for Visit: pain issues complained of abdomen pain from his colostomy, chronic. Takes oxycodone for pain. Nursing facility does not have his short acting oxycodone 10 mg which he gets every 4 hours only long acting 20 mg dose which he received at 9 p.m. tonight. States his colostomy bag is always leaking .His abdominal wall cellulitis may also be irritant dermatitis from the feces. He was started back on his chronic pain medications. Patient initially did not want to return to his facility. He then notified me that he swallowed a battery. Psychiatry was consulted and Cymbalta was increased to 80 mg daily. X-ray of the abdomen was completed that showed metallic cylindrical object in the left upper quadrant. Chest x-ray showed 2 cm focal opacity however he does have a skin tag in that region. GI was consulted and proceeded with EGD on 6/22 and was unable to retrieve foreign body. He was also noted to have elevated liver enzymes may be due to Cymbalta. He was continued on Cymbalta due to benefits of medication. Surgery was consulted. CT abdomen pelvis was completed that showed cylindrical metallic density within the small bowel loop in the lower mid abdomen with moderate stool burden. He was unable to pass battery. GI proceeded with colonoscopy and was able to retrieve the battery. He was restarted on regular diet which he tolerated well .Impression: Ingested foreign body-AAA battery battery-successfully removed by ileoscopy through ileostomy. Record review of Resident #1's Local Hospital Record dated 6/23/23 revealed Pouch was leaking on arrival. Pouch was last changed on 6/19/23 wound ostomy continence note. Changed pouch. Applied marathon liquid skin protectant to peristomal, raw, denuded openings. Applied 1 piece pouch with convex barrier ostomy ring. Good seal achieved. Record review of Resident #1's Psychological Services Progress Note dated 6/27/23 revealed: Symptoms: (Symptoms that were focused on in this session) Psychological: depression, Physical: Physical decline, Functional/Behavioral challenges: Adjustment difficulty (illness/decline/Loss, Stressors/Changes in Mental Status: Declining health .Results of Psychotherapy: Functional improvement noted .Identified- external emotional triggers, Disposition/Rationale for continued treatment: Symptoms require more attention. In an observation and interview with Resident #1 on 6/28/23 at 1:20 p.m. revealed Resident #1 rolling around the hallway. Resident #1 stated he ate a battery and he explained he had an ileostomy bag and it was leaking and it leaked all the time no matter what the facility did. Resident #1 stated he had it for 4 years and he had trouble with the facility getting ostomy bags all the time and he had trouble with them getting his PRN pain meds to him. Resident #1 stated he had swallowed a battery before. Resident #1 stated he had several talks with Administration about these incidents asking them to tighten this up (his pain medication and ostomy bags). Resident #1 stated he spoke with Doctor's in the hospital to make things better and they said it was nothing they could do. He stated before he went to the hospital on 6/17/23, he found out his medicine (oxycodone 10 mg) had lapsed and he told the nurse to send him to the hospital and that he had discussions with them several times and she said no they will just send him right back. Resident #1 stated with the state of mind he was in, he thought he would just do something that he had to go. He stated he was in a lot in pain with the ileostomy leaking and it burned his skin and he also had cerebral palsy and scoliosis. Resident #1 stated the state of mind he was in, he said to himself he would do what he had to do what to get out of the facility. Resident #1 stated since this incident he spoke with the psych specialist at the facility and she was getting him medication for anxiety and she said if a scenario happened again and the facility ran out of meds then he (Resident #1) would tell the staff he wants to go to the hospital and he did not feel safe so he can get what he needed done. Resident #1 stated since that issue happened the facility had a new unit manager and she stayed on top of the meds and he stated he was staying on top of the meds also. Observation of Resident #1's ileostomy bag revealed it was leaking onto his brief and his skin. Resident #1 stated he felt that the facility neglected him and he did not mean to snitch on anyone but it is what it is. Resident #1 stated he could not remember the Nurses name. Resident #1 stated the staff say they could not make the ileostomy bag stop leaking. Resident #1 stated the ileostomy was not leaking as bad as it was yesterday. He said the ileostomy bag leaked a lot and that was an understatement and it had burned him in the past where he had to go to the hospital. Resident #1 stated the last time he went to the hospital for the ileostomy burning his skin was a few months ago. In an interview and record review on 6/28/23 at 1:40 p.m. with Unit Manager A she stated Resident #1 was frustrated about his pain meds when they do not get them right when they are due. Unit Manager A stated Resident #1 was asking about his pain meds closer to 6p.m. and he asked for the pain meds and the med aide was in another room and he got frustrated. One med was PRN, but they made it routine a few days before he went out. Unit Manager A stated Resident #1 went out on 6/17/23 and came back on 6/25/23. Record review of Resident #1's narcotic count sheet with Unit Manager A revealed Resident #1 did run out of Oxycontin ER 20 mg on 6/17/23 at 9 p.m. She stated he ran out of meds on 6/17/23 so no meds were given. Unit Manager A did call the local pharmacy at 2:13 p.m. and they stated Resident #1's Oxycontin ER 20 mg was delivered on 6/17/23 at 6:45 p.m. with 14 tablets. Unit Manager A stated Resident #1 ran out of Oxycodone 10mg. Observation of Resident #1's narcotic count sheet revealed the last tablet was given on 6/17/23 and he had 0 pills left. Unit Manager A stated the local pharmacy stated oxycodone 10 mg was delivered on 6/18/23 at 6:32 p.m. Unit Manager A stated Resident #1 missed 1 dose of oxycodone 10 mg on 6/17/23 for 9 p.m. In an interview on 6/28/23 at 2:20 p.m. with the DON she stated Resident #1 called 911 and they showed up at the building. The DON stated he had not told them that he swallowed the battery. In an interview on 6/29/23 at 1:18 p.m. with LVN A she stated the Doctor messed up. She stated she got report from shift change saying the Nurse got in touch with NP because Resident #1 ran out of meds and they contacted the Doctor to call the medication in. LVN A stated she received report saying Unit Manager A took care of that, but the pharmacy only brought the oxycodone 20 mg and not the oxycodone 10 mg. LVN A stated the pharmacist said Resident #1 ran out of Oxycodone 10 mg and would need a new prescription. LVN A stated she got in touch with the NP and asked the NP to have the Doctor to contact LVN A. LVN A stated Resident #1 was suicidal and if he did not get his medicine he would start doing things. She stated the Doctor did not respond back and he was supposed to call in those dosages. LVN A stated the meds came in the next day on 6/18/23. LVN A stated Resident #1 was screaming, and she realized Resident #1 was trying to cause harm to himself. She stated she told NP and said Resident #1 said call 911 and the NP said call 911 . LVN A stated Resident #1 was holding some scissors and razors and she removed it from him. She stated she called 911 and said he was complaining of pain. LVN A stated Resident #1 was really angry and upset and he said it happened all the time that the facility ran out of his medication. LVN A stated Resident #1 was scheduled to get 20 mg twice a day and she went to his room saying it was his night meds 20mg for 10p.m. LVN A stated she told Resident #1 the did not have the 10 mg because they ran out of the 10 mg and was waiting for the pharmacy. She stated Resident #1 started yelling and raging screaming out of control. LVN A stated Resident #1 just got his oxycodone 20 mg long acting meds at 9 p.m. and he started screaming and raging at 9p.m. She stated she had to leave Resident #1 to call the NP and he started yelling god dam it and saying things like he was going to harm himself. LVN A stated Resident #1 was mad the previous days because he was out of his medicine. LVN A stated Resident #1 was holding items in his hand, scissors and razors that could harm him. LVN A stated Resident #1 said he was going to harm himself. She stated Resident #1 was holding a pair of scissors, 4 disposable razors, a plastic lid from a plastic cup and he keep saying he was going to hurt himself. LVN A stated she was already aware of Resident #1's history and she took the items from him (Resident #1) and brought it to the Nurse station then she called 911 (Unknown time). LVN A stated 911 came and he told 911 he had a colostomy that was excoriated, and the stomach contents leaked out and he told 911 he was having stomach pain, the facility had been out of his meds for a few days and he could not take it anymore and he did not want to be at the facility. She stated Resident #1 could not bear the pain and he was insisting to go to the hospital and NP said go ahead and send the resident. LVN A stated she did not know anything about a battery. She stated the only thing Resident #1 was holding in his hand were the scissors and razors and she took them away from him and called 911. LVN A stated she did not trust Resident #1. LVN A stated she did not call anyone to assist her with Resident #1 because the CNA was busy working and Resident #1 was sitting in the wheelchair crying, yelling and screaming god dam it, god dam it, god dam it. LVN A stated Resident #1 had not received oxycontin for 2 days and he told the previous shift and Unit Manager tried to take care of the meds. LVN A stated she called the pharmacy and they said they need a new prescription, so she called the NP. LVN A stated the Doctor did not call in both dosages and they were supposed to call when they have 7 pills in the blister pack. LVN A stated Resident #1 had a history of trying to harm himself. LVN A stated the facility had an adequate supply for ileostomy bags and the only issue was about pain meds for Resident #1. In an interview on 6/29/23 at 1:53 p.m. with Resident #1 he stated prior to this happening he had several conversations about having enough ostomy supplies because before the new Unit Manager got here supplies was an issue. He stated he was having problems getting his prn pain meds when he needed and he had several conversations with the previous Management (Administrator B). Resident #1 stated before he went to the hospital he has gone days without his pain medication. He stated on 6/17/23, that evening he took his last prn dose of pain meds oxycodone 10 mg and they said by the time it was time to get it again, the meds would be at the facility and he said great. Resident #1 stated the medicine did not come in and they only brought the scheduled pain meds (oxycodone 20 mg) and he had asked for his pain meds (oxycodone 10 mg) and LVN A said the pharmacy only brought in the scheduled pain meds (oxycodone 20 mg). Resident #1 stated it was Saturday night and the next day was Sunday and if they run out on a Saturday you do not get meds until Monday. Resident #1 stated the med aide that day said it was his last dose at 5:30 to 6 p.m. and they said his meds should be in by the time the next dose is due. He stated he told the late night nurse (LVN A) he was out of here (the facility) and that he was going to the hospital where they could take care of him. Resident #1 stated LVN A said let her give him (Resident #1) the scheduled dose and she said she would get a hold of the Doctor and he should let her see what she could do. Resident #1 stated the ostomy supply kept running out, there was the issue with getting prn meds and them running out of pain medication. He said he had it and he blew up. Resident #1 stated he spoke with Unit Manager A before and he tried to solve the issue. It was a little after 9 p.m. He stated LVN A took the scissors from him at 9:45 to 10 p.m. when she saw them in his hand and he said nothing nothing. Resident #1 stated in the box was razors and scissors and he had hidden batteries in his pocket. Resident #1 stated it was after 9 p.m. when she gave the scheduled meds and she was having trouble getting hold of the Doctor. Resident #1 stated he told LVN A he wanted to get out of the facility and she said if you just go for pain meds they will give you one dose and send him right back. Resident #1 stated he had already told LVN A that he wanted to leave going to the hospital right after 9p.m. He stated LVN A took the scissors and razors, and after she (LVN A) left out of his room at around 9:45 to 10 p.m., Resident #1 shut his room door and swallowed the battery. He stated he went out of his room after he swallowed the battery and continued to blow up and said he did not feel safe at the facility and wanted to go to the hospital and he was leaving. Resident #1 said that's fine, let her call the Doctor and they sent him out to the hospital. Resident #1 stated LVN A allowed a couple of hours to go by and he was by himself in his room. He stated he stayed in the hallway for a while and LVN A told him to calm down and that he was waking people up, but by this time his ostomy bag was leaking, his skin was burning and he was hurting. Resident #1 stated he was sent to the hospital in a mess with feces on him and his ostomy bag was still leaking. Resident #1 stated he never told LVN A he swallowed a battery, he told the hospital 24 to 48 hours after he had gotten to the hospital that he swallowed the battery and they rushed him to emergency. Resident #1 stated when he went into the hallway he stayed until 911 got there. In an interview on 6/29/23 at 3 p.m. with Unit Manager A she stated the residents were not allowed to have razors and that the residents do not have access to razors and they are in the supply room. Unit Manager A stated Resident #1 asked for razors today, 6/29/23 to shave himself with and she told him no and the facility would shave him. In an interview on 6/30/23 at 12:54 p.m. with the Medical Director he stated the team had been aware that Resident #1 was admitted with suicide ideations and he had been followed by psychiatry and psychology in May 2023. The Medical Director stated Resident #1 denied that the resident made any outcries that he wanted to harm himself since being admitted at the facility. The Medical Director stated he did not know why Resident #1 had scissors or razors. The Medical Director stated he did not have his pain medicine because it was running low and they were waiting for the attending physician to send in a refill. The Medical Director stated he was not aware the medication was completely out. The Medical Director stated an ileostomy bag is for hygiene and cleanliness, but sometimes due to the persons body or the way they are it may be difficult to keep the bag adhered. The Medical Director stated they want the bag to stay adhered for cleanliness, but if the stool leakage occurs and its left unattended it could burn the skin. In an interview on 6/30/23 at 1:35 p.m. with the DON she stated she was told Resident #1 was sent to the hospital. The DON stated if a patient needs to go to the hospital it needs to be from the Doctor or NP and If a resident said they wanted to go to the hospital they have to let the Dr know what's going on and they have to give the okay to send the resident out. The DON stated if the resident was admitted into the facility that means they are not on suicidal watch. She stated the moment the resident was admitted to the facility unless they voice out they are suicidal they have to ask them what their plan is then follow the steps of what they need to do. The DON stated it the resident had a diagnosis, there was nothing they would do if they were not voicing that they would hurt themselves. She stated although because they have the history of, they would get psych services involved. The DON stated Resident #1 was not care planned for suicidal ideations and she stated she could not answer why and she would have to get the MDS Coordinator to see why. The DON stated she did not know how Resident #1 got the scissors and razors. She stated when Resident #1 returned from the hospital; they did a head to toe assessment and documented to make sure there were no new issues. The DON stated if the hospital deemed Resident #1 competent and okay to come back to the facility, then they go by the recommendations of what the hospital asked them to do. The DON stated if the hospital said they need psych services, the facility would follow the recommendations the hospital gave them. The DON stated she did not know why they were running out of medications. The DON stated the facility had a pharmacy and the Nurses now to call the pharmacy to replenish the medication. The DON stated every pharmacy was different, with this pharmacy they need to call them within 3 days if the resident was running out of medications unless the PRN medication had a 14 day stop date. In an interview on 6/30/23 at 1:50 p.m. with the NP she stated Resident #1 was mentally competent but was in a lot of general pain. She stated Resident #1 was on oxycodone ER release every 12 hours (long acting) and oxycodone 10 mg (a short acting one). The NP stated when she saw Resident #1 he sat in the wheelchair and he looked like he was in a lot of pain. She stated she thought he was used to getting a lot of narcotic meds. The NP stated Resident #1 recently requested to go to the hospital because he ran out of oxycodone. The NP stated the hospital found Resident #1 with a UTI and they treated him with antibiotics. The NP stated when she saw Resident #1, he said he did not want to deal with the pain and he did not want to deal with this kind of life. The NP stated Resident #1 requested to be on hospice, but she was not sure if hospice would accept him. The NP stated Resident #1 did not mention to her that he wanted to harm himself. She stated Resident #1 said he did not want to deal with this kind of pain in his life. The NP stated she spoke with Resident #1 and he was calm and smiling. The NP stated the day he was sent out to the hospital the nurse (LVN A) told her Resident #1 was screaming and threw stuff at her (LVN A) and asked to go to the hospital. The NP stated it was 2 weeks ago on Saturday, 6/17/23 and Resident #1 said he was in a lot of pain. The NP stated he received the pain medication every 4 hours and every 12 hrs. The NP stated she did not know Resident #1 was diagnosed with suicidal ideations. She stated she just started seeing Resident #1 and she just started working at the facility about 3 weeks ago. The NP stated she did not see any documents of suicidal ideations. The NP stated if she was aware she would have put in an order for transfer to psychiatric hospital because Resident #1 needed inpatient psych and therapy. She stated if she saw that she would have asked the nurse to send him to behavioral hospital. The NP stated on 6/17/23, LVN A said Resident #1 was agitated and aggressive. She stated the nurses should document it and give it to the hospital and the hospital should put a psychiatric consult for an inpatient unit. The NP stated Resident #1 was not safe to stay and he needed really close monitoring with that kind of behavior, but at the facility no one can sit with him 24/7. She stated if Resident #1 had that kind of intention it's really hard to prevent it. In an interview on 6/30/23 at 2:07 p.m. with CNA A she stated the facility did not make any changes for Resident #1 when he returned from the hospital. CNA A stated the staff were told to make sure they do not go in the room alone because he can get a little cranky. CNA A stated when Resident #1 did not have his medicine he starts worrying. In an interview on 6/30/23 at 2:20 p.m. with LVN F she stated Resident #1 when he did not have his meds he was in so much pain because of leakage from his ostomy bag. She stated on 6/17/23, she was working and his pain meds were not in the building and he stated he was suicidal. LVN F stated when Resident #1 came back from the hospital she did see him and they made sure that he had his meds in stock and they checked his colostomy. LVN F stated when everything was in place and Resident #1 was assured he had his pain meds he is okay and now they got his pain medication scheduled instead of I being PRN. She stated they scheduled meds so it gives him ease so he knows he has his meds with no additional worry. When he does not have his meds he is not calm and in pain and it gives him a lack of hope. LVN F stated she was leaving the facility late that day and she heard Resident #1 was attempting to hurt himself. LVN F stated she never left the facility at 630 p.m. when her shift ended, but she normally left at 7 p.m. or 7:30 p.m. In an interview on 6/30/23 at 2:29 p.m. with CNA B she stated when Resident #1 did not get his pain meds he was upset and wants to go to the hospital. CNA B stated she heard Resident #1 say he did not want to be at the facility and that he was not happy. CNA B stated the facility never gave her special instructions for Resident #1. In an interview on 6/30/23 at 2:36 p.m. with the MDS Coordinator she stated when Resident #1 was admitted to the facility there were 2 MDS Nurses, one does skilled and the other does long term. The MDS Coordinator stated they just got a violation from the State for care plans. The MDS Coordinator stated they were updating all the previous care plans and she did not know how Resident #1 was over looked and why he was not care planned for suicidal ideations. She stated if [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 13 residents reviewed for accidents, hazards, and supervision. -The facility failed to provide adequate supervision for Resident #1 to prevent harm from suicidal ideations and self-injurious behaviors that resulted in him swallowing a battery, having a plan to swallow razors, and being hospitalized . -The facility failed to adequately educate staff on caring for residents with diagnosis of suicidal ideations and self-harming behaviors. -The facility failed to care plan and put additional services in place for Resident #1 when he admitted to the facility with suicidal ideations and having multiple suicide attempts on 2/6/23 and readmitted on [DATE] after swallowing another battery. An Immediate Jeopardy (IJ) was identified on 06/30/23. The IJ template was provided to the facility on [DATE] at 2:59 p.m. While the IJ was removed on 07/05/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not an Immediate Jeopardy because all staff had not been trained on accidents and supervision, caring for residents with suicidal ideations, neglect, ordering pain medications timely, changing ileostomy bags, and care planning for suicidal ideations. These failures placed residents who have a diagnosis of suicidal ideations at risk of not being properly monitored, not having their immediate needs being met and possibly resulting in hospitalization or death. Findings include: Record review of Resident #1's face sheet dated 6/28/23 revealed a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of being initially admitting to the facility with suicidal ideations, systemic inflammatory response syndrome (SIRS) of Non-Infectious origin without acute organ dysfunction (exaggerated defense response of the body), cerebral palsy (disorder that affects a persons ability to maintain balance and posture), sepsis due to enterococcus, fistula of intestine (abnormal opening or intestine that allows the contents to leak to another part of the body), idiopathic peripheral autonomic neuropathy (damage of the peripheral nerves where cause can not be deermined), intervertebral disc degeneration, lumbar region, residual schizophrenia, scoliosis, bipolar disorder, colostomy status, major depressive disorder, and anxiety. Record review of Resident #1's Care Plan dated 6/26/23 revealed resident complains of increased pain/discomfort and is at risk for further episodes of increased pain/discomfort and injury. Goal: Resident 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. Interventions: Allow to verbalize feelings of pain/discomfort . Resident #1 has a Colostomy due to Medical Condition. Goal: Resident #1 will have no complications from ostomy site over the next 90 days. Intervention: Monitor site for swelling, pain, redness, etc.Apply Nystatin powder to Colostomy Site. Resident #1 has a diagnosis of depression with Goal: have fewer or no episodes of depression and will voice feelings about self over the next 90 days. Interventions/Tasks: Allow [Resident #1] to verbalize feelings of depression. Give medications per order-monitor labs - report abnormalities to MD. Resident #1 has a behavior problem of not waiting on staff to change his colostomy will call the police 911. Intervention: Anticipate and meet [Resident #1's] needs. Resident #1 call 911 due to meds not here. Interventions/Tasks: If reasonable, discuss [Resident #1's] behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. Further Record review of Resident #1's Care Plan dated 6/26/23 revealed he was not care planned for suicidal ideations when he admitted to the facility with the diagnosis on 2/6/23. Record review of Resident #1's Quarterly MDS dated [DATE] revealed his BIMS Summary Score was 15 indicating he was cognitively intact. Resident #1's functional status revealed walking in room and corridor did not occur, supervision with set up help only for locomotion on and off the unit and eating. Resident #1 required limited assistance with one person assisting for transfer, toilet use, and personal hygiene and he needed extensive assistance with one person physically assisting him for dressing. Record review of Resident #1's Physician Orders dated 6/30/23 revealed: Discontinue Oxycontin 20 mg ER when 30 mg tablet has arrived. One time only for 3 days dated 6/28/23 and ended 7/1/23. Oxycodone HCL Oral tablet 10 mg give 1 tablet by mouth every 4 hours related to systemic inflammatory response syndrome of non-infectious origin without acute organ dysfunction dated 4/11/23. Oxycontin Oral tablet ER 12 Hour Abuse-Deterrent 30 mg give 1 tablet orally every 12 hours for chronic pain. Oxycontin Oral Tablet ER 12 Hour Abuse-Deterrent 20 mg Give 1 tablet orally every 12 hours for chronic pain. Record review of Resident #1's Medication Administration Record for 6/1-6/30/23 revealed: Observation: Behaviors. Target Behaviors : withdrawn, crying, lack of appetite every shift Monitor Resident for Presence of Behaviors withdrawn, crying, lack of appetite. Document Yes or No to whether Behaviors were Observed. Notify MD as needed for Behaviors. The box was blank on 6/6/23 at 6 p.m. 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 for pain observation. The box was blank on 6/6/23 at 6 p.m. Oxycodone HCL Oral Tablet 10 mg. The box was blank on 6/6/23 at 6 p.m. Oxycontin Oral Tablet ER 12 Hour (Oxycodone HCl). The box was blank on 6/6/23, 6/10/23, and 6/11/23 at 9 p.m. Further review of the MAR revealed no documentation to indicate Resident #1 was out of the facility on the days the MAR was blank. Record review of Resident #1's Controlled Drug Administration Record Tablet for Oxycodone IR 10 mg oral date issued 5/3/23 revealed: 6/16/23 at 9 a.m. 6/16/23 at 1 p.m. 6/16/23 at 5 p.m. 6/16/23 at 8 p.m. 6/17/23 at 1 a.m. 6/17/23 at 5 a.m. 6/17/23 at 9 a.m. 6/17/23 at 1 p.m. 6/17/23 at 5 p.m. the last dose was administered and there were 0 tablets left. Record review of Resident #1's SBAR (Change of Condition) dated 6/18/23 at 12:31 a.m. by LVN A revealed: [Resident #1] complaining of extreme pain to his stomach. [Resident #1] requested to be sent out to the hospital. NP notified .[Resident #1] requested to be sent out to the hospital because he can't take it anymore because of his pain. Nurse caught [Resident #1] holding some tools in his hand. Nurse took away from patient holding 4 disposable shaving razors, a small scissors and a plastic water cover from the kitchen while he was sitting up. NP notified and approved to send him out. Patient was yelling out loud, disturbing the peace of other residents'. Cursing out loud by using different offensive words that are derogatory. Unable to calm patient down. Patient went out via 911 at 11:47 p.m. Record review of Resident #1's progress note dated 6/6/23 at 2:30 a.m. by LVN E revealed, Resident is currently stable .PRN Oxycodone HCl oral tablet 10 mg administered at 7:32 p.m. and 1:32 a.m. respectively due to burning pain on skin. Record review of Resident #1's progress note dated 6/8/23 at 4:06 p.m. by LVN D revealed Resident #1 alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's progress note dated 6/9/23 at 4:56 a.m. by LVN A revealed Resident #1 alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's progress notes dated 6/11/23 at 5:54 a.m. by LVN C revealed Resident #1 called 911 because his colostomy was not change prompt, at the time of his call the nurse/writer was on break, colostomy was changed .[Resident #1] alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's Progress note dated 6/13/23 at 11:07 p.m. by LVN A revealed Confirmed new order from [Doctor] to discontinue patient PRN oxycodone HCL Oral Tablet 10 mg (Oxycodone HCL) every 4 hours. [Resident #1] started on scheduled oxycodone HCl Oral tablet 10 mg (Oxycodone HCl) every 4 hours for his pain management. Resident #1 remains oxycodone HCl oral tablet ER 20 mg (Oxycodone HCl) twice daily. Resident #1 made aware of new changes with his pain medications. Record review of Resident #1's Follow up with Physician dated 6/13/23 at 12 a.m. revealed Past Medical History: Borderline personality disorder, cerebral palsy, depressive disorder, difficult intravenous access, PTSD, self-injury behavior, schizophrenia, chronic enterocutaneous fistula, right ureteropelvic junction renal stone with intermittent obstruction .Social History: .History of multiple suicide attempts via self-mutilating behavior and ingestion of various objects .History of Present Illness: This is a 43-yeaar old while male with a past history of significant for PTSD/bipolar disorder with multiple suicide attempts with self-injurious behavior and ingestion of various objects, cerebral palsy, scoliosis, and a chronic enterocutaneous fistula 2/2 self-inflicted stab wound on his abdominal wall that required exploratory laparotomy x2 and excision of infected abdominal wall mesh (11/28/20), extensive adhesiolysis, and partial small bowel resection complicated by chronic draining wound .Patient states that his chronic abdominal pain is now becoming uncontrolled. He states that he is at his wits end and expressing a desire to go back to the hospital. His colostomy continues to leak stool creating a red rash around the site. He still refuses fentanyl patch saying that he doesn't like the way it makes him feel. He is requesting to have the oxy schedule and seeing if that helps. He has appt with surgery on 6/20/23. He also mentions that he is feeling more depressed but not suicidal. Record review of Resident #1's Nurse notes dated 6/17/23 at 6:57 p.m. by LVN A revealed Only Oxycontin ER 20 mg came in at this time from pharmacy. Nurse spoke with pharmacy on call. He stated Doctor only called in the 20 mg and they still need new prescription for Oxycontin 10 mg. Nurse sent message to the NP request new prescription to be sent to the pharmacy. Record review of Resident #1's Nurse notes dated 6/17/23 at 9:01 p.m. by LVN A revealed oxycodone HCl oral tablet 10 mg. Give 1 tablet orally every 4 hours for chronic pain was pending pharmacy delivery. Record review of Resident #1's Progress note dated 6/17/23 at 10:15 p.m. by LVN A revealed NP notified that pharmacy only send patient Oxycontin 20 mg. [Resident #1] wasn't happy and was yelling that this can't be happening. NP stated that she did notified Doctor that pharmacy did not deliver [Resident #1] Oxycontin IR 10 mg. NP said she haven't gotten a response from the Doctor yet. [Resident #1] was made aware and did reassure him that we're working on it. Record review of Resident #1's Progress notes dated 6/25/23 at 7:53 p.m. by LVN B revealed Received [AGE] year-old patient in the building via EMS Stretcher 2 men crew Awake Alert and Oriented x3, with medical history of cerebral palsy, depression, scoliosis, abdominal stab wound post colostomy that been leaking for the past 4 years and known history of drug seeking behavior just discharged from [local hospital]. Upon arrival patient continue to demand for the pain medication on the same spot and called another 911 that he is going back to hospital if nobody gave him immediate attention, medication confirm and verified with the doctor, presently eyes closed in the room continue to monitor throughout the night. Record review of Resident #1's Local Hospital Record Discharge Summary dated 6/25/23 at 7:50 p.m. revealed, Reason for Visit: pain issues complained of abdomen pain from his colostomy, chronic. Takes oxycodone for pain. Nursing facility does not have his short acting oxycodone 10 mg which he gets every 4 hours only long acting 20 mg dose which he received at 9 p.m. tonight. States his colostomy bag is always leaking .His abdominal wall cellulitis may also be irritant dermatitis from the feces. He was started back on his chronic pain medications. Patient initially did not want to return to his facility. He then notified me that he swallowed a battery. Psychiatry was consulted and Cymbalta was increased to 80 mg daily. X-ray of the abdomen was completed that showed metallic cylindrical object in the left upper quadrant. Chest x-ray showed 2 cm focal opacity however he does have a skin tag in that region. GI was consulted and proceeded with EGD on 6/22 and was unable to retrieve foreign body. He was also noted to have elevated liver enzymes may be due to Cymbalta. He was continued on Cymbalta due to benefits of medication. Surgery was consulted. CT abdomen pelvis was completed that showed cylindrical metallic density within the small bowel loop in the lower mid abdomen with moderate stool burden. He was unable to pass battery. GI proceeded with colonoscopy and was able to retrieve the battery. He was restarted on regular diet which he tolerated well .Impression: Ingested foreign body-AAA battery battery-successfully removed by ileoscopy through ileostomy. Record review of Resident #1's Psychological Services Progress Note dated 6/27/23 revealed: Symptoms: (Symptoms that were focused on in this session) Psychological: depression, Physical: Physical decline, Functional/Behavioral challenges: Adjustment difficulty (illness/decline/Loss, Stressors/Changes in Mental Status: Declining health .Results of Psychotherapy: Functional improvement noted .Identified- external emotional triggers, Disposition/Rationale for continued treatment: Symptoms require more attention. In an observation and interview with Resident #1 on 6/28/23 at 1:20 p.m. revealed Resident #1 rolling around the hallway. Resident #1 stated he ate a battery and he explained he had an ileostomy bag, and it was leaking, and it leaked all the time no matter what the facility did. Resident #1 stated he had it for 4 years and he had trouble with the facility getting ostomy bags all the time and he had trouble with them getting his PRN pain meds to him. Resident #1 stated he had swallowed a battery before. Resident #1 stated he had several talks with Administration about these incidents asking them to tighten this up (his pain medication and ostomy bags). Resident #1 stated he spoke with Doctor's in the hospital to make things better and they said it was nothing they could do. He stated before he went to the hospital on 6/17/23, he found out his medicine (oxycodone 10 mg) had lapsed, and he told the nurse to send him to the hospital and that he had discussions with them several times and she said no they will just send him right back. Resident #1 stated with the state of mind he was in, he thought he would just do something that he had to go. He stated he was in a lot in pain with the ileostomy leaking and it burned his skin and he also had cerebral palsy and scoliosis. Resident #1 stated the state of mind he was in, he said to himself he would do what he had to do what to get out of the facility. Resident #1 stated since this incident he spoke with the psych specialist at the facility and she was getting him medication for anxiety and she said if a scenario happened again and the facility ran out of meds then he (Resident #1) would tell the staff he wants to go to the hospital and he did not feel safe so he can get what he needed done. Resident #1 stated since that issue happened the facility had a new unit manager and she stayed on top of the meds, and he stated he was staying on top of the meds also. Observation of Resident #1's ileostomy bag revealed it was leaking onto his brief and his skin. Resident #1 stated he felt that the facility neglected him, and he did not mean to snitch on anyone, but it is what it is. Resident #1 stated he could not remember the Nurses name. In an interview and record review on 6/28/23 at 1:40 p.m. with Unit Manager A she stated Resident #1 was frustrated about his pain meds when they do not get them right when they are due. Unit Manager A stated Resident #1 was asking about his pain meds closer to 6p.m. and he asked for the pain meds and the med aide was in another room and he got frustrated. One med was PRN, but they made it routine a few days before he went out. Unit Manager A stated Resident #1 went out on 6/17/23 and came back on 6/25/23. Record review of Resident #1's narcotic count sheet with Unit Manager A revealed Resident #1 did run out of Oxycontin ER 20 mg on 6/17/23 at 9 p.m. She stated he ran out of meds on 6/17/23 so no meds were given. Unit Manager A did call the local pharmacy at 2:13 p.m. and they stated Resident #1's Oxycontin ER 20 mg was delivered on 6/17/23 at 6:45 p.m. with 14 tablets. Unit Manager A stated Resident #1 ran out of Oxycodone 10mg. Observation of Resident #1's narcotic count sheet revealed the last tablet was given on 6/17/23 and he had 0 pills left. Unit Manager A stated the local pharmacy stated oxycodone 10 mg was delivered on 6/18/23 at 6:32 p.m. Unit Manager A stated Resident #1 missed 1 dose of oxycodone 10 mg on 6/17/23 for 9 p.m. In an interview on 6/28/23 at 2:20 p.m. with the DON she stated Resident #1 called 911 and they showed up at the building. The DON stated he had not told them that he swallowed the battery. In an interview on 6/29/23 at 1:18 p.m. with LVN A she stated the Doctor messed up. She stated she got report from shift change on 6/17/23 saying the Nurse got in touch with NP because Resident #1 ran out of meds, and they contacted the Doctor to call the medication in. LVN A stated she received report saying Unit Manager A took care of that, but the pharmacy only brought the oxycodone 20 mg and not the oxycodone 10 mg. LVN A stated the pharmacist said on 6/17/23 Resident #1 ran out of Oxycodone 10 mg and would need a new prescription. LVN A stated she got in touch with the NP and asked the NP to have the Doctor to contact LVN A. LVN A stated Resident #1 was suicidal and if he did not get his medicine, he would start doing things. She stated the Doctor did not respond back and he was supposed to call in those dosages. LVN A stated the meds came in the next day on 6/18/23. LVN A stated on 6/17/23 Resident #1 was screaming, and she realized Resident #1 was trying to cause harm to himself. She stated she told NP that Resident #1 said call 911 and the NP said call 911 . LVN A stated Resident #1 was holding some scissors and razors on 6/17/23 and she removed it from him and she continued to try to get the oxycodone 10 mg by contacting the NP. She stated she called 911 and said he was complaining of pain. LVN A stated Resident #1 was really angry and upset. He said it happened all the time that the facility ran out of his medication. LVN A stated Resident #1 was scheduled to get Oxycodone 20 mg twice a day and she went to his room saying it was his night meds 20mg for 10p.m. LVN A stated she told Resident #1 they did not have the 10 mg because they ran out of the 10 mg and was waiting for the pharmacy. She stated Resident #1 started yelling and raging screaming out of control. LVN A stated Resident #1 just got his oxycodone 20 mg long-acting meds at 9 p.m. and he started screaming and raging at 9p.m. She stated she had to leave Resident #1 to call the NP and he started yelling god dammit and saying things like he was going to harm himself. LVN A stated Resident #1 was mad the previous days because he was out of his medicine. LVN A stated Resident #1 was holding items in his hand, scissors and razors that could harm him. LVN A stated Resident #1 said he was going to harm himself. She stated Resident #1 was holding a pair of scissors, 4 disposable razors, a plastic lid from a plastic cup and he keep saying he was going to hurt himself. LVN A stated she was already aware of Resident #1's history and she took the items from him (Resident #1) and brought it to the Nurse station then she called 911 (Unknown time). LVN A stated 911 came and he told 911 he had a colostomy that was excoriated, and the stomach contents leaked out and he told 911 he was having stomach pain, the facility had been out of his meds for a few days, and he could not take it anymore and he did not want to be at the facility. She stated Resident #1 could not bear the pain and he was insisting to go to the hospital and NP said go ahead and send the resident. LVN A stated she did not know anything about a battery. She stated the only thing Resident #1 was holding in his hand were the scissors and razors and she took them away from him and called 911. LVN A stated she did not trust Resident #1. LVN A stated she did not call anyone to assist her with Resident #1 because the CNA was busy working and Resident #1 was sitting in the wheelchair crying, yelling and screaming god dammit LVN A stated the Doctor did not call in both dosages and they were supposed to call when they had 7 pills in the blister pack. LVN A stated Resident #1 had a history of trying to harm himself. LVN A stated the facility had an adequate supply for ileostomy bags and the only issue was about pain meds for Resident #1. In an interview on 6/29/23 at 1:53 p.m. with Resident #1 he stated prior to this happening he had several conversations about having enough ostomy supplies because before the new Unit Manager got here supplies was an issue. He stated he was having problems getting his prn pain meds when he needed, and he had several conversations with the previous Management (Administrator B). Resident #1 stated before he went to the hospital, he has gone days without his pain medication. He stated on 6/17/23, that evening he took his last prn dose of pain meds oxycodone 10 mg, and they said by the time it was time to get it again, the meds would be at the facility, and he said great. Resident #1 stated the medicine did not come in and they only brought the scheduled pain meds (oxycodone 20 mg) and he had asked for his pain meds (oxycodone 10 mg) and LVN A said the pharmacy only brought in the scheduled pain meds (oxycodone 20 mg). Resident #1 stated it was Saturday night and the next day was Sunday and if they run out on a Saturday you do not get meds until Monday. Resident #1 stated the med aide that day said it was his last dose at 5:30 to 6 p.m. and they said his meds should be in by the time the next dose is due. He stated he told the late-night nurse (LVN A) he was out of here (the facility) and that he was going to the hospital where they could take care of him. Resident #1 stated LVN A said let her give him (Resident #1) the scheduled dose and she said she would get a hold of the Doctor and he should let her see what she could do. Resident #1 stated the ostomy supply kept running out, there was the issue with getting prn meds and them running out of pain medication. He said, he had it and he blew up. Resident #1 stated he spoke with Unit Manager A before and he tried to solve the issue. It was a little after 9 p.m. He stated LVN A took the scissors from him at 9:45 to 10 p.m. when she saw them in his hand, and he said nothing nothing. Resident #1 stated in the box was razors and scissors and he had hidden batteries in his pocket. Resident #1 stated it was after 9 p.m. when she gave the scheduled meds, and she was having trouble getting hold of the Doctor. Resident #1 stated he told LVN A he wanted to get out of the facility, and she said if you just go for pain meds, they will give you one dose and send him right back. Resident #1 stated he had already told LVN A that he wanted to leave going to the hospital right after 9p.m. He stated LVN A took the scissors and razors, and after she (LVN A) left out of his room at around 9:45 to 10 p.m., Resident #1 shut his room door and swallowed the battery. He stated he went out of his room after he swallowed the battery and continued to blow up and said he did not feel safe at the facility and wanted to go to the hospital, and he was leaving. Resident #1 said that's fine, let her call the Doctor and they sent him out to the hospital. Resident #1 stated LVN A allowed a couple of hours to go by and he was by himself in his room. He stated he stayed in the hallway for a while and LVN A told him to calm down and that he was waking people up, but by this time his ostomy bag was leaking, his skin was burning, and he was hurting. Resident #1 stated he was sent to the hospital in a mess with feces on him and his ostomy bag was still leaking. Resident #1 stated he never told LVN A he swallowed a battery; he told the hospital 24 to 48 hours after he had gotten to the hospital that he swallowed the battery, and they rushed him to emergency. Resident #1 stated when he went into the hallway he stayed until 911 got there. In an interview on 6/29/23 at 2:46 p.m. with the DON she stated if a resident is suicidal the facility would put them on one-on-one observation and call the doctor to let them know. The DON stated the facility would call the psychiatrist and let them know as well so they can come and evaluate the resident. The DON stated she was not sure how the pharmacy in the company operates because she just started working at the facility on 5/22/23 as interim. The DON stated the staff should not leave the resident who was trying to commit suicide by themselves, and she would stay there and get the Doctor on the phone. The DON stated that was why she said if someone was suicidal, they need to be one on one observation. The DON stated she did not know what to say about the battery because the facility did not know he swallowed a battery until he came back from the hospital. The DON stated she understood that you do not turn your back on someone who is suicidal, but where there is a will there is a way, they will swallow even in your presence. In an interview on 6/29/23 at 2:57 p.m. with the Administrator she stated she did not know what to say about the battery. In an interview on 6/29/23 at 3 p.m. with Unit Manager A she stated the residents were not allowed to have razors and that the residents do not have access to razors, and they are in the supply room. Unit Manager A stated Resident #1 asked for razors today, 6/29/23 to shave himself with and she told him no and the facility would shave him. In an interview on 6/30/23 at 12:54 p.m. with the Medical Director he stated the nursing home staff had been aware that Resident #1 was admitted with suicide ideations, and he had been followed by psychiatry and psychology in May 2023. The Medical Director stated Resident #1 denied that the resident made any outcries that he wanted to harm himself since being admitted at the facility. The Medical Director stated he did not know why Resident #1 had scissors or razors. The Medical Director stated he did not have his pain medicine because it was running low, and they were waiting for the attending physician to send in a refill. The Medical Director stated he was not aware the medication was completely out. The Medical Director stated an ileostomy bag is for hygiene and cleanliness, but sometimes due to the person's body or the way they are it may be difficult to keep the bag adhered. The Medical Director stated they want the bag to stay adhered for cleanliness, but if the stool leakage occurs and its left unattended it could burn the skin. In an interview on 6/30/23 at 1:35 p.m. with the DON she stated she was told Resident #1 was sent to the hospital. The DON stated if a patient needs to go to the hospital it needs to be from the Doctor or NP and If a resident said they wanted to go to the hospital they have to let the Dr know what's going on and they have to give the okay to send the resident out. The DON stated if the resident was admitted into the facility that means they are not on suicidal watch. She stated the moment the resident was admitted to the facility unless they voice out, they are suicidal they have to ask them what their plan is then follow the steps of what they need to do. The DON stated it the resident had a diagnosis, there was nothing they would do if they were not voicing that they would hurt themselves. She stated although because they have the history of, they would get psych services involved. The DON stated Resident #1 was not care planned for suicidal ideations and she stated she could not answer why, and she would have to get the MDS Coordinator to see why. The DON stated she did not know how Resident #1 got the scissors and razors. She stated when Resident #1 returned from the hospital; they did a head-to-toe assessment and documented to make sure there were no new issues. The DON stated if the hospital deemed Resident #1 competent and okay to come back to the facility, then they go by the recommendations of what the hospital asked them to do. The DON stated if the hospital said they need psych services, the facility would follow the recommendations the hospital gave them. The DON stated she did not know why they were running out of medications. The DON stated the facility had a pharmacy and the Nurses now to call the pharmacy to replenish the medication. The DON stated every pharmacy was different, with this pharmacy they need to call them within 3 days if the resident was running out of medications unless the PRN medication had a 14 day stop date. In an interview on 6/30/23 at 1:50 p.m. with the NP she stated Resident #1 was mentally competent but was in a lot of general pain. She stated Resident #1 was on oxycodone ER release every 12 hours (long acting) and oxycodone 10 mg (a short acting one). The NP stated when she saw Resident #1, he sat in the wheelchair, and he looked like he was in a lot of pain. She stated she thought he was used to getting a lot of narcotic meds. The NP stated Resident #1 recently requested to go to the hospital because he ran out of oxycodone. The NP stated the hospital found Resident #1 with a UTI and they treated him with antibiotics. The NP stated when she saw Resident #1, he said he did not want to deal with the pain, and he did not want to deal with this kind of life. The NP stated Resident #1 requested to be on hospice, but she was not sure if hospice would accept him. The NP stated Resident #1 did not mention to her that he wanted to harm himself. She stated Resident #1 said he did not want to deal with this kind of pain in his life. The NP stated she spoke with Resident #1, and he was calm and smiling. The NP stated the day he was sent out to the hospital the nurse (LVN A) told her Resident #1 was screaming and threw stuff at her (LVN A) and asked to go to the hospital. The NP stated it was 2 weeks ago on Saturday, 6/17/23 and Resident #1 said he was in a lot of pain. The NP stated he received the pain medication every 4 hours and every 12 hrs. The NP stated she did not know Resident #1 was diagnosed with suicidal ideations. She stated she just started seeing Resident #1 and she just started working at the facility about 3 weeks ago. The NP stated she did not see any documents of suicidal ideations. The NP stated if she was aware she would have put in an order for transfer to psychiatric hospital because Resident #1 needed inpatient psych and therapy. She stated if she saw that she would have asked the nurse to send him to behavioral hospital. The NP stated on 6/17/23, LVN A said Resident #1 was agitated and aggr [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for Administration. -The administration failed to complete a comprehensive review of Resident #1's medical records which detailed his prior and current destructive behaviors including swallowing batteries and stabbing himself and was unaware until this surveyor informed them. -The administration failed to ensure interventions were in place to protect Resident #1 after readmission to the facility. -The administration failed to care plan, implement, and provide care and services to Resident #1 in accordance with facility policies and procedures for suicidal ideations. An Immediate Jeopardy (IJ) was identified on 06/30/23 at 2:59 p.m. The IJ template was provided to the facility on [DATE] at 2:59 p.m. While the IJ was removed on 07/05/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not an Immediate Jeopardy because all staff had not been trained on caring for residents with suicidal ideations, neglect, ordering pain medications timely, changing ileostomy bags, and care planning for suicidal ideations. These failures could affect all residents placing them at risk of the facility not being administered in a way to assist with physical, mental, and psychosocial needs. Findings include: Record review of Resident #1's face sheet dated 6/28/23 revealed a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of being initially admitting to the facility with suicidal ideations, systemic inflammatory response syndrome (SIRS) of Non-Infectious origin without acute organ dysfunction (exaggerated defense response of the body), cerebral palsy (disorder that affects a person's ability to maintain balance and posture), sepsis due to enterococcus, fistula of intestine (abnormal opening or intestine that allows the contents to leak to another part of the body), idiopathic peripheral autonomic neuropathy (damage of the peripheral nerves where cause cannot be determined), intervertebral disc degeneration, lumbar region, residual schizophrenia, scoliosis, bipolar disorder, colostomy status, major depressive disorder, and anxiety. Record review of Resident #1's Care Plan dated 6/26/23 revealed resident complains of increased pain/discomfort and is at risk for further episodes of increased pain/discomfort and injury. Goal: Resident 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. Interventions: Allow to verbalize feelings of pain/discomfort . Resident #1 has a Colostomy due to Medical Condition. Goal: Resident #1 will have no complications from ostomy site over the next 90 days. Intervention: Monitor site for swelling, pain, redness, etc.Apply Nystatin powder to Colostomy Site. Resident #1 has a diagnosis of depression with Goal: have fewer or no episodes of depression and will voice feelings about self over the next 90 days. Interventions/Tasks: Allow [Resident #1] to verbalize feelings of depression. Give medications per order-monitor labs - report abnormalities to MD. Resident #1 has a behavior problem of not waiting on staff to change his colostomy will call the police 911. Intervention: Anticipate and meet [Resident #1's] needs. Resident #1 call 911 due to meds not here. Interventions/Tasks: If reasonable, discuss [Resident #1's] behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. Further Record review of Resident #1's Care Plan dated 6/26/23 revealed he was not care planned for suicidal ideations when he admitted to the facility with the diagnosis on 2/6/23. Record review of Resident #1's Quarterly MDS dated [DATE] revealed his BIMS Summary Score was 15 indicating he was cognitively intact. Resident #1's functional status revealed walking in room and corridor did not occur, supervision with set up help only for locomotion on and off the unit and eating. Resident #1 required limited assistance with one person assisting for transfer, toilet use, and personal hygiene and he needed extensive assistance with one person physically assisting him for dressing. Record review of Resident #1's Physician Orders dated 6/30/23 revealed: Discontinue Oxycontin 20 mg ER when 30 mg tablet has arrived. One time only for 3 days dated 6/28/23 and ended 7/1/23. Oxycodone HCL Oral tablet 10 mg give 1 tablet by mouth every 4 hours related to systemic inflammatory response syndrome of non-infectious origin without acute organ dysfunction dated 4/11/23. Oxycontin Oral tablet ER 12 Hour Abuse-Deterrent 30 mg give 1 tablet orally every 12 hours for chronic pain. Oxycontin Oral Tablet ER 12 Hour Abuse-Deterrent 20 mg Give 1 tablet orally every 12 hours for chronic pain. Nystatin External Powder 100000 UNIT/GM (Nystatin (Topical)) Apply to colostomy topically three times a day for colostomy site irritated dated 04/04/23. Zinc Oxide External Ointment 20 % (Zinc Oxide (Topical)) Apply to colostomy site topically four times a day for colostomy site irritated dated 02/16/23. Record review of Resident #1's Medication Administration Record for 6/1-6/30/23 revealed: Colostomy Observation every shift Monitor Resident's colostomy. Ensure Colostomy is intact, free from s/s of infection and functioning properly. The box was blank on 6/6/23 at 6 p.m. Colostomy: Empty every shift Licensed Nurse will monitor colostomy and ensure it is emptied every shift and as needed. The box was blank on 6/6/23 at 6 p.m. Observation: Behaviors. Target Behaviors : withdrawn, crying, lack of appetite every shift Monitor Resident for Presence of Behaviors withdrawn, crying, lack of appetite. Document Yes or No to whether Behaviors were Observed. Notify MD as needed for Behaviors. The box was blank on 6/6/23 at 6 p.m. 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 for pain observation. The box was blank on 6/6/23 at 6 p.m. Skin: Protective skin barrier ointment after each incontinent episode and PRN every shift. The box was blank on 6/6/23 at 6 p.m. Nystatin External Powder 100000 UNIT/GM (Nystatin (Topical)) Apply to colostomy topically three times a day for colostomy site irritated. The box was blank on 6/6/23 at 6 p.m. Zinc Oxide External Ointment 20 % (Zinc Oxide (Topical)) Apply to colostomy site topically four times a day for colostomy site irritated. The box was blank on 6/6/23 at 9 p.m. Oxycodone HCL Oral Tablet 10 mg. The box was blank on 6/6/23 at 6 p.m. Oxycontin Oral Tablet ER 12 Hour (Oxycodone HCl). The box was blank on 6/6/23, 6/10/23, and 6/11/23 at 9 p.m. Further review of the MAR revealed no documentation to indicate Resident #1 was out of the facility on the days the MAR was blank. Record review of Resident #1's Controlled Drug Administration Record Tablet for Oxycodone IR 10 mg oral date issued 5/3/23 revealed: 6/16/23 at 9 a.m. 6/16/23 at 1 p.m. 6/16/23 at 5 p.m. 6/16/23 at 8 p.m. 6/17/23 at 1 a.m. 6/17/23 at 5 a.m. 6/17/23 at 9 a.m. 6/17/23 at 1 p.m. 6/17/23 at 5 p.m. the last dose was administered and there were 0 tablets left. Record review of Resident #1's progress note dated 6/6/23 at 2:30 a.m. by LVN E revealed, Resident is currently stable .PRN Oxycodone HCl oral tablet 10 mg administered at 7:32 p.m. and 1:32 a.m. respectively due to burning pain on skin. Record review of Resident #1's progress note dated 6/8/23 at 4:06 p.m. by LVN D revealed Resident #1 alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's progress note dated 6/9/23 at 4:56 a.m. by LVN A revealed Resident #1 alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's progress notes dated 6/11/23 at 5:54 a.m. by LVN C revealed Resident #1 called 911 because his colostomy was not change prompt, at the time of his call the nurse/writer was on break, colostomy was changed .[Resident #1] alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's Progress note dated 6/13/23 at 11:07 p.m. by LVN A revealed Confirmed new order from [Doctor] to discontinue patient PRN oxycodone HCL Oral Tablet 10 mg (Oxycodone HCL) every 4 hours. [Resident #1] started on scheduled oxycodone HCl Oral tablet 10 mg (Oxycodone HCl) every 4 hours for his pain management. Resident #1 remains oxycodone HCl oral tablet ER 20 mg (Oxycodone HCl) twice daily. Resident #1 made aware of new changes with his pain medications. Record review of Resident #1's Follow up with Physician dated 6/13/23 at 12 a.m. revealed Past Medical History: Borderline personality disorder, cerebral palsy, depressive disorder, difficult intravenous access, PTSD, self-injury behavior, schizophrenia, chronic enterocutaneous fistula, right ureteropelvic junction renal stone with intermittent obstruction .Social History: .History of multiple suicide attempts via self-mutilating behavior and ingestion of various objects .History of Present Illness: This is a [AGE] year old while male with a past history of significant for PTSD/bipolar disorder with multiple suicide attempts with self-injurious behavior and ingestion of various objects, cerebral palsy, scoliosis, and a chronic enterocutaneous fistula 2/2 self-inflicted stab wound on his abdominal wall that required exploratory laparotomy x2 and excision of infected abdominal wall mesh (11/28/20), extensive adhesiolysis, and partial small bowel resection complicated by chronic draining wound .Patient states that his chronic abdominal pain is now becoming uncontrolled. He states that he is at his wits end and expressing a desire to go back to the hospital. His colostomy continues to leak stool creating a red rash around the site. He still refuses fentanyl patch saying that he doesn't like the way it makes him feel. He is requesting to have the oxy schedule and seeing if that helps. He has appt with surgery on 6/20/23. He also mentions that he is feeling more depressed but not suicidal. Record review of Resident #1's Progress note dated 6/17/23 at 10:15 p.m. by LVN A revealed NP notified that pharmacy only send patient Oxycontin 20 mg. [Resident #1] wasn't happy and was yelling that this can't be happening. NP stated that she did notified Doctor that pharmacy did not deliver [Resident #1] Oxycontin IR 10 mg. NP said she haven't gotten a response from the Doctor yet. [Resident #1] was made aware and did reassure him that we're working on it. Record review of Resident #1's SBAR (Change of Condition) dated 6/18/23 at 12:31 a.m. by LVN A revealed: [Resident #1] complaining of extreme pain to his stomach. [Resident #1] requested to be sent out to the hospital. NP notified .[Resident #1] requested to be sent out to the hospital because he can't take it anymore because of his pain. Nurse caught [Resident #1] holding some tools in his hand. Nurse took away from patient holding 4 disposable shaving razors, a small scissors and a plastic water cover from the kitchen while he was sitting up. NP notified and approved to send him out. Patient was yelling out loud, disturbing the peace of other residents'. Cursing out loud by using different offensive words that are derogatory. Unable to calm patient down. Patient went out via 911 at 11:47 p.m. Record review of Resident #1's Local Hospital Record dated 6/23/23 revealed Pouch was leaking on arrival. Pouch was last changed on 6/19/23 wound ostomy continence note. Changed pouch. Applied marathon liquid skin protectant to peristomal, raw, denuded openings. Applied 1 piece pouch with convex barrier ostomy ring. Good seal achieved. Record review of Resident #1's Progress notes dated 6/25/23 at 7:53 p.m. by LVN B revealed Received [AGE] year-old patient in the building via EMS Stretcher 2 men crew Awake Alert and Oriented x3, with medical history of cerebral palsy, depression, scoliosis, abdominal stab wound post colostomy that been leaking for the past 4 years and known history of drug seeking behavior just discharged from [local hospital]. Upon arrival patient continue to demand for the pain medication on the same spot and called another 911 that he is going back to hospital if nobody gave him immediate attention, medication confirm and verified with the doctor, presently eyes closed in the room continue to monitor throughout the night. Record review of Resident #1's Local Hospital Record Discharge Summary dated 6/25/23 at 7:50 p.m. revealed, Reason for Visit: pain issues complained of abdomen pain from his colostomy, chronic. Takes oxycodone for pain. Nursing facility does not have his short acting oxycodone 10 mg which he gets every 4 hours only long acting 20 mg dose which he received at 9 p.m. tonight. States his colostomy bag is always leaking .His abdominal wall cellulitis may also be irritant dermatitis from the feces. He was started back on his chronic pain medications. Patient initially did not want to return to his facility. He then notified me that he swallowed a battery. Psychiatry was consulted and Cymbalta was increased to 80 mg daily. X-ray of the abdomen was completed that showed metallic cylindrical object in the left upper quadrant. Chest x-ray showed 2 cm focal opacity however he does have a skin tag in that region. GI was consulted and proceeded with EGD on 6/22 and was unable to retrieve foreign body. He was also noted to have elevated liver enzymes may be due to Cymbalta. He was continued on Cymbalta due to benefits of medication. Surgery was consulted. CT abdomen pelvis was completed that showed cylindrical metallic density within the small bowel loop in the lower mid abdomen with moderate stool burden. He was unable to pass battery. GI proceeded with colonoscopy and was able to retrieve the battery. He was restarted on regular diet which he tolerated well .Impression: Ingested foreign body-AAA battery battery-successfully removed by ileoscopy through ileostomy. Record review of Resident #1's Psychological Services Progress Note dated 6/27/23 revealed: Symptoms: (Symptoms that were focused on in this session) Psychological: depression, Physical: Physical decline, Functional/Behavioral challenges: Adjustment difficulty (illness/decline/Loss, Stressors/Changes in Mental Status: Declining health .Results of Psychotherapy: Functional improvement noted .Identified- external emotional triggers, Disposition/Rationale for continued treatment: Symptoms require more attention. In an observation and interview with Resident #1 at the facility on 6/28/23 at 1:20 p.m. revealed Resident #1 rolling around the hallway in his wheelchair. Resident #1 stated he ate a battery and he explained he had an ileostomy bag, and it was leaking and it burned his skin. He stated it leaked all the time no matter what the facility did. Resident #1 stated he had it for 4 years and he had trouble with the facility getting ostomy bags all the time and he had trouble with them getting his PRN pain meds to him. Resident #1 stated he had several talks with Administration about these incidents asking them to tighten this up (his pain medication and ostomy bags). Resident #1 stated he spoke with Doctor's in the hospital to make things better and they said there was nothing they could do. He stated before he went to the hospital on 6/17/23, he found out his medicine (oxycodone 10 mg) had lapsed, and he told the nurse to send him to the hospital at 9 p.m. He said he had discussions with them several times and LVN A said no they will just send him right back. Resident #1 stated with the state of mind he was in, he thought he would just do something that he had to go. He stated he was in a lot in pain with the ileostomy leaking and it burned his skin and he also had cerebral palsy and scoliosis. Resident #1 stated the state of mind he was in, he said to himself he would do what he had to do to get out of the facility. Resident #1 stated since this incident he spoke with the psych specialist at the facility and she was getting him medication for anxiety and she said if a scenario happened again and the facility ran out of meds then he (Resident #1) would tell the staff he wants to go to the hospital and he did not feel safe. Resident #1 stated since that issue happened the facility had a new unit manager and she stayed on top of the meds, and he stated he was staying on top of the meds also. Observation of Resident #1's ileostomy bag revealed it was leaking onto his brief and his skin. Resident #1 stated he felt that the facility neglected him, and he did not mean to snitch on anyone, but it is what it is. Resident #1 stated he could not remember the Nurses name. Resident #1 stated the staff said they could not make the ileostomy bag stop leaking. Resident #1 stated the ileostomy was not leaking as bad as it was yesterday. He said, the ileostomy bag leaked a lot and that was an understatement and it had burned him in the past where he had to go to the hospital. Resident #1 stated the last time he went to the hospital for the ileostomy burning his skin was a few months ago. In an interview and record review on 6/28/23 at 1:40 p.m. with Unit Manager A, she stated Resident #1 getsfrustrated about his pain meds when the facility does not get them right when they were due. Unit Manager A stated, Resident #1 was asking about his pain meds closer to 6 p.m. on 6/17/23 and he asked for the pain meds and the med aide was in another room and he got frustrated. Unit Manager A stated Oxycodone 10 mg was PRN, but they made it routine a few days before he went out. Unit Manager A stated Resident #1 went out on 6/17/23 and came back on 6/25/23. Record review of Resident #1's narcotic count sheet with Unit Manager A revealed Resident #1 did run out of Oxycontin ER 20 mg on 6/17/23 at 9 p.m. She stated he ran out of meds on 6/17/23 so no meds were given. Unit Manager A did call the local pharmacy on 6/28/23 at 2:13 p.m. and they stated Resident #1's Oxycontin ER 20 mg was delivered on 6/17/23 at 6:45 p.m. with 14 tablets. Unit Manager A stated Resident #1 ran out of Oxycodone 10mg. Record review of Resident #1's narcotic count sheet with Unit Manager A revealed the last Oxycodone 10 mg tablet was given on 6/17/23 and he had 0 pills left. Unit Manager A stated the local pharmacy stated oxycodone 10 mg was delivered on 6/18/23 at 6:32 p.m. Unit Manager A stated Resident #1 missed 1 dose of oxycodone 10 mg on 6/17/23 for 9 p.m. In an interview on 6/28/23 at 2:20 p.m. with the DON she stated thought Resident #1 called 911 on 6/17/23 and they showed up at the building. The DON stated he had not told them that he swallowed the battery. In an interview on 6/29/23 at 1:18 p.m. with LVN A she stated the Doctor messed up. She stated she got report from shift change on 6/17/23 saying the Nurse got in touch with NP because Resident #1 ran out of meds, and they contacted the Doctor to call the medication in. LVN A stated she received report saying Unit Manager A took care of that, but the pharmacy only brought the oxycodone 20 mg and not the oxycodone 10 mg. LVN A stated the pharmacist said on 6/17/23 Resident #1 ran out of Oxycodone 10 mg and would need a new prescription. LVN A stated she got in touch with the NP and asked the NP to have the Doctor to contact LVN A. LVN A stated Resident #1 was suicidal and if he did not get his medicine, he would start doing things. She stated the Doctor did not respond back and he was supposed to call in those dosages. LVN A stated the meds came in the next day on 6/18/23. LVN A stated on 6/17/23 Resident #1 was screaming, and she realized Resident #1 was trying to cause harm to himself. She stated she told NP that Resident #1 said call 911 and the NP said call 911 . LVN A stated Resident #1 was holding some scissors and razors on 6/17/23 and she removed it from him and she continued to try to get the oxycodone 10 mg by contacting the NP. She stated she called 911 and said he was complaining of pain. LVN A stated Resident #1 was really angry and upset. He said it happened all the time that the facility ran out of his medication. LVN A stated Resident #1 was scheduled to get Oxycodone 20 mg twice a day and she went to his room saying it was his night meds 20mg for 10p.m. LVN A stated she told Resident #1 they did not have the 10 mg because they ran out of the 10 mg and was waiting for the pharmacy. She stated Resident #1 started yelling and raging screaming out of control. LVN A stated Resident #1 just got his oxycodone 20 mg long-acting meds at 9 p.m. and he started screaming and raging at 9p.m. She stated she had to leave Resident #1 to call the NP and he started yelling god dammit and saying things like he was going to harm himself. LVN A stated Resident #1 was mad the previous days because he was out of his medicine. LVN A stated Resident #1 was holding items in his hand, scissors and razors that could harm him. LVN A stated Resident #1 said he was going to harm himself. She stated Resident #1 was holding a pair of scissors, 4 disposable razors, a plastic lid from a plastic cup and he keep saying he was going to hurt himself. LVN A stated she was already aware of Resident #1's history and she took the items from him (Resident #1) and brought it to the Nurse station then she called 911 (Unknown time). LVN A stated 911 came and he told 911 he had a colostomy that was excoriated, and the stomach contents leaked out and he told 911 he was having stomach pain, the facility had been out of his meds for a few days, and he could not take it anymore and he did not want to be at the facility. She stated Resident #1 could not bear the pain and he was insisting to go to the hospital and NP said go ahead and send the resident. LVN A stated she did not know anything about a battery. She stated the only thing Resident #1 was holding in his hand were the scissors and razors and she took them away from him and called 911. LVN A stated she did not trust Resident #1. LVN A stated she did not call anyone to assist her with Resident #1 because the CNA was busy working and Resident #1 was sitting in the wheelchair crying, yelling and screaming god dammit LVN A stated the Doctor did not call in both dosages and they were supposed to call when they had 7 pills in the blister pack. LVN A stated Resident #1 had a history of trying to harm himself. LVN A stated the facility had an adequate supply for ileostomy bags and the only issue was about pain meds for Resident #1. In an interview on 6/29/23 at 1:53 p.m. with Resident #1, he stated prior to him swallowing the battery he had several conversations about having enough ostomy supplies because before the new Unit Manager got there, supplies was an issue. He stated he was having problems getting his prn pain meds when he needed, and he had several conversations with the previous Management (Administrator B). Resident #1 stated before he went to the hospital, he had gone days without his pain medication. He stated on 6/17/23, that evening he took his last prn dose of pain meds oxycodone 10 mg, and they said by the time it was time to get it again, the meds would be at the facility, and he said great. Resident #1 stated the medicine did not come in and they only brought the scheduled pain meds (oxycodone 20 mg) and he had asked for his pain meds (oxycodone 10 mg) and LVN A said the pharmacy only brought in the scheduled pain meds (oxycodone 20 mg). Resident #1 stated it was Saturday night and the next day was Sunday and if they run out on a Saturday you do not get meds until Monday. Resident #1 stated the med aide that day on 6/17/23 said it was his last dose at 5:30 to 6 p.m. and they said his meds should be in by the time the next dose was due. He stated he told the late-night nurse (LVN A) he was out of here (the facility) and that he was going to the hospital where they could take care of him. Resident #1 stated LVN A said let her give him (Resident #1) the scheduled dose and she said she would get a hold of the Doctor and he should let her see what she could do. Resident #1 stated the ostomy supply kept running out, there was the issue with getting prn meds and them running out of pain medication. He said, he had it and he blew up. Resident #1 stated he spoke with Unit Manager A before and he tried to solve the issue. Resident #1 stated it was a little after 9 p.m. on 6/17/23 when LVN A took the scissors from him at 9:45 to 10 p.m. when she saw them in his hand, and he said nothing nothing. Resident #1 stated in the box was razors, scissors and he had hidden batteries in his pocket. Resident #1 stated it was after 9 p.m. when she gave the scheduled meds, and she was having trouble getting hold of the Doctor. Resident #1 stated he told LVN A he wanted to get out of the facility, and she said if you just go for pain meds, they will give you one dose and send him right back. Resident #1 stated he had already told LVN A that he wanted to leave going to the hospital right after 9p.m. He stated LVN A took the scissors and razors, and after she (LVN A) left out of his room at around 9:45 to 10 p.m., Resident #1 shut his room door and swallowed the battery that he got from the TV remote. He stated he went out of his room after he swallowed the battery and continued to blow up and said he did not feel safe at the facility and wanted to go to the hospital, and he was leaving. Resident #1 said LVN A said let her call the Doctor and they sent him out to the hospital. Resident #1 stated LVN A allowed a couple of hours to go by and he was by himself in his room. He stated he stayed in the hallway for a while and LVN A told him to calm down and that he was waking people up, but by this time his ostomy bag was leaking, his skin was burning, and he was hurting. Resident #1 stated he was sent to the hospital in a mess with feces on him and his ostomy bag was still leaking. Resident #1 stated he never told LVN A he swallowed a battery; he told the hospital 24 to 48 hours after he had gotten to the hospital that he swallowed the battery, and they rushed him to emergency. Resident #1 stated when he went into the hallway he stayed until 911 got there. In an interview and Record review on 6/29/23 at 2:30 p.m. with Administrator she stated she was not aware that Resident #1 swallowed a battery and she stated she thought the battery was from Resident #1's previous hospitalization when he swallowed the battery. The Administrator stated she was not aware until the State Surveyor informed her that Resident #1 swallowed the battery. The Administrator did review with this Surveyor Resident #1's hospital records where Resident #1 swallowed a battery prior to being admitted to their facility on 2/6/23. When asked why the Administrator was not aware of the battery, she stated she was newly hired and had only been at the facility a few days. In an interview with the Assistant Administrator on 6/29/23 at 2:35 p.m. he stated he was not aware Resident #1 swallowed a battery. In an interview on 6/29/23 at 2:46 p.m. with the DON she stated if a resident was suicidal the facility would put them on one-on-one observation and call the doctor to let them know. The DON stated the facility would call the psychiatrist and let them know as well so they can come and evaluate the resident. The DON stated she was not sure how the pharmacy in the company operates because she just started working at the facility on 5/22/23 as interim. The DON stated the staff should not leave the resident who was trying to commit suicide by themselves, and she would stay there and get the Doctor on the phone. The DON stated that was why she said if someone was suicidal, they need to be one on one observation. The DON stated she did not know what to say about the battery because the facility did not know he swallowed a battery until he came back from the hospital. The DON stated she understood that you do not turn your back on someone who is suicidal, but where there is a will there is a way, they will swallow even in your presence. In an interview on 6/29/23 at 2:57 p.m. with the Administrator, she stated she did not know what to say about the battery. In an interview on 6/29/23 at 3:00 p.m. with Unit Manager A, she stated the residents were not allowed to have razors and that the residents do not have access to razors, and they were in the supply room. Unit Manager A stated Resident #1 asked for razors today, 6/29/23 to shave himself with and she told him no and the facility would shave him. In an interview on 6/30/23 at 12:54 p.m. with the Medical Director, he stated the nursing home staff had been aware that Resident #1 was admitted with suicide ideations, and he had been followed by psychiatry and psychology in May 2023. The Medical Director stated Resident #1 denied that the resident made any outcries that he wanted to harm himself since being admitted at the facility. The Medical Director stated he did not know why Resident #1 had scissors or razors. The Medical Director stated he did not have his pain medicine because it was running low, and they were waiting for the attending physician to send in a refill. The Medical Director stated he was not aware the medication was completely out. The Medical Director stated an ileostomy bag was for hygiene and cleanliness, but sometimes due to the person's body or the way they were it may be difficult to keep the bag adhered. The Medical Director stated they want the bag to stay adhered for cleanliness, but if the stool leakage occurs and it was left unattended it could burn the skin. In an interview on 6/30/23 at 1:35 p.m. with the DON she stated she was told Resident #1 was sent to the hospital on 6/17/23. The DON stated if a patient needs to go to the hospital it needs to be from the Doctor or NP and If a resident said they wanted to go to the hospital they have to let the Dr know what's going on and they have to give the okay to send the resident out. The DON stated if the resident was admitted into the facility that means they were not on suicidal watch. She stated the moment the resident was admitted to the facility unless they voice out, they were suicidal they have to ask them what their plan was, then follow the steps of what they need to do. The DON stated it the resident had a diagnosis, there was nothing they would do if they were not voicing that they would hurt themselves. She stated although because the resident have the history of suicidal ideations, they would get psych services involved. The DON stated Resident #1 was not care planned for suicidal ideations and she stated she could not answer why, and she would have to get the MDS Coordinator to see why. The DON stated she did not know how Resident #1 got the scissors and razors. She stated when Resident #1 returned from the hospital on 6/25/23; they did a head-to-toe assessment and documented to make sure there were no new issues. The DON stated if the hospital deemed Resident #1 competent and okay to come back to the facility, then they go by the recommendations of what the hospital asked them to do. The DON stated if the hospital said they need psych services, the facility would follow the recommendations the hospital gave them. The DON stated she did not know why they were running out of [NAME] [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure each resident was free from abuse for 6 of 25 residents ( Resident #2, Resident #6, Resident #7, Resident #8, Resident #9 and Resident #10) reviewed for abuse. - The facility failed to ensure Resident #2, a resident with severe IDD and behaviors, was free from physical abuse on 03/31/23 from Resident #6 by placing them in the same room resulting in bleeding from the mouth and lacerations to the lip. - The facility failed to ensure Resident #8 was free from repeated physical abuse from Resident #7, resulting in Resident #8 suffering from a busted lip and a cigarette burn over multiple altercations. - The facility failed to ensure Resident #9, and Resident #10 were free from physical abuse from Resident #2, a resident with severe IDD and behaviors by placing them in the same room. On 05/22/23 at 03:21 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 05/29/23 at 07:10 PM, the facility remained out of compliance at an H (severity level of actual harm that is not immediate and a scope of pattern) due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures could place residents at risk of increased abuse, major injury and a decreased quality of life Findings included: Resident #2 Record review of Resident #2's Face Sheet dated 05/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: unspecified dementia, depression, difficulty swallowing, G-tube (a tube that goes into the stomach to provide food and medications), anxiety disorders, left hand contractures, right hand contractures and sever intellectual disabilities. Record review of Resident #2's Quarterly MDS dated [DATE] revealed, unclear speech, s rarely understood, sometimes understands, severely impaired cognition as indicated by a BIMS score of 00 out of 15, no response to resident mood interview questions, no documented behavioral symptoms (physical behaviors directed towards others, verbal behavioral symptoms directed to others or other behavioral symptoms not directed towards others), no rejection of care, no wandering, total dependence on all ADLs, use of a wheelchair, always incontinent of both bladder and bowel, non-traumatic brain dysfunction and left and right hand contractures. Record review of Resident #2's undated Care Plan printed 05/16/23 revealed, focus-IDD Resident #2 has been identified as PASRR positive related to intellectual disability; intervention- provide recommended services (habilitation coordination, independent living skills training and OT). Focus- nonverbal for communication needs/wants; potential for unmet needs/social isolation/boredom, escalating anxiety and agitation; intervention- provide emotional support to resident, refer resident for additional support relative to potential for escalating behaviors, referrals to psychiatric services for medication management and stabilization of behaviors. Focus- 2/09/23 Resident #2 was not hitting his roommate; intervention- resident was moved to another room. No incidents of physical aggression were documented on the Resident #2's care plan. No documentation of the type of Resident #2's behaviors. Record review of Resident #2's Census List starting at admission 08/25/22 to 05/18/23 revealed, since 01/2023 Resident #2 has had 3 room changes. Record review of Resident #2's Psychiatric assessment dated [DATE] signed by the Psychiatric NP revealed, reason for referral: anxiety, irritability, anger, non-verbal with a history of resistance and combative behaviors. Collateral information: aggression on and off. Record review of Resident #2's Nursing Note dated 02/10/23 at 01:34 PM and signed by LVN B revealed, Resident #2 initiated physical aggression against his roommate (Resident #9) on 02/09/23 LVN B was notified by the housekeeper that she saw Resident #2 hit his roommate while in bed. The roommate was moved out from room immediately. Record review of Resident #2's Nursing Note dated 02/22/23 at 05:46 PM signed by LVN B revealed, Patient is combative , hitting other patients. Patient was seen on his roommate's (Resident #10) body. Roommate (Resident #10) stated take this man out of here, I want peace. Resident #2 was taken to another room. Resident #2 was seen hitting other patients on the hallway, refused to stay in room. Record review of Resident #2's Psychiatric Provider note dated 02/22/23 revealed, Resident #2 was awake and agitated, monitored for behaviors and staff reported Resident #2 has been increasingly agitated and aggressive. He has been attempting to hit staff Orders to send to behavior hospital will be provided. Record review of Resident #2's Nursing Note dated 02/23/23 at 09:15 AM signed by LVN B revealed, Patient is becoming a threat to other patients and staff. He refused to stay in room Patient in hallway hitting everyone passing by. Patient needs to be moved to a psych hospital ASAP . Record review of Resident #2's Psychiatric assessment dated [DATE] signed by the Psychiatric NP revealed, reason for referral: aggression, hitting staff, hitting other residents, safety to self. Collateral Information: Staff reports patient has intermittent aggression towards others and fluctuating mood. Assessment/Plan: increased Risperdal (an antipsychotic) due to physical aggression, reported paranoia and negative symptoms. Severe IDD- is not treated with medications . There was no reference of the resident's appropriateness to have a roommate. Record review of Resident #2's Psychiatric Provider note dated 02/24/23 revealed, behavioral hospital admission denied. Record review of Resident #2's Nursing Note dated 03/31/23 at 11:55 AM signed by LVN C revealed, at about 09:35 AM write noted Resident #2 roommate (Resident #6) standing over residents' wheelchair pushing wheelchair over resident. Resident #2 was noted to be lying on the floor between bed and wheelchair with blood coming from his mouth. LVN C separated the residents and Resident #6 got into bed and stated, somebody better get him before I kill him. Laceration noted to upper lip area, Resident #2 was brought to the nurse's station in a wheelchair at which he was observed to hit another resident while sitting at the nursing station. At this time facility is working on room changes for resident and possible admit to psych facility. Record review of Resident #2's Nursing Note dated 03/31/23 at 01:12 PM signed by LVN B revealed, LVN B was told by staff that at 08:00 AM Resident #2 was hit by his roommate (Resident #6) because he was close to his bed, so the patient was taken out of the room. At 09:00 AM, Resident #2 was returned to his bed because he was throwing himself off the wheelchair at which point another staff saw Resident #6 hitting Resident #2 using a wheelchair. At 11:02, LVN B observed Resident #6 hitting Resident #2 with a shoe. Record review of Resident #2's Social Worker Notes dated 03/31/23 signed by Social Worker A revealed, referral made for inpatient psych evaluation and stay for Resident #2, but admission was denied to resident being unable to advocate for himself. Resident sent out for acute medical ER for evaluation. PLEASE NOTE when resident returns to facility, he will need to go to a different room from previous room with roommate. Record review of Resident #2's Psychiatric assessment dated [DATE] signed by the Psychiatric NP revealed, reason for referral: aggression, hitting staff, hitting other residents, safety to self. Collateral Information: staff reports patient can be irritable and restless. An observation on 05/17/23 at 08:13 AM revealed, Resident #2 sleeping in bed in no immediate distress with contracted left and right hands wearing hand rolls with fingernails approximately 1/4 inch long. An observation on 05/17/23 at 11:55 AM revealed, Resident #2 on knees on the floor playing with his gown on the side of his fall mat. Resident #6 Record review of Resident #6's Face Sheet dated 05/17/23 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, bipolar disorder, delusional disorders, unspecified psychosis, and hypertension. Record review of Resident #6's undated Care Plan printed 05/17/23 revealed, focus- PASRR positive related to severe mental illness; intervention- continue psychiatrist services at the facility. Focus- diagnosis of bipolar disorder with risk for inappropriate behaviors; Goal- Resident #6 will not harm himself or others; intervention- psych consult, monitor behaviors ever shift. Focus- Resident #6 has displayed frequent episodes of refusal of medications and ADL cares and was at risk for injury; Interventions- keep MD/NP informed of resident's refusal of medications and/or ADL care. Focus initiated on 10/28/21 and revised on 04/20/22- diagnoses of schizophrenia, bipolar disorder, psychosis, delusional disorder. sometimes become aggressive with facility properties and staff. Focus- ADL self-care deficits and is at risk for further decline in ADL functioning and injury; intervention- Resident #6 will be well dressed, groomed and clean; intervention- 1on1 for personal hygiene. Record review of Resident #6's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 03 out of 15, no signs of delirium, no rejection of care, supervision with most ADLs, use of a wheelchair and occasionally incontinent of both bladder and bowel. Record review of Resident #6's Psychiatric Subsequent assessment dated [DATE] and signed by the Psychiatric NP revealed, Mental Status Examination- risk of aggression none. Record review of Resident #6's Psychiatric Subsequent assessment dated [DATE] and signed by the Psychiatric NP revealed, Mental Status Examination- risk of aggression none. Record review of Resident #6's Incident and Accident Report dated 03/31/23 signed by LVN B revealed, LVN B was informed by staff that at 08:00 AM Resident #6 was seen hitting his roommate (Resident #2) because he was close to his bed. Another staff also saw roommate Resident #6 hitting Resident #2 with a wheelchair. At 11:02 AM, LVN B also saw Resident #6 hitting Resident #2 with a shoe. Record review of Resident #6's Psychological Services Supportive Care Progress Note from 03/29/23 to 04/19/23 revealed, no reference to Resident #6 assaulting Resident #2 on 3 different occasions on 03/31/23. Record review of Resident #6's Psychiatric Subsequent assessment dated [DATE] and signed by the Psychiatric NP revealed, Collateral Information: staff reports Resident #6 has been refusing his medication for weeks and had behavioral physical incident with his roommate. Mental Status Examination- risk of aggression none. An observation and interview on 05/18/23 at 12:00 PM revealed, Resident #6 lying in bed in no immediate distress. Resident #6 said he did not remember any incidents of physical aggression with Resident #2. In an interview of 05/17/23 at 11:22 AM, LVN B said Resident #6 was usually verbally and physically aggressive and did not want to be disturbed. She said on 03/31/23 Resident #6 attacked Resident #2 on three different occasions of which she witnessed the third. LVN B said she was informed that Resident #6 had hit Resident #2 once in the morning and later- on, in the morning Resident #6 pushed a wheelchair over Resident #2 as he laid on the floor causing Resident #2 to bleed from the mouth. She said Resident #2 was initially removed from the room, but he was later returned to the same room as Resident #6 because there was no other room to place him, and Resident #2 kept throwing himself on the floor and it was at that point that she witnessed Resident #6 hit Resident #2 with a shoe. LVN B said she immediately separated the two residents and placed Resident #2 at the nursing station until he was sent out of evaluation. She said the expectation for resident-to-resident altercations was that the resident's be immediately separated to prevent further abuse and Resident #2 should not have been returned to the same room as Resident #6. In an interview on 05/18/23 at 11:43 AM, the Administrator said she failed to identify that Resident #6 was the perpetrator of abuse against Resident #2 on 03/31/23. She said she believed Resident #1 assaulted Resident #2 and completed her investigation based on that. She could not explain why she believed the assailant was Resident #1 and not Resident #6. The Administrator said she did not look into Resident #6 at all, she did not notify the provider about Resident #6's aggression and no corrective action was taken about Resident #6's assault of Resident #2. She said since she did not investigate Resident #6, she did not know staff identified him as being physically aggressive or that the NP would be removing Resident #6's psych meds due to the resident refusing. The Administrator said based on the information she learned about Resident #6, it was not appropriate for the resident to have a roommate due to him being a danger to others. She said failure to investigate the correct resident could place residents at risk of injury. In an interview on 05/18/23 at 12:56, the Psychiatric NP said Resident #6 had history of aggression and she was never informed of the incidents of abuse between Resident #6 and Resident #2 that occurred on 03/31/23. She said Resident #6 had been refusing all his medications including his psych medications, so her plan was to GDR to discontinue all his medications. The Psychiatric NP said the facility was expected to notify her of any cases of physical aggression in any residents but it would not have mattered in this case because Resident #6 had refused all his medication so she could not make any pharmaceutical interventions and therapist handles non-pharmaceutical interventions. When asked how Resident #6's behaviors would be controlled and if his lack of medication would place others in danger, the Psychiatric NP said if Resident #6 was deemed to be a risk to himself or other then he would have to be sent out to a behavioral hospital Resident #9 Record review of Resident #9's face sheet dated 05/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: dementia and bipolar disorder with psychotic features. Record review of Resident #9's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, total dependence on most ADLs and always incontinent of both bladder and bowel. Record review of Resident #9's undated Care Plan dated 05/25/23 revealed Focus- Resident #6 has potential to be verbally/physically aggressive behaviors related bipolar disorder; interventions- analyze key times, places, circumstances, triggers and what de-escalates behaviors and document. Record review of Resident #9's Psychiatric Subsequent assessment dated [DATE] signed by the Psychiatric NP revealed, mental status examination- risk of aggression: physical. Record review of Resident #9's Psychiatric Subsequent assessment dated [DATE] signed by the Psychiatric NP revealed, mental status examination- risk of aggression: physical. Record review of Resident #9's Progress Notes dated 02/10/23 and signed by LVN B revealed, housekeeper stated she saw Resident #9 being hit by his roommate (Resident #2). Resident #9 was moved out from the room immediately, a head-to-toe assessment was performed and no bruising or bleeding was noted. Record review of Resident #9's Psychiatric Subsequent assessment dated [DATE] signed by the Psychiatric NP revealed, mental status examination- risk of aggression: physical. Collateral Information: no mood or behavior changes reported by staff. Resident #10 Record review of Resident #10's Face Sheet dated 05/23/23 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, partial traumatic amputation level between knee and ankle and chronic pain syndrome. Record review of Resident #10's quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, no behaviors, total dependence on most ADLs. Record review of Resident #10's undated Care Plan printed 05/25/23 revealed, focus- below the right knee amputation. Record review of Resident #10's 02/2023 Progress Notes revealed, no documentation of Resident #10 being hit by Resident #2. Record review of Resident #10's Census List printed 05/18/23 revealed, Resident #10 was in room [ROOM NUMBER]-A from 02/11/23 to 02/23/23. In an interview of 05/17/23 at 11:22 AM, LVN B said Resident #2's behaviors involve throwing himself on the floor, throwing himself on roommates, hitting residents and staff. She said Resident #2 will always instigate altercations with his roommates and she feels like Resident #2 should be in a room by himself because of his behaviors. She said Resident #2 was a fall risk so the idea from administration was to place him with a roommate that could watch him and report any falls or injuries Resident #2 may suffer. LVN B said Resident #2 has had multiple altercations with different roommates like Resident #6, Resident #9 and Resident #10. LVN B said Resident #2 had a severe intellectual disability and could not control his behaviors, his behaviors were not intentional and he did not understand what he was doing to others. In an interview on 05/18/23 at 12:43 PM, Resident #31 said his roommate Resident #2 has a history of hitting other residents. He said prior to rooming with Resident #2 the resident had hit him in the hallway so he was concerned about rooming with him in case he hit him, but he guessed that the facility put them together so he could look out for Resident #2 since he falls. Resident #31 said so far, he had not had any issues with Resident #2 because the resident was sick and had not been active. He said Resident #2's behaviors included getting on the floor to just stare at him (Resident #31) and rolling off his own bed blocking the door . Resident #31 said he has not had any issues with Resident #2 so far but if he did, he would hurt Resident #2. In an interview on 05/18/23 at 12:56, the Psychiatric NP said Resident #2 admitted to the facility with a diagnosis of severe IDD. She said his behaviors include jumping off the bed, hitting and touching others and she can see him instigating altercations with other residents. She said that these behaviors are his baseline, and his behaviors c could be troublesome to his roommates. When asked if Resident #2 was appropriate for a roommate, the Psychiatric NP would not answer. Resident #7 Record review of Resident #7's Face Sheet dated 05/23/23 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: dementia without behavioral disturbance, psychotic disturbance, depression, and anxiety. Record review of Resident #7's quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 10 out of 15, no potential indicators of psychosis such as hallucinations and delusions. No behavioral symptoms directed towards others, no verbal behavioral symptoms directed towards others, no behavioral symptoms not directed towards others, supervision needed for locomotion on the unit, supervision needed for location off the unit and use of a manual wheelchair. Record review of Resident #7's undated Care Plan revealed, focus- have verbal aggressive behavior (cussing staff) related to dementia. Focus- Resident #7 has been physically aggressive; goal- Resident #7 will demonstrate effective coping skills through the review date. Record review of Resident #7's Incident by Incident Type Report from 11/01/22 to 05/23/23 revealed, Resident #7 initiated 3 separate incidents of physical aggression on 11/19/22, 05/03/23 and 05/17/23. Record review of Resident #7's Psychiatric Subsequent assessment dated [DATE] and signed by the Psychiatric NP revealed, reason for referral: verbal aggression and resistance to care. Collateral information: staff reports patient behaviors have not worsened, patient calmer since medication changes. Mental Status Examination- risk of aggression: none. Record review of Resident #7's Progress Notes dated 11/19/22 at 9:56 PM revealed, Resident #7 assaulted another resident (Resident #8) outside in the smoking area. He punched him on the mouth resulting in a laceration on the lip, the residents were separated and the provider, DON and Administrator were notified. Record review of Resident #7's Progress Notes dated 11/21/22 at 11:16 AM and signed by DON C revealed, Resident #7 had a history of assaulting people and due to his institutionalized mentality, he will continue to strike out physically and he is not appropriate for the facility. Resident #7 as unapologetic about his behavior and has repeatedly stated if he says anything to me, I will hit him again. Staff continued to make frequent rounds monitoring Resident #7's interactions with others. Record review of Resident #7's Progress Notes dated 11/21/22 at 02:09 PM and signed by the Social Worker B, RP notified Resident #7 was not appropriate for continued stay in the interest of safety for others. During past months since admission Resident #7 has had significant physically aggressive behaviors towards other residents. Record review of Resident #7's 'Psychiatric Subsequent Assessment' dated 12/03/22 revealed, patient admits that he recently had an altercation with another resident and stated that it wasn't his fault. Collateral Information: staff reports patient recently punched another resident (Resident #8) in the face . Reports there was an altercation in the smoking area. Record review of Resident #7's Fair Hearing Medicaid Nursing Facility Discharge' letter dated 01/12/23 revealed, the facility could not discharge Resident #7 based on events that occurred on or prior to a discharge letter issued on 11/29/22 because, the hearing officer did not receive evidence from the facility prior to the hearing and a representative from the facility was not present at the hearing on 12/28/22 to explain or support the facility's actions to discharge Resident 7 so the Hearings Officer closed the record without a response from the facility. Record review of Resident #7's Progress Notes dated 05/03/23 at 05:15 AM revealed, Resident #7 struck another resident in dining area, resident was escorted back to room and both parties were divided. Record review of Resident #7's Physician's Notes dated 05/15/23 revealed, Resident #7 continues to be receptive to supportive care and there have been no changes in moods or behaviors. There are no complaints at this time. Record review of Resident #7's Progress Notes dated 05/17/23 at 10:36 PM revealed, at 07:30 AM Resident #8 was brought to the nursing station and told the nurse that Resident #7 hit him in the face and the chest. Resident #7 said Resident #8 called him a derogatory term and that was the reason he punched him in the face. Record review of Resident #7's Social Worker A dated 05/18/23 at 10:44 AM revealed, Resident #7 hit another resident (Resident #8) late in the evening yesterday Resident would benefit from emergency psych evaluation as he was a current threat to other residents due to his disorientation and confusion. An observation and Interview on 05/17/23 at 09:55 AM revealed, Resident #7 lying in bed well-groomed and in no immediate distress. He said a white man in a wheelchair hit him in the back so he came back and hit him back. He said Resident #8 talked about his mother and that was why he hit Resident #8, he said he had not had any other issues with any other residents and no other issues with Resident #7. In an interview on 05/24/23 at 01:16 PM, the Assistant Administrator said there was no incident report on record for the incident involving Resident #7 and #8 on 11/19/22. Resident #8 Record review of Resident #8's Face Sheet printed 06/15/23 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: paraplegia (paralysis of the legs and lower body), history of traumatic brain injury, type 2 diabetes, mood disorder, assault by unspecified firearm. Record review of Resident #8's quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, no signs of delirium or hallucinations, no physical behavioral symptoms directed toward others, no verbal behavioral symptoms directed towards others, no other behavioral symptoms not directed toward others, no rejection of care, total dependence on most ADLs and use of a wheelchair. Record review of Resident #8's undated Care Plan revealed, focus- Resident #8 was a smoker with potential for injury. Record review of Resident #8's Incident/Accident Report dated 11/18/22 at 07:30 PM revealed, Resident #7 punched Resident #8 in the mouth at 07:00 PM resulting in a laceration to the lip while outside in the smoke area. Record review of Resident #8's Progress Notes dated 11/19/22 at 07:03 AM revealed, Resident #7 punched Resident #8 on 11/18/22 at 07:00 PM in the mouth when both of them were in the smoking area and Resident #8 had a deep laceration to his lip. Resident #8 stated Resident #7 punched him because he told him to stop assaulting staff because of cigarettes . Resident #8 was assessed, and MD was notified about laceration who gave orders for the resident to be sent out to the hospital for sutures. Resident #8 was sent to the hospital on 11/18/22 at 07:00 PM. Record review of Resident #8's Progress Notes dated 11/19/22 at 07:33 AM revealed, Resident #8 returned from the Hospital on 11/19/22 at 04:00 AM and did not appear to have stitches. Record review of Resident #8's Progress Notes dated 11/19/22 at 11:31 AM revealed, Resident #8 said Resident #7 threw finger at him and was yelling at him. Resident #8 was escorted out of the dining room to go out during smoke time. Record review of Resident #8's Physician Note dated 11/22/22 revealed, Resident #8 was reportedly punched in the face by another resident (Resident #7). Resident #8 sustained a laceration to the lip; he was sent to the ER however he did not have any sutures placed. Record review of Resident #8's Progress Note dated 05/03/22 revealed, Resident #8 got hit by another resident (Resident #7) on his chest in the dining room. Resident #8 said he was yelling for someone to adjust him properly in his chair and the Resident #7 got irritated wheeled close to him and hit him in the chest. Head to toe assessment completed and Resident #8 had no bruising or swelling noted. Record review of Resident #8's Progress Notes dated 05/17/23 at 07:30 PM revealed, Resident #8 got into a fight with Resident #7 on the smoking patio but the incident was not witnessed. Resident #7 hit Resident #8 on the lips chest and ne ck. Resident #8 was observed to have bruised lips, a purple bruise on the neck/throat area from trauma and Resident #8 reported Resident #7 burned him with a cigarette to which a blister was observed . Record review of Resident #8's Physician Note dated 05/23/23 signed by MD A revealed, chief complaint: follow up for coffee burn, cigarette burn, sunburn and trauma to neck. MD A was notified by staff on 05/23/23 that Resident #8 was in a fight with another resident in which he was punched in the jaw/neck and sustained a cigarette burn to his right arm. Resident #8 still has a bruise to his neck, but the cigarette burn was almost healed. An observation and Interview on 05/21/23 at 06:27 PM revealed, Resident #8 sitting in his wheelchair in his room, well-groomed and in no immediate distress. Resident #8 said he has had multiple altercations with Resident #7 and he didn't feel safe in the facility when Resident #7 was there. He said Resident #7 always curses at him in the hallways, the dining room and in the smoking area every day. Resident #8 said the facility has made no efforts to move Resident #7 so they don't meet in the hallway, change their dinning or smoking breaks and did not ensure they were separated or supervised during meals in the dining room or smoke breaks in the courtyard even though he had made multiple complaints. Resident #8 said Resident #7 has punched him in the chest and lip on multiple occasions causing him to bleed and get stitches. He said in the last incident Resident #7 burned him on his arm with a cigarette. He said the facility have taken no action to ensure he was safe from Resident #7. In an interview on 05/17/23 at 09:00 AM, the Administrator said she was the abuse coordinator and she was responsible for reporting and investigating all allegations of abuse and neglect. She said when there was a resident to resident altercation nursing staff are expected to separate the resident's immediately to ensure their safety, complete head to toe assessments and then notify the family, the MD and then facility administration. She said if residents have a history of physical aggression they should be supervised or separated from others to ensure they are not a danger. The Administrator said failure to take appropriate action following an allegation/incident of abuse places residents at risk of further abuse and injury. In an interview on 05/17/23 at 09:05 AM, DON A said following a resident-to-resident altercation residents must be immediately separated immediately for safety, a head to toe assessment must be completed and documented. She said at no point in time should a resident be returned to the same room as the assailant and in the long term the residents should not be left alone unsupervised in the same area for safety. In an interview on 05/17/23 at 08:45 AM, the Assistant Administrator said on 05/03/23 he heard Resident #8 screaming and observed Resident #7 pushing back. He said the nurses reported that Resident #7 hit Resident #8 twice in the chest because Resident #8 was screaming which agitated Resident #7 and caused him to hit Resident #8 in response. The Assistant Administrator said the residents were separated and there have been no incidents since then. He said there had been previous incidents between Resident #7 and Resident #8 in the smoking area, when Resident #8 took up for the staff so Resident #7 hit him in the face. The Administrator said he believed Resident #8 was triggered by loud noises. In an interview on 05/18/23 at 10:30 AM, the Administrator said she was the facility abuse coordinator and was responsible for investigating all allegations of abuse. She said once an allegation of abuse was made or abuse was observed nursing staff are required to stop the abuse, ensure the resident was safe, the nurse performs a head-to-toe assessment checking for injuries and then report the incident to her. The Administrator said she or the designees are responsible to complete a thorough investigation completing witness statements from staff, any alert residents and any staff or residents who have interactions with the perpetrator. She said the facility staff must perform follow up assessments with residents for a week following the alleged incident of abuse. She said failure to complete detailed investigations and implement facility policies on abuse places residents at risk for further abuse. The Administrator was unable to describe what action was taken to prevent abuse with Resident #2, Resident 5, Resident #6, Resident #7. Resident #8, Resident #9 and Resident #10. In an interview on 05/22/23 at 04:00 PM, the Assistant Administrator said following the incident on 05/18/23 Resident #7 was sent out to a behavioral hospital and he will not be returning. He said Resident #7 and Resident #8 have had multiple altercations in the smoking area and the dining area. He said Resident #7 and Resident #8 normally take their smoking break or dining area together and to his knowledge there have never been measures in place to ensure that these two re [TRUNCATED]

Based on interview and record review the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 7 of 22 Residents (Resident #2, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, and Resident #10) reviewed for abuse. 1. The facility failed to ensure Resident #2, a resident with severe IDD and behaviors, was free from abuse on 03/31/23 from Resident #6 by placing them in the same room resulting in bleeding and injuries. 2. The facility failed to ensure Resident #8 was free from repeated abuse from Resident #7, resulting in Resident #8 suffering from a busted lip and a cigarette burn over multiple altercations. 3. The facility failed to ensure Resident #9 and Resident #10 were free from abuse from Resident #2, a resident with severe IDD and behaviors by placing them in the same room. 4. The facility failed to perform a detailed investigation and follow her documented provider action taken post investigation for an allegation of abuse regarding Resident #5 by allowing CNA X to return to work with residents who could not speak for themselves in the secure unit. On 05/22/23 at 03:21 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 05/29/23 at 07:10 PM, the facility remained out of compliance at an H (severity level of actual harm that is not immediate and a scope of pattern) due to the facility continuing to monitor the implementation and effectiveness of their plan of removal These failures could place residents at risk of increased abuse, major injury, and decreased quality of life. Findings Included Resident #2 Record review of Resident #2's Face Sheet dated 05/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: unspecified dementia, depression, difficulty swallowing, G-tube (a tube that goes into the stomach to provide food and medications), anxiety disorders, left hand contractures, right hand contractures and sever intellectual disabilities. Record review of Resident #2's Quarterly MDS dated [DATE] revealed, unclear speech, s rarely understood, sometimes understands, severely impaired cognition as indicated by a BIMS score of 00 out of 15, no response to resident mood interview questions, no documented behavioral symptoms (physical behaviors directed towards others, verbal behavioral symptoms directed to others or other behavioral symptoms not directed towards others), no rejection of care, no wandering, total dependence on all ADLs, use of a wheelchair, always incontinent of both bladder and bowel, non-traumatic brain dysfunction and left and right hand contractures. Record review of Resident #2's undated Care Plan printed 05/16/23 revealed, focus-IDD Resident #2 has been identified as PASRR positive related to intellectual disability; intervention- provide recommended services (habilitation coordination, independent living skills training and OT). Focus- nonverbal for communication needs/wants; potential for unmet needs/social isolation/boredom, escalating anxiety and agitation; intervention- provide emotional support to resident, refer resident for additional support relative to potential for escalating behaviors, referrals to psychiatric services for medication management and stabilization of behaviors. Focus- 2/09/23 Resident #2 was not hitting his roommate; intervention- resident was moved to another room. No incidents of physical aggression were documented on the Resident #2's care plan. No documentation of the type of Resident #2's behaviors. Record review of Resident #2's Census List starting at admission 08/25/22 to 05/18/23 revealed, since 01/2023 Resident #2 has had 3 room changes. Record review of Resident #2's Psychiatric assessment dated [DATE] signed by the Psychiatric NP revealed, reason for referral: anxiety, irritability, anger, non-verbal with a history of resistance and combative behaviors. Collateral information: aggression on and off. Record review of Resident #2's Nursing Note dated 02/10/23 at 01:34 PM and signed by LVN B revealed, Resident #2 initiated physical aggression against his roommate (Resident #9) on 02/09/23 LVN B was notified by the housekeeper that she saw Resident #2 hit his roommate while in bed. The roommate was moved out from room immediately. Record review of Resident #2's Nursing Note dated 02/22/23 at 05:46 PM signed by LVN B revealed, Patient is combative, hitting other patients. Patient was seen on his roommate's (Resident #10) body. Roommate (Resident #10) stated take this man out of here, I want peace. Resident #2 was taken to another room. Resident #2 was seen hitting other patients on the hallway, refused to stay in room. Record review of Resident #2's Psychiatric Provider note dated 02/22/23 revealed, Resident #2 was awake and agitated, monitored for behaviors and staff reported Resident #2 has been increasingly agitated and aggressive. He has been attempting to hit staff Orders to send to behavior hospital will be provided. Record review of Resident #2's Nursing Note dated 02/23/23 at 09:15 AM signed by LVN B revealed, Patient is becoming a threat to other patients and staff. He refused to stay in room. Patient in hallway hitting everyone passing by. Patient needs to be moved to a psych hospital ASAP. Record review of Resident #2's Psychiatric assessment dated [DATE] signed by the Psychiatric NP revealed, reason for referral: aggression, hitting staff, hitting other residents, safety to self. Collateral Information: Staff reports patient has intermittent aggression towards others and fluctuating mood. Assessment/Plan: increased Risperdal (an antipsychotic) due to physical aggression, reported paranoia and negative symptoms. Severe IDD- is not treated with medications. There was no reference of the resident's appropriateness to have a roommate. Record review of Resident #2's Psychiatric Provider note dated 02/24/23 revealed, behavioral hospital admission denied. Record review of Resident #2's Nursing Note dated 03/31/23 at 11:55 AM signed by LVN C revealed, at about 09:35 AM writer noted Resident #2's roommate (Resident #6) standing over residents' wheelchair pushing wheelchair over resident. Resident #2 was noted to be lying on the floor between bed and wheelchair with blood coming from his mouth. LVN C separated the residents and Resident #6 got into bed and stated, somebody better get him before I kill him. Laceration noted to upper lip area, Resident #2 was brought to the nurse's station in a wheelchair at which he was observed to hit another resident while sitting at the nursing station. At this time facility is working on room changes for resident and possible admit to psych facility. Record review of Resident #2's Nursing Note dated 03/31/23 at 01:12 PM signed by LVN B revealed, LVN B was told by staff that at 08:00 AM Resident #2 was hit by his roommate (Resident #6) because he was close to his bed, so the patient was taken out of the room. At 09:00 AM, Resident #2 was returned to his bed because he was throwing himself off the wheelchair at which point another staff saw Resident #6 hitting Resident #2 using a wheelchair. At 11:02, LVN B observed Resident #6 hitting Resident #2 with a shoe. Record review of Resident #2's Social Worker Notes dated 03/31/23 signed by Social Worker A revealed, referral made for inpatient psych evaluation and stay for Resident #2, but admission was denied to resident being unable to advocate for himself. Resident sent out for acute medical ER for evaluation. PLEASE NOTE when resident returns to facility, he will need to go to a different room from previous room with roommate. Record review of Resident #2's Psychiatric assessment dated [DATE] signed by the Psychiatric NP revealed, reason for referral: aggression, hitting staff, hitting other residents, safety to self. Collateral Information: staff reports patient can be irritable and restless. An observation on 05/17/23 at 11:55 AM revealed, Resident #2 on needs on the floor playing with his gown on the side of his fall mat. Resident #6 Record review of Resident #6's Face Sheet dated 05/17/23 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, bipolar disorder, delusional disorders, unspecified psychosis, and hypertension. Resident #6 did not have a diagnosis of contractures. Record review of Resident #6's undated Care Plan printed 05/17/23 revealed, focus- PASRR positive related to severe mental illness; intervention- continue psychiatrist services at the facility. Focus- diagnosis of bipolar disorder with risk for inappropriate behaviors; Goal- Resident #6 will not harm himself or others; intervention- psych consult, monitor behaviors ever shift. Focus- Resident #6 has displayed frequent episodes of refusal of medications and ADL cares and was at risk for injury; Interventions- keep MD/NP informed of resident's refusal of medications and/or ADL care. Focus initiated on 10/28/21 and revised on 04/20/22- diagnoses of schizophrenia, bipolar disorder, psychosis, delusional disorder. sometimes become aggressive with facility properties and staff. Focus- ADL self-care deficits and is at risk for further decline in ADL functioning and injury; intervention- Resident #6 will be well dressed, groomed and clean; intervention- 1on1 for personal hygiene. Record review of Resident #6's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 03 out of 15, no signs of delirium, no rejection of care, supervision with most ADLs, use of a wheelchair and occasionally incontinent of both bladder and bowel. Record review of Resident #6's Psychiatric Subsequent assessment dated [DATE] and signed by the Psychiatric NP revealed, Mental Status Examination- risk of aggression none. Record review of Resident #6's Psychiatric Subsequent assessment dated [DATE] and signed by the Psychiatric NP revealed, Mental Status Examination- risk of aggression none. Record review of Resident #6's Incident and Accident Report dated 03/31/23 signed by LVN B revealed, LVN B was informed by staff that at 08:00 AM Resident #6 was seen hitting his roommate (Resident #2) because he was close to his bed. Another staff also saw roommate Resident #6 hitting Resident #2 with a wheelchair. At 11:02 AM, LVN B also saw Resident #6 hitting Resident #2 with a shoe. Record review of Resident #6's Psychological Services Supportive Care Progress Note from 03/29/23 to 04/19/23 revealed, no reference to Resident #6 assaulting Resident #2 on 3 different occasions on 03/31/23. Record review of Resident #6's Psychiatric Subsequent assessment dated [DATE] and signed by the Psychiatric NP revealed, Collateral Information: staff reports Resident #6 has been refusing his medication for weeks and had behavioral physical incident with his roommate. Mental Status Examination- risk of aggression none. An observation and interview on 05/18/23 at 12:00 PM revealed, Resident #6 lying in bed in no immediate distress. Resident #6 said he did not remember any incidents of physical aggression with Resident #2. In an interview of 05/17/23 at 11:22 AM, LVN B said Resident #6 was usually verbally and physically aggressive and did not want to be disturbed. She said on 03/31/23 Resident #6 attacked Resident #2 on three different occasions of which she witnessed the third. LVN B said she was informed that Resident #6 had hit Resident #2 once in the morning and later-on, in the morning Resident #6 pushed a wheelchair over Resident #2 as he laid on the floor causing Resident #2 to bleed from the mouth. She said Resident #2 was initially removed from the room, but he was later returned to the same room as Resident #6 because there was no other room to place him, and Resident #2 kept throwing himself on the floor and it was at that point that she witnessed Resident #6 hit Resident #2 with a shoe. LVN B said she immediately separated the two residents and placed Resident #2 at the nursing station until he was sent out of evaluation. She said the expectation for resident-to-resident altercations was that the resident's be immediately separated to prevent further abuse and Resident #2 should not have been returned to the same room as Resident #6. In an interview on 05/18/23 at 11:43 AM, the Administrator said she failed to identify that Resident #6 was the perpetrator of abuse against Resident #2 on 03/31/23. She said she believed Resident #1 assaulted Resident #2 and completed her investigation based on that. She could not explain why she believed the assailant was Resident #1 and not Resident #6. The Administrator said she did not look into Resident #6 at all, she did not notify the provider about Resident #6's aggression and no corrective action was taken about Resident #6's assault of Resident #2. She said since she did not investigate Resident #6, she did not know staff identified him as being physically aggressive or that the NP would be removing Resident #6's psych meds due to the resident refusing. The Administrator said based on the information she learned about Resident #6, it was not appropriate for the resident to have a roommate due to him being a danger to others. She said failure to investigate the correct resident could place residents at risk of injury. In an interview on 05/18/23 at 12:56, the Psychiatric NP said Resident #6 had history of aggression and she was never informed of the incidents of abuse between Resident #6 and Resident #2 that occurred on 03/31/23. She said Resident #6 had been refusing all his medications including his psych medications, so her plan was to GDR to discontinue all his medications. The Psychiatric NP said the facility was expected to notify her of any cases of physical aggression in any residents but it would not have mattered in this case because Resident #6 had refused all his medication so she could not make any pharmaceutical interventions and therapist handles non-pharmaceutical interventions. When asked how Resident #6's behaviors would be controlled and if his lack of medication would place others in danger, the Psychiatric NP said if Resident #6 was deemed to be a risk to himself or other then he would have to be sent out to a behavioral hospital Resident #9 Record review of Resident #9's face sheet dated 05/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: dementia and bipolar disorder with psychotic features. Record review of Resident #9's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, total dependence on most ADLs and always incontinent of both bladder and bowel. Record review of Resident #9's undated Care Plan dated 05/25/23 revealed Focus- Resident #6 has potential to be verbally/physically aggressive behaviors related bipolar disorder; interventions- analyze key times, places, circumstances, triggers and what de-escalates behaviors and document. Record review of Resident #9's Psychiatric Subsequent assessment dated [DATE] signed by the Psychiatric NP revealed, mental status examination- risk of aggression: physical. Record review of Resident #9's Psychiatric Subsequent assessment dated [DATE] signed by the Psychiatric NP revealed, mental status examination- risk of aggression: physical. Record review of Resident #9's Progress Notes dated 02/10/23 and signed by LVN B revealed, housekeeper stated she saw Resident #9 being hit by his roommate (Resident #2). Resident #9 was moved out from the room immediately, a head-to-toe assessment was performed and no bruising or bleeding was noted. Record review of Resident #9's Psychiatric Subsequent assessment dated [DATE] signed by the Psychiatric NP revealed, mental status examination- risk of aggression: physical. Collateral Information: no mood or behavior changes reported by staff. Resident #10 Record review of Resident #10's Face Sheet dated 05/23/23 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, partial traumatic amputation level between knee and ankle and chronic pain syndrome. Record review of Resident #10's quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, no behaviors, total dependence on most ADLs. Record review of Resident #10's undated Care Plan printed 05/25/23 revealed, focus- below the right knee amputation. Record review of Resident #10's 02/2023 Progress Notes revealed, no documentation of Resident #10 being hit by Resident #2. Record review of Resident #10's Census List printed 05/18/23 revealed, Resident #10 was in room [ROOM NUMBER]-A from 02/11/23 to 02/23/23. In an interview of 05/17/23 at 11:22 AM, LVN B said Resident #2's behaviors involve throwing himself on the floor, throwing himself on roommates, hitting residents and staff. She said Resident #2 will always instigate altercations with his roommates and she feels like Resident #2 should be in a room by himself because of his behaviors. She said Resident #2 was a fall risk so the idea from administration was to place him with a roommate that could watch him and report any falls or injuries Resident #2 may suffer. LVN B said Resident #2 has had multiple altercations with different roommates like Resident #6, Resident #9 and Resident #10. LVN B said Resident #2 had a severe intellectual disability and could not control his behaviors, his behaviors were not intentional and he did not understand what he was doing to others. In an interview on 05/18/23 at 12:43 PM, Resident #31 said his roommate Resident #2 has a history of hitting other residents. He said prior to rooming with Resident #2 the resident had hit him in the hallway so he was concerned about rooming with him in case he hit him, but he guessed that the facility put them together so he could look out for Resident #2 since he falls. Resident #31 said so far, he had not had any issues with Resident #2 because the resident was sick and had not been active. He said Resident #2's behaviors included getting on the floor to just stare at him (Resident #31) and rolling off his own bed blocking the door. Resident #31 said he has not had any issues with Resident #2 so far but if he did, he would hurt Resident #2. In an interview on 05/18/23 at 12:56, the Psychiatric NP said Resident #2 admitted to the facility with a diagnosis of severe IDD. She said his behaviors include jumping off the bed, hitting and touching others and she can see him instigating altercations with other residents. She said that these behaviors are his baseline, and his behaviors could be troublesome to his roommates. When asked if Resident #2 was appropriate for a roommate, the Psychiatric NP would not answer. Resident #7 Record review of Resident #7's Face Sheet dated 05/23/23 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: dementia without behavioral disturbance, psychotic disturbance, depression, and anxiety. Record review of Resident #7's quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 10 out of 15, no potential indicators of psychosis such as hallucinations and delusions. No behavioral symptoms directed towards others, no verbal behavioral symptoms directed towards others, no behavioral symptoms not directed towards others, supervision needed for locomotion on the unit, supervision needed for location off the unit and use of a manual wheelchair. Record review of Resident #7's undated Care Plan revealed, focus- have verbal aggressive behavior (cussing staff) related to dementia. Focus- Resident #7 has been physically aggressive; goal- Resident #7 will demonstrate effective coping skills through the review date. Record review of Resident #7's Incident by Incident Type Report from 11/01/22 to 05/23/23 revealed, Resident #7 initiated 3 separate incidents of physical aggression on 11/19/22, 05/03/23 and 05/17/23. Record review of Resident #7's Psychiatric Subsequent assessment dated [DATE] and signed by the Psychiatric NP revealed, reason for referral: verbal aggression and resistance to care. Collateral information: staff reports patient behaviors have not worsened, patient calmer since medication changes. Mental Status Examination- risk of aggression: none. Record review of Resident #7's Progress Notes dated 11/19/22 at 9:56 PM revealed, Resident #7 assaulted another resident (Resident #8) outside in the smoking area. He punched him on the mouth resulting in a laceration on the lip, the residents were separated and the provider, DON and Administrator were notified. Record review of Resident #7's Progress Notes dated 11/21/22 at 11:16 AM and signed by DON C revealed, Resident #7 had a history of assaulting people and due to his institutionalized mentality, he will continue to strike out physically and he is not appropriate for the facility. Resident #7 as unapologetic about his behavior and has repeatedly stated if he says anything to me, I will hit him again. Staff continued to make frequent rounds monitoring Resident #7's interactions with others. Record review of Resident #7's Progress Notes dated 11/21/22 at 02:09 PM and signed by the Social Worker B, RP notified Resident #7 was not appropriate for continued stay in the interest of safety for others. During past months since admission Resident #7 has had significant physically aggressive behaviors towards other residents. Record review of Resident #7's 'Psychiatric Subsequent Assessment' dated 12/03/22 revealed, patient admits that he recently had an altercation with another resident and stated that it wasn't his fault. Collateral Information: staff reports patient recently punched another resident (Resident #8) in the face. Reports there was an altercation in the smoking area. Record review of Resident #7's Fair Hearing Medicaid Nursing Facility Discharge' letter dated 01/12/23 revealed, the facility could not discharge Resident #7 based on events that occurred on or prior to a discharge letter issued on 11/29/22 because, the hearing officer did not receive evidence from the facility prior to the hearing and a representative from the facility was not present at the hearing on 12/28/22 to explain or support the facility's actions to discharge Resident 7 so the Hearings Officer closed the record without a response from the facility. Record review of Resident #7's Progress Notes dated 05/03/23 at 05:15 AM revealed, Resident #7 struck another resident in dining area, resident was escorted back to room and both parties were divided. Record review of Resident #7's Physician's Notes dated 05/15/23 revealed, Resident #7 continues to be receptive to supportive care and there have been no changes in moods or behaviors. There are no complaints at this time. Record review of Resident #7's Progress Notes dated 05/17/23 at 10:36 PM revealed, at 07:30 AM Resident #8 was brought to the nursing station and told the nurse that Resident #7 hit him in the face and the chest. Resident #7 said Resident #8 called him a derogatory term and that was the reason he punched him in the face. Record review of Resident #7's Social Worker A dated 05/18/23 at 10:44 AM revealed, Resident #7 hit another resident (Resident #8) late in the evening yesterday Resident would benefit from emergency psych evaluation as he was a current threat to other residents due to his disorientation and confusion. An observation and Interview on 05/17/23 at 09:55 AM revealed, Resident #7 lying in bed well-groomed and in no immediate distress. He said a white man in a wheelchair hit him in the back so he came back and hit him back. He said Resident #8 talked about his mother and that was why he hit Resident #8, he said he had not had any other issues with any other residents and no other issues with Resident #7. In an interview on 05/24/23 at 01:16 PM, the Assistant Administrator said there was no incident report on record for the incident involving Resident #7 and #8 on 11/19/22. Resident #8 Record review of Resident #8's Face Sheet printed 06/15/23 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: paraplegia (paralysis of the legs and lower body), history of traumatic brain injury, type 2 diabetes, mood disorder, assault by unspecified firearm. Record review of Resident #8's quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, no signs of delirium or hallucinations, no physical behavioral symptoms directed toward others, no verbal behavioral symptoms directed towards others, no other behavioral symptoms not directed toward others, no rejection of care, total dependence on most ADLs and use of a wheelchair. Record review of Resident #8's undated Care Plan revealed, focus- Resident #8 was a smoker with potential for injury. Record review of Resident #8's Incident/Accident Report dated 11/18/22 at 07:30 PM revealed, Resident #7 punched Resident #8 in the mouth at 07:00 PM resulting in a laceration to the lip while outside in the smoke area. Record review of Resident #8's Progress Notes dated 11/19/22 at 07:03 AM revealed, Resident #7 punched Resident #8 on 11/18/22 at 07:00 PM in the mouth when both of them were in the smoking area and Resident #8 had a deep laceration to his lip. Resident #8 stated Resident #7 punched him because he told him to stop assaulting staff because of cigarettes. Resident #8 was assessed, and MD was notified about laceration who gave orders for the resident to be sent out to the hospital for sutures. Resident #8 was sent to the hospital on 11/18/22 at 07:00 PM. Record review of Resident #8's Progress Notes dated 11/19/22 at 07:33 AM revealed, Resident #8 returned from the Hospital on 11/19/22 at 04:00 AM and did not appear to have stitches. Record review of Resident #8's Progress Notes dated 11/19/22 at 11:31 AM revealed, Resident #8 said Resident #7 threw finger at him and was yelling at him. Resident #8 was escorted out of the dining room to go out during smoke time. Record review of Resident #8's Physician Note dated 11/22/22 revealed, Resident #8 was reportedly punched in the face by another resident (Resident #7). Resident #8 sustained a laceration to the lip; he was sent to the ER however he did not have any sutures placed. Record review of Resident #8's Progress Note dated 05/03/22 revealed, Resident #8 got hit by another resident (Resident #7) on his chest in the dining room. Resident #8 said he was yelling for someone to adjust him properly in his chair and the Resident #7 got irritated wheeled close to him and hit him in the chest. Head to toe assessment completed and Resident #8 had no bruising or swelling noted. Record review of Resident #8's Progress Notes dated 05/17/23 at 07:30 PM revealed, Resident #8 got into a fight with Resident #7 on the smoking patio but the incident was not witnessed. Resident #7 hit Resident #8 on the lips chest and neck. Resident #8 was observed to have bruised lips, a purple bruise on the neck/throat area from trauma and Resident #8 reported Resident #7 burned him with a cigarette to which a blister was observed. Record review of Resident #8's Physician Note dated 05/23/23 signed by MD A revealed, chief complaint: follow up for coffee burn, cigarette burn, sunburn and trauma to neck. MD A was notified by staff on 05/23/23 that Resident #8 was in a fight with another resident in which he was punched in the jaw/neck and sustained a cigarette burn to his right arm. Resident #8 still has a bruise to his neck, but the cigarette burn was almost healed. An observation and Interview on 05/21/23 at 06:27 PM revealed, Resident #8 sitting in his wheelchair in his room, well-groomed and in no immediate distress. Resident #8 said he has had multiple altercations with Resident #7 and he didn't feel safe in the facility when Resident #7 was there. He said Resident #7 always curses at him in the hallways, the dining room and in the smoking area every day. Resident #8 said the facility has made no efforts to move Resident #7 so they don't meet in the hallway, change their dinning or smoking breaks and did not ensure they were separated or supervised during meals in the dining room or smoke breaks in the courtyard even though he had made multiple complaints. Resident #8 said Resident #7 has punched him in the chest and lip on multiple occasions causing him to bleed and get stitches. He said in the last incident Resident #7 burned him on his arm with a cigarette. He said the facility have taken no action to ensure he was safe from Resident #7. In an interview on 05/17/23 at 08:45 AM, the Assistant Administrator said on 05/03/23 he heard Resident #8 screaming and observed Resident #7 pushing back in his wheelchair. He said the nurses reported that Resident #7 hit Resident #8 twice in the chest because Resident #8 was screaming which agitated Resident #7 and caused him to hit him in response. The Assistant Administrator said the residents were separated and there have been no incidents since then. He said there had been previous incidents between Resident #7 and Resident #8 in the smoking area, when Resident #8 took up for the staff so Resident #7 hit him in the face. The Assistant Administrator said he believed Resident #8 was triggered by loud noises. In an interview on 05/22/23 at 04:00 PM, the Assistant Administrator said following the incident on 05/18/23 Resident #7 was sent out to a behavioral hospital and he would not be returning to the facility. He said Resident #7 and Resident #8 have had multiple altercations in the smoking area and the dining area. He said Resident #7 and Resident #8 normally take their smoking break or are sitting in the dining area together and to his knowledge there have never been measures in place to ensure that these two residents were separated. Resident #5 Record review of Resident #5's face sheet, dated 5/18/2023, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Hemiplegia (paralysis of one side of the body), Cognitive Communication Deficit, Unspecified Lack of coordination. Record review of Resident #5's Annual MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, limited to extensive assistance for most ADLs, and personal hygiene and always incontinent of both bladder and bowel. Record review of Resident #5's Care Plan dated 03/16/23 revealed, focus- at risk for confusion, aggression and decline in ADL related to dementia; goal- be able to function in the environment safely; intervention- administer medication as ordered by MD, assist resident with ADL's. Record review of the facility submitted FORM 3613-A Provider 5 day Report signed 04/06/23 by the administrator revealed, CNA X was re-assigned to work with residents to work with residents who could speak up for themselves In an interview on 05/16/23 at 09:00 AM, the Administrator said she was the abuse coordinator and she was responsible for reporting and investigating all allegations of abuse and neglect. She said when there is a resident to resident altercation nursing staff are expected to separate the resident's immediately to ensure their safety, complete head to toe assessments and then notify the family, the MD and then facility administration. She said if residents have a history of physical aggression they should be supervised or separated from others to ensure they are not a danger. The Administrator said failure to take appropriate action following an allegation/incident of abuse places residents at risk of further abuse and injury. In an interview on 05/16/23 at 09:05 AM, DON A said following a resident-to-resident altercation residents must be immediately separated immediately for safety, a head to toe assessment must be completed an [TRUNCATED]

Based on observation, interview and record review the facility failed to thoroughly investigated and take measures to prevent further potential abuse, neglect, exploitation or mistreatment while the investigation is in process, and failed to ensure corrective action must be taken for 12 of 22 Residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, and Resident #10, Resident #20, Resident #21 and Resident #22) reviewed for abuse. 1. The facility failed to thoroughly invesitage allegations of abuse and ensure corrective actions were in place to ensure Resident #2, a resident with severe IDD, history behaviors and history of resident to resident altercations, was free from abuse on 03/31/23 from Resident #6 resulting in bleeding and injuries. 2. The facility failed to investigate Resident #6's allegation of abuse of Resident #2 by failing to identify the correct resident involved in the incident. 3. The facility failed to thoroughly investiage allegations of abuse and ensure corrective actions were in place to ensure Resident #8 was free from repeated abuse from Resident #7, resulting in Resident #8 suffering from a busted lip and a cigarette burn over multiple altercations. 4. The facility failed to thoroughly investigated allegations of abuse ensure corrective actions were in place to ensure Resident #9 and Resident #10 were free from abuse from Resident #2, a resident with severe IDD, history of behaviors and history of resident to resident altercations by placing them in the same room. 5. The facility failed to thoroughly investigate allegations of abuse of Resident #3, Resident #4, Resident #5, Resident #20. Resident #21 and Resident #22. On 05/22/23 at 03:21 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 05/29/23 at 07:10 PM, the facility remained out of compliance at an H (severity level of actual harm that is not immediate and a scope of pattern) due to the facility continuing to monitor the implementation and effectiveness of their plan of removal These failures could place residents at risk of increased abuse, major injury and decreased quality of life. Resident #2 Record review of Resident #2's Face Sheet dated 05/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: unspecified dementia, depression, difficulty swallowing, G-tube (a tube that goes into the stomach to provide food and medications), anxiety disorders, left hand contractures, right hand contractures and sever intellectual disabilities. Record review of Resident #2's Quarterly MDS dated [DATE] revealed, unclear speech, s rarely understood, sometimes understands, severely impaired cognition as indicated by a BIMS score of 00 out of 15, no response to resident mood interview questions, no documented behavioral symptoms (physical behaviors directed towards others, verbal behavioral symptoms directed to others or other behavioral symptoms not directed towards others), no rejection of care, no wandering, total dependence on all ADLs, use of a wheelchair, always incontinent of both bladder and bowel, non-traumatic brain dysfunction and left and right hand contractures. Record review of Resident #2's undated Care Plan printed 05/16/23 revealed, focus-IDD Resident #2 has been identified as PASRR positive related to intellectual disability; intervention- provide recommended services (habilitation coordination, independent living skills training and OT). Focus- nonverbal for communication needs/wants; potential for unmet needs/social isolation/boredom, escalating anxiety and agitation; intervention- provide emotional support to resident, refer resident for additional support relative to potential for escalating behaviors, referrals to psychiatric services for medication management and stabilization of behaviors. Focus- 2/09/23 Resident #2 was not hitting his roommate; intervention- resident was moved to another room. No incidents of physical aggression were documented on the Resident #2's care plan. No documentation of the type of Resident #2's behaviors. Record review of Resident #2's Census List starting at admission 08/25/22 to 05/18/23 revealed, since 01/2023 Resident #2 has had 3 room changes. Record review of Resident #2's Psychiatric assessment dated [DATE] signed by the Psychiatric NP revealed, reason for referral: anxiety, irritability, anger, non-verbal with a history of resistance and combative behaviors. Collateral information: aggression on and off. Record review of Resident #2's Nursing Note dated 02/10/23 at 01:34 PM and signed by LVN B revealed, Resident #2 initiated physical aggression against his roommate (Resident #9) on 02/09/23 LVN B was notified by the housekeeper that she saw Resident #2 hit his roommate while in bed. The roommate was moved out from room immediately. Record review of Resident #2's Nursing Note dated 02/22/23 at 05:46 PM signed by LVN B revealed, Patient is combative, hitting other patients. Patient was seen on his roommate's (Resident #10) body. Roommate (Resident #10) stated take this man out of here, I want peace. Resident #2 was taken to another room. Resident #2 was seen hitting other patients on the hallway, refused to stay in room. Record review of Resident #2's Psychiatric Provider note dated 02/22/23 revealed, Resident #2 was awake and agitated, monitored for behaviors and staff reported Resident #2 has been increasingly agitated and aggressive. He has been attempting to hit staff Orders to send to behavior hospital will be provided. Record review of Resident #2's Nursing Note dated 02/23/23 at 09:15 AM signed by LVN B revealed, Patient is becoming a threat to other patients and staff. He refused to stay in room Patient in hallway hitting everyone passing by. Patient needs to be moved to a psych hospital ASAP. Record review of Resident #2's Psychiatric assessment dated [DATE] signed by the Psychiatric NP revealed, reason for referral: aggression, hitting staff, hitting other residents, safety to self. Collateral Information: Staff reports patient has intermittent aggression towards others and fluctuating mood. Assessment/Plan: increased Risperdal (an antipsychotic) due to physical aggression, reported paranoia and negative symptoms. Severe IDD- is not treated with medications. There was no reference of the resident's appropriateness to have a roommate. Record review of Resident #2's Psychiatric Provider note dated 02/24/23 revealed, behavioral hospital admission denied. Record review of Resident #2's Nursing Note dated 03/31/23 at 11:55 AM signed by LVN C revealed, at about 09:35 AM write noted Resident #2 roommate (Resident #6) standing over residents' wheelchair pushing wheelchair over resident. Resident #2 was noted to be lying on the floor between bed and wheelchair with blood coming from his mouth. LVN C separated the residents and Resident #6 got into bed and stated, somebody better get him before I kill him. Laceration noted to upper lip area, Resident #2 was brought to the nurse's station in a wheelchair at which he was observed to hit another resident while sitting at the nursing station. At this time facility is working on room changes for resident and possible admit to psych facility. Record review of Resident #2's Nursing Note dated 03/31/23 at 01:12 PM signed by LVN B revealed, LVN B was told by staff that at 08:00 AM Resident #2 was hit by his roommate (Resident #6) because he was close to his bed, so the patient was taken out of the room. At 09:00 AM, Resident #2 was returned to his bed because he was throwing himself off the wheelchair at which point another staff saw Resident #6 hitting Resident #2 using a wheelchair. At 11:02, LVN B observed Resident #6 hitting Resident #2 with a shoe. Record review of Resident #2's Social Worker Notes dated 03/31/23 signed by Social Worker A revealed, referral made for inpatient psych evaluation and stay for Resident #2, but admission was denied to resident being unable to advocate for himself. Resident sent out for acute medical ER for evaluation. PLEASE NOTE when resident returns to facility, he will need to go to a different room from previous room with roommate. Record review of Resident #2's Psychiatric assessment dated [DATE] signed by the Psychiatric NP revealed, reason for referral: aggression, hitting staff, hitting other residents, safety to self. Collateral Information: staff reports patient can be irritable and restless. An observation on 05/17/23 at 11:55 AM revealed, Resident #2 on needs on the floor playing with his gown on the side of his fall mat. Blood was observed on the floor by the resident. Resident #6 Record review of Resident #6's Face Sheet dated 05/17/23 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, bipolar disorder, delusional disorders, unspecified psychosis, and hypertension. Record review of Resident #6's undated Care Plan printed 05/17/23 revealed, focus- PASRR positive related to severe mental illness; intervention- continue psychiatrist services at the facility. Focus- diagnosis of bipolar disorder with risk for inappropriate behaviors; Goal- Resident #6 will not harm himself or others; intervention- psych consult, monitor behaviors ever shift. Focus- Resident #6 has displayed frequent episodes of refusal of medications and ADL cares and was at risk for injury; Interventions- keep MD/NP informed of resident's refusal of medications and/or ADL care. Focus initiated on 10/28/21 and revised on 04/20/22- diagnoses of schizophrenia, bipolar disorder, psychosis, delusional disorder. sometimes become aggressive with facility properties and staff. Focus- ADL self-care deficits and is at risk for further decline in ADL functioning and injury; intervention- Resident #6 will be well dressed, groomed and clean; intervention- 1on1 for personal hygiene. Record review of Resident #6's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 03 out of 15, no signs of delirium, no rejection of care, supervision with most ADLs, use of a wheelchair and occasionally incontinent of both bladder and bowel. Record review of Resident #6's Psychiatric Subsequent assessment dated [DATE] and signed by the Psychiatric NP revealed, Mental Status Examination- risk of aggression none. Record review of Resident #6's Psychiatric Subsequent assessment dated [DATE] and signed by the Psychiatric NP revealed, Mental Status Examination- risk of aggression none. Record review of Resident #6's Incident and Accident Report dated 03/31/23 signed by LVN B revealed, LVN B was informed by staff that at 08:00 AM Resident #6 was seen hitting his roommate (Resident #2) because he was close to his bed. Another staff also saw roommate Resident #6 hitting Resident #2 with a wheelchair. At 11:02 AM, LVN B also saw Resident #6 hitting Resident #2 with a shoe. Record review of Resident #6's Psychological Services Supportive Care Progress Note from 03/29/23 to 04/19/23 revealed, no reference to Resident #6 assaulting Resident #2 on 3 different occasions on 03/31/23. Record review of the facility Form 3613-A: Provider Investigation Report signed 04/07/23 revealed, Resident #1 was identified as assaulting Resident #2 with a wheelchair on 03/31/23 instead of Resident #6. There was no mention of Resident #6 in the investigation report. Record review of Resident #6's Psychiatric Subsequent assessment dated [DATE] and signed by the Psychiatric NP revealed, Collateral Information: staff reports Resident #6 has been refusion his medication for weeks and had behavioral physical incident with his roommate. Mental Status Examination- risk of aggression none. An observation and interview on 05/18/23 at 12:00 PM revealed, Resident #6 lying in bed in no immediate distress. Resident #6 said he did not remember any incidents of physical aggression with Resident #2. In an interview of 05/17/23 at 11:22 AM, LVN B said Resident #6 was usually verbally and physically aggressive and did not want to be disturbed. She said on 03/31/23 Resident #6 attacked Resident #2 on three different occasions of which she witnessed the third. LVN B said she was informed that Resident #6 had hit Resident #2 once in the morning and later on in the morning Resident #6 pushed a wheelchair over Resident #2 as he laid on the floor causing Resident #2 to bleed from the mouth. She said Resident #2 was initially removed from the room but he was later returned to the same room as Resident #6 because there was no other room to place him and Resident #2 kept throwing himself on the floor and it was at that point that she witnessed Resident #6 hit Resident #2 with a shoe. LVN B said she immediately separated the two residents and placed Resident #2 at the nursing station until he was sent out of evaluation. She said the expectation for resident to resident altercations is that the resident's be immediately separated to prevent further abuse and Resident #2 should not have been returned to the same room as Resident #6. In an interview on 05/18/23 at 11:43 AM, the Administrator said she failed to identify that Resident #6 was the perpetrator of abuse against Resident #2 on 03/31/23. She said she believed Resident #1 assaulted Resident #2 and completed her investigation based on that. She could not explain why she believed the assailant was Resident #1 and not Resident #6. The Administrator said she did not look into Resident #6 at all, she did not notify the provider about Resident #6's aggression and no corrective action was taken about Resident #6's assault of Resident #2. She said since she did not investigate Resident #6, she did not know staff identified him as being physically aggressive or that the NP would be removing Resident #6's psych meds due to the resident refusing. The Administrator said based on the information she learned about Resident #6, it was not appropriate for the resident to have a roommate due to him being a danger to others. She said failure to investigate the correct resident could place residents at risk of injury. In an interview on 05/18/23 at 12:56, the Psychiatric NP said Resident #6 had history of aggression and she was never informed of the incidents of abuse between Resident #6 and Resident #2 that occurred on 03/31/23. She said Resident #6 had been refusing all his medications including his psych medications so her plan was to GDR to discontinue all his medications. The Psychiatric NP said the facility is expected to notify her of any cases of physical aggression in any residents being followed but it would not have mattered in this case because Resident #6 had refused all his medication so she could not make any pharmaceutical interventions and therapist handles non-pharmaceutical interventions. When asked how Resident #6's behaviors would be controlled and if his lack of medication would place others in danger the Psychiatric NP said if Resident #6 is deemed to be a risk to himself or other then he would have to be sent out to a behavioral hospital Resident #9 Record review of Resident #9's face sheet dated 05/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: dementia and bipolar disorder with psychotic features. Record review of Resident #9's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, total dependence on most ADLs and always incontinent of both bladder and bowel. Record review of Resident #9's undated Care Plan dated 05/25/23 revealed Focus- Resident #6 has potential to be verbally/physically aggressive behaviors related bipolar disorder; interventions- analyze key times, places, circumstances, triggers and what de-escalates behaviors and document. Record review of Resident #9's Psychiatric Subsequent assessment dated [DATE] signed by the Psychiatric NP revealed, mental status examination- risk of aggression: physical. Record review of Resident #9's Psychiatric Subsequent assessment dated [DATE] signed by the Psychiatric NP revealed, mental status examination- risk of aggression: physical. Record review of Resident #9's Progress Notes dated 02/10/23 and signed by LVN B revealed, housekeeper stated she saw Resident #6 being hit by his roommate (Resident #2). Resident #6 was moved out from the room immediately, a head to toe assessment was performed and no bruising or bleeding was noted. Record review of Resident #9's Psychiatric Subsequent assessment dated [DATE] signed by the Psychiatric NP revealed, mental status examination- risk of aggression: physical. Collateral Information: no mood or behavior changes reported by staff. There is no documentation Resident #10 Record review of Resident #10's Face Sheet dated 05/23/23 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, partial traumatic amputation level between knee and ankle and chronic pain syndrome. Record review of Resident #10's quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, no behaviors, total dependence on most ADLs. Record review of Resident #10's undated Care Plan printed 05/25/23 revealed, focus- below the right knee amputation. Record review of Resident #10's 02/2023 Progress Notes revealed, no documentation of Resident #10 being hit by Resident #2. Record review of Resident #10's Census List printed 05/18/23 revealed, Resident #10 was in room [ROOM NUMBER]-A from 02/11/23 to 02/23/23. In an interview of 05/17/23 at 11:22 AM, LVN B said Resident #2's behaviors involve throwing himself on the floor, throwing himself on roommates, hitting residents and staff. She said Resident #2 will always instigate altercations with his roommates and she feels like Resident #2 should be in a room by himself because of his behaviors. She said Resident #2 was a fall risk so the idea from administration was to place him with a roommate that could watch him and report any falls or injuries Resident #2 may suffer. LVN B said Resident #2 has had multiple altercations with different roommates like Resident #6, Resident #9 and Resident #10. LVN B said Resident #2 had a severe intellectual disability and could not control his behaviors, his behaviors were not intentional and he did not understand what he was doing to others. In an interview on 05/18/23 at 12:43 PM, Resident #31 said his roommate Resident #2 has a history of hitting other residents. He said prior to rooming with Resident #2 the resident had hit him in the hallway so he was concerned about rooming with him in case he hit him, but he guessed that the facility put them together so he could look out for Resident #2 since he falls. Resident #31 said so far, he had not had any issues with Resident #2 because the resident was sick and had not been active. He said Resident #2's behaviors included getting on the floor to just stare at him (Resident #31) and rolling off his own bed blocking the door. Resident #31 said he has not had any issues with Resident #2 so far but if he did, he would hurt Resident #2. In an interview on 05/18/23 at 12:56, the Psychiatric NP said Resident #2 admitted to the facility with a diagnosis of severe IDD. She said his behaviors include jumping off the bed, hitting and touching others and she can see him instigating altercations with other residents. She said that these behaviors are his baseline, and his behaviors could be troublesome to his roommates. When asked if Resident #2 was appropriate for a roommate, the Psychiatric NP would not answer. Resident #7 Record review of Resident #7's Face Sheet dated 05/23/23 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: dementia without behavioral disturbance, psychotic disturbance, depression and anxiety. Record review of Resident #7's quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 10 out of 15, no potential indicators of psychosis such as hallucinations and delusions. No behavioral symptoms directed towards others, no verbal behavioral symptoms directed towards others, no behavioral symptoms not directed towards others, supervision needed for locomotion on the unit, supervision needed for location off the unit and use of a manual wheelchair. Record review of Resident #7's undated Care Plan revealed, focus- have verbal aggressive behavior (cussing staff) related to dementia. Focus- Resident #7 has been physically aggressive; goal- Resident #6 will demonstrate effective coping skills through the review date. Record review of Resident #7's Incident by Incident Type Report from 11/01/22 to 05/23/23 revealed, Resident #7 initiated 3 separate incidents of physical aggression on 11/19/22, 05/03/23 and 05/17/23. Record review of Resident #7's Psychiatric Subsequent assessment dated [DATE] and signed by the Psychiatric NP revealed, reason for referral: verbal aggression and resistance to care. Collateral information: staff reports patient behaviors have not worsened, patent calmer since medication changes. Mental Status Examination- risk of aggression: none. Record review of Resident #7's Progress Notes dated 11/19/22 at 9:56 PM revealed, Resident #7 assaulted another resident (Resident #8) outside in the smoking area. He punched him on the mouth resulting in a laceration on the lip, the residents were separated and the provider, DON and Administrator were notified. Record review of Resident #7's Progress Notes dated 11/21/22 at 11:16 AM and signed by DON C revealed, Resident #6 had a history of assaulting people and due to his institutionalized mentality he will continue to strike out physically and he is not appropriate for the facility. Resident #6 was unapologetic about his behavior and has repeatedly stated if he says anything to me I will hit him again. Staff continued to make frequent rounds monitoring Resident #6's interactions with others. Record review of Resident #7's Progress Notes dated 11/21/22 at 02:09 PM and signed by the Social Worker B, RP notified Resident #7 is not appropriate for continued stay in the interest of safety for others. During past months since admission Resident #7 has had significant physically aggressive behaviors towards other residents. Record review of Resident #7's 'Psychiatric Subsequent Assessment' dated 12/03/22 revealed, patient admits that he recently had an altercation with another resident and states that it wasn't his fault. Collateral Information: staff reports patient recently punched another resident in the face. Reports there was an altercation in the smoking area. Record review of Resident #7's Fair Hearing Medicaid Nursing Facility Discharge' letter dated 01/12/23 revealed, the facility could not discharge Resident #7 based on events that occurred on or prior to a discharge letter issued on 11/29/22 because, the hearing officer did not receive evidence from the facility prior to the hearing and a representative from the facility was not present at the hearing on 12/28/22 to explain or support the facility's actions to discharge Resident 7 so the Hearings Officer closed the record without a response from the facility. Record review of Resident #7's Progress Notes dated 05/03/23 at 05:15 AM revealed, Resident #7 struck another resident in dining area, resident was escorted back to room and both parties were divided. Record review of Resident #7's Physician's Notes dated 05/15/23 revealed, Resident #7 continues to be receptive to supportive care and there have been no changes in moods or behaviors. There are no complaints at this time. Record review of Resident #7's Progress Notes dated 05/17/23 at 10:36 PM revealed, at 07:30 AM Resident #8 was brought to the nursing station and told the nurse that Resident #7 hit him in the face and the chest. Resident #7 said Resident #8 called him a derogatory term and that was the reason he punched him in the face. Record review of Resident #7's Social Worker A dated 05/18/23 at 10:44 AM revealed, Resident #7 hit another resident (Resident #8) late in the evening yesterday Resident would benefit from emergency psych evaluation as he is a current threat to other residents due to his disorientation and confusion. An observation and Interview on 05/17/23 at 09:55 AM revealed, Resident #7 lying in bed well-groomed and in no immediate distress. He said a white man in a wheelchair hit him in the back so he came back and hit him back. He said Resident #8 talked about his mother and that is why he hit him, he said he had not had any other issues with any other residents and no other issues with Resident #7. In an interview on 05/24/23 at 01:16 PM, the Assistant Administrator said there was no incident report on record for the incident involving Resident #7 and #8 on 11/19/22. Resident #8 Record review of Resident #8's Face Sheet printed 06/15/23 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: paraplegia (paralysis of the legs and lower body), history of traumatic brain injury, type 2 diabetes, mood disorder, assault by unspecified firearm. Record review of Resident #8's quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, no signs of delirium or hallucinations, no physical behavioral symptoms directed toward others, no verbal behavioral symptoms directed towards others, no other behavioral symptoms not directed toward others, no rejection of care, total dependence on most ADLs and use of a wheelchair. Record review of Resident #8's undated Care Plan revealed, focus- Resident #8 was a smoker with potential for injury. Record review of Resident #8's Incident/Accident Report dated 11/18/22 at 07:30 PM revealed, Resident #7 punched Resident #8 in the mouth at 07:00 PM resulting in a laceration to the lip while outside in the smoke area. Record review of Resident #8's Progress Notes dated 11/19/22 at 07:03 AM revealed, Resident #7 punched Resident #8 on 11/18/22 at 07:00 PM in the mouth when both of them were in the smoking area and Resident #8 had a deep laceration to his lip. Resident #8 stated Resident #7 punched him because he told him to stop assaulting staff because of cigarettes. Resident #8 was assessed, and MD was notified about laceration who gave orders for the resident to be sent out to the hospital for sutures. Resident #8 was sent to the hospital on 11/18/22 at 07:00 PM. Record review of Resident #8's Progress Notes dated 11/19/22 at 07:33 AM revealed, Resident #8 returned from the Hospital on 11/19/22 at 04:00 AM and did not appear to have stitches. Record review of Resident #8's Progress Notes dated 11/19/22 at 11:31 AM revealed, Resident #8 said Resident #7 threw finger at him and was yelling at him. Resident #8 was escorted out of the dining room to go out during smoke time. Record review of Resident #8's Physician Note dated 11/22/22 revealed, Resident #8 was reportedly punched in the face by another resident (Resident #7). Resident #8 sustained a laceration to the lip; he was sent to the ER however he did not have any sutures placed. Record review of Resident #8's Progress Note dated 05/03/22 revealed, Resident #8 got hit by another resident (Resident #7) on his chest in the dining room. Resident #8 said he was yelling for someone to adjust him properly in his chair and the Resident #7 got irritated wheeled close to him and hit him in the chest. Head to toe assessment completed and Resident #8 had no bruising or swelling noted. Record review of Resident #8's Progress Notes dated 05/17/23 at 07:30 PM revealed, Resident #8 got into a fight with Resident #7 on the smoking patio but the incident was not witnessed. Resident #7 hit Resident #8 on the lips chest and neck. Resident #8 was observed to have bruised lips, a purple bruise on the neck/throat area from trauma and Resident #8 reported Resident #7 burned him with a cigarette to which a blister was observed. Record review of Resident #8's Physician Note dated 05/23/23 signed by MD A revealed, chief complaint: follow up for coffee burn, cigarette burn, sunburn and trauma to neck. MD A was notified by staff on 05/23/23 that Resident #8 was in a fight with another resident in which he was punched in the jaw/neck and sustained a cigarette burn to his right arm. Resident #8 still has a bruise to his neck, but the cigarette burn was almost healed. An observation and Interview on 05/21/23 at 06:27 PM revealed, Resident #8 sitting in his wheelchair in his room, well-groomed and in no immediate distress. Resident #8 said he has had multiple altercations with Resident #7 and he didn't feel safe in the facility when Resident #7 was there. He said Resident #7 always curses at him in the hallways, the dining room and in the smoking area every day. Resident #8 said the facility has made no efforts to move Resident #7 so they don't meet in the hallway, change their dinning or smoking breaks and did not ensure they were separated or supervised during meals in the dining room or smoke breaks in the courtyard even though he had made multiple complaints. Resident #8 said Resident #7 has punched him in the chest and lip on multiple occasions causing him to bleed and get stitches. He said in the last incident Resident #7 burned him on his arm with a cigarette. He said the facility have taken no action to ensure he was safe from Resident #7. In an interview on 05/17/23 at 08:45 AM, the Assistant Administrator said on 05/03/23 he heard Resident #8 screaming and observed Resident #7 pushing back in his wheelchair. He said the nurses reported that Resident #7 hit Resident #8 twice in the chest because Resident #8 was screaming which agitated Resident #7 and caused him to hit him in response. The Assistant Administrator said the residents were separated and there have been no incidents since then. He said there had been previous incidents between Resident #7 and Resident #8 in the smoking area, when Resident #8 took up for the staff so Resident #7 hit him in the face. The Assistant Administrator said he believed Resident #8 was triggered by loud noises. In an interview on 05/22/23 at 04:00 PM, the Assistant Administrator said following the incident on 05/18/23 Resident #7 was sent out to a behavioral hospital and he would not be returning to the facility. He said Resident #7 and Resident #8 have had multiple altercations in the smoking area and the dining area. He said Resident #7 and Resident #8 normally take their smoking break or are sitting in the dining area together and to his knowledge there have never been measures in place to ensure that these two residents were separated. Resident #5 Record review of Resident #5's face sheet, dated 5/18/2023, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Hemiplegia (paralysis of one side of the body), Cognitive Communication Deficit, Unspecified Lack of coordination. Record review of Resident #5's Annual MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, limited to extensive assistance for most ADLs, and personal hygiene and always incontinent of both bladder and bowel. Record review of Resident #5's Care Plan dated 03/16/23 revealed, focus- at risk for confusion, aggression and decline in ADL related to dementia; goal- be able to function in the environment safely; intervention- administer medication as ordered by MD, assist resident with ADL's. Record review of Resident #5's Nursing Note dated 01/25/23 revealed, CNA reported that Resident #5 was found in room fighting and exchanging blows with Resident #22. Both parties were redirected, no physical injury noted at the time of the incident. Record review of the facility submitted FORM 3613-A Provider 5 day Report signed 04/06/23 by the administrator revealed, on 03/30/23 MA A [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 7 of 12 residents (Resident #2, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10 and Resident #13) reviewed for supervision. 1. The facility failed to provide adequate supervision for Resident #2, a resident with severe IDD and behaviors, by placing him in the same room as Resident #6 which resulted in Resident #2 suffering from multiple occasions of abuse on 03/31/23. 2. The facility failed to provide adequate supervision for Resident #8 and Resident #7 which resulted in Resident #8 suffering from multiple incidents of abuse by Resident #7 which included a busted lip and a cigarette burn. 3. The facility failed to provide adequate supervision to prevent Resident #9 and Resident #10 from suffering from abuse from Resident #2, a resident with severe IDD and behaviors by placing them in the same room. 4. The facility failed to provide adequate supervision to Resident #13 (identified outside of the IJ), to prevent an injury of unknown origin which resulted in hospitalization with bilateral (both sides) hip fractures which required surgical repair. An Immediate Jeopardy (IJ) situation was identified on 05/22/23 at 03:21 PM. While the IJ was removed on 05/29/23 at 07:10 PM, the facility remained out of compliance at an H (severity level of actual harm that is not immediate and a scope of pattern)due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of increased abuse, major injury, and a decreased quality of life. Findings include: Resident #2 Record review of Resident #2's face sheet, dated 05/23/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: unspecified dementia, depression, difficulty swallowing, G-tube (a tube that goes into the stomach to provide food and medications), anxiety disorders, left hand contractures, right hand contractures and sever intellectual disabilities. Record review of Resident #2's Quarterly MDS, dated [DATE], revealed unclear speech, the resident was rarely understood, sometimes understands, had severely impaired cognition as indicated by a BIMS score of 00 out of 15, no response to resident mood interview questions, no documented behavioral symptoms (physical behaviors directed towards others, verbal behavioral symptoms directed to others or other behavioral symptoms not directed towards others), no rejection of care, no wandering, total dependence on all ADLs, use of a wheelchair, always incontinent of both bladder and bowel, non-traumatic brain dysfunction and left and right hand contractures. Record review of Resident #2's, undated, Care Plan, printed 05/16/23, revealed a focus-IDD Resident #2 was identified as PASRR positive related to intellectual disability; intervention- provide recommended services (habilitation coordination, independent living skills training and OT). Focus- nonverbal for communication needs/wants; potential for unmet needs/social isolation/boredom, escalating anxiety and agitation; intervention- provide emotional support to resident, refer resident for additional support relative to potential for escalating behaviors, referrals to psychiatric services for medication management and stabilization of behaviors. Focus- 2/09/23 Resident #2 was not hitting his roommate; intervention- resident was moved to another room. No incidents of physical aggression were documented on the Resident #2's care plan. There was no documentation of Resident #2's type of behaviors. Record review of Resident #2's Census List starting at admission 08/25/22 to 05/18/23 revealed, since 01/2023 Resident #2 has had 3 room changes. Record review of Resident #2's Psychiatric Assessment, dated 09/16/22, signed by the Psychiatric NP revealed, reason for referral: anxiety, irritability, anger, non-verbal with a history of resistance and combative behaviors. Collateral information: aggression on and off. Record review of Resident #2's Nursing Note, dated 02/10/23 at 01:34 PM, and signed by LVN B revealed, Resident #2 initiated physical aggression against his roommate (Resident #9) on 02/09/23 LVN B was notified by the housekeeper that she saw Resident #2 hit his roommate while in bed. The roommate was moved out from room immediately. Record review of Resident #2's Nursing Note, dated 02/22/23 at 05:46 PM, signed by LVN B, revealed Patient is combative , hitting other patients. Patient was seen on his roommate's (Resident #10) body. Roommate (Resident #10) stated take this man out of here, I want peace. Resident #2 was taken to another room. Resident #2 was seen hitting other patients on the hallway, refused to stay in room. Record review of Resident #2's Psychiatric Provider note, dated 02/22/23, revealed Resident #2 was awake and agitated, monitored for behaviors and staff reported Resident #2 was increasingly agitated and aggressive. He was attempting to hit staff. Orders to send to behavior hospital will be provided. Record review of Resident #2's Nursing Note, dated 02/23/23 at 09:15 AM, signed by LVN B revealed Patient is becoming a threat to other patients and staff. He refused to stay in room . Patient in hallway hitting everyone passing by. Patient needs to be moved to a psych hospital ASAP. Record review of Resident #2's Psychiatric Assessment, dated 02/24/23, signed by the Psychiatric NP, revealed reason for referral: aggression, hitting staff, hitting other residents, safety to self. Collateral Information: Staff reports patient has intermittent aggression towards others and fluctuating mood. Assessment/Plan: increased Risperdal (an antipsychotic) due to physical aggression, reported paranoia and negative symptoms. Severe IDD- is not treated with medications. There was no reference of the resident's appropriateness to have a roommate. Record review of Resident #2's Psychiatric Provider Note, dated 02/24/23, revealed behavioral hospital admission denied. The note did not include the reason Resident #2's behavioral hospital admission was denied. Record review of Resident #2's Nursing Note, dated 03/31/23 at 11:55 AM, signed by LVN C, revealed at about 09:35 AM Resident #2's roommate (Resident #6) was standing over residents' wheelchair pushing wheelchair over resident. Resident #2 was noted to be lying on the floor between bed and wheelchair with blood coming from his mouth. LVN C separated the residents and Resident #6 got into bed and stated somebody better get him before I kill him. Laceration noted to upper lip area, Resident #2 was brought to the nurses station in a wheelchair at which he was observed to hit another resident while sitting at the nursing station. At this time facility is working on room changes for resident and possible admit to psych facility. Record review of Resident #2's Nursing Note, dated 03/31/23 at 01:12 PM, signed by LVN B, revealed LVN B was told by staff that at 08:00 AM Resident #2 was hit by his roommate (Resident #6) because he was close to his bed so the patient was taken out of the room. At 09:00 AM, Resident #2 was returned to his bed because he was throwing himself off the wheelchair at which point another staff saw Resident #6 hitting Resident #2 using a wheelchair. At 11:02 AM, LVN B observed Resident #6 hitting Resident #2 with a shoe. Record review of Resident #2's Social Worker Notes, dated 03/31/23, signed by Social Worker A revealed, referral made for inpatient psych evaluation and stay for Resident #2 but admission was denied due to resident being unable to advocate for himself. Resident sent out for acute medical ER for evaluation. Please Note when resident returns to facility, he will need to go to a different room from previous room with roommate. Record review of Resident #2's Psychiatric Assessment, dated 04/06/23, signed by the Psychiatric NP, revealed reason for referral: aggression, hitting staff, hitting other residents, safety to self. Collateral Information: staff reports patient can be irritable and restless. An observation on 05/17/23 at 11:55 AM revealed, Resident #2 on his knees on the floor playing with his gown on the side of his fall mat. Resident #6 Record review of Resident #6's face sheet, dated 05/17/23, revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, bipolar disorder, delusional disorders, unspecified psychosis and hypertension. Record review of Resident #6's Quarterly MDS, dated [DATE], revealed the resident had severely impaired cognition as indicated by a BIMS score of 03 out of 15, no signs of delirium, no rejection of care, supervision with most ADLs, use of a wheelchair and was occasionally incontinent of both bladder and bowel. Record review of Resident #6's, undated, Care Plan, printed 05/17/23, revealed, focus- PASRR positive related to severe mental illness; intervention- continue psychiatrist services at the facility. Focus- diagnosis of bipolar disorder with risk for inappropriate behaviors; Goal- Resident #6 will not harm himself or others; intervention- psych consult, monitor behaviors every shift. Focus- Resident #6 has displayed frequent episodes of refusal of medications and ADL care and is at risk for injury; Interventions- keep MD/NP informed of resident's refusal of medications and/or ADL care. Focus initiated on 10/28/21 and revised on 04/20/22- diagnoses of schizophrenia, bipolar disorder, psychosis, delusional disorder. Sometimes became aggressive with facility properties and staff. Focus- ADL self-care deficits and was at risk for further decline in ADL functioning and injury; intervention- Resident #6 will be well dressed, groomed and clean; intervention- 1on1 for personal hygiene. Record review of Resident #6's Psychiatric Subsequent Assessment, dated 03/03/23, and signed by the Psychiatric NP, revealed Mental Status Examination- risk of aggression none. Record review of Resident #6's Psychiatric Subsequent Assessment, dated 03/22/23, and signed by the Psychiatric NP, revealed Mental Status Examination- risk of aggression none. Record review of Resident #6's Incident and Accident Report, dated 03/31/23, signed by LVN B revealed LVN B was informed by staff that at 08:00 AM Resident #6 was seen hitting his roommate (Resident #2) because he was close to his bed. Another staff also saw roommate Resident #6 hitting Resident #2 with a wheelchair. At 11:02 AM, LVN B also saw Resident #6 hitting Resident #2 with a shoe. Record review of Resident #6's Psychological Services Supportive Care Progress Note from 03/29/23 to 04/19/23, revealed no reference to Resident #6 assaulting Resident #2 on 3 different occasions on 03/31/23. Record review of Resident #6's Psychiatric Subsequent Assessment, dated 04/14/23, and signed by the Psychiatric NP, revealed Collateral Information: staff reports Resident #6 has been refusing his medication for weeks and had behavioral physical incident with his roommate. Mental Status Examination- risk of aggression none. An observation and interview on 05/18/23 at 12:00 PM revealed, Resident #6 lying in bed in no immediate distress. Resident #6 said he did not remember any incidents of physical aggression with Resident #2. In an interview of 05/17/23 at 11:22 AM, LVN B said Resident #6 was usually verbally and physically aggressive and did not want to be disturbed. She said on 03/31/23 Resident #6 attacked Resident #2 on three different occasions of which she witnessed the third. LVN B said she was informed Resident #6 had hit Resident #2 once in the morning and later on in the morning Resident #6 pushed a wheelchair over Resident #2 as he laid on the floor causing Resident #2 to bleed from the mouth. She said Resident #2 was initially removed from the room but he was later returned to the same room as Resident #6 because there was no other room to place him and Resident #2 kept throwing himself on the floor and it was at that point she witnessed Resident #6 hit Resident #2 with a shoe. LVN B said she immediately separated the two residents and placed Resident #2 at the nursing station until he was sent out for an evaluation. She said the expectation for resident to resident altercations was the resident's be immediately separated to prevent further abuse and Resident #2 should not have been returned to the same room as Resident #6. In an interview on 05/18/23 at 11:43 AM, the Administrator said she failed to identify Resident #6 was the perpetrator of abuse against Resident #2 on 03/31/23. She said she believed Resident #1 assaulted Resident #2 and completed her investigation based on her. The Administrator said she did not look into Resident #6 at all because she had not identified him as the assailant, she did not notify the provider about Resident #6's aggression and no corrective action was taken about Resident #6's assault of Resident #2. She said since she did not investigate Resident #6 she did not know staff identified him as being physically aggressive or that the NP would be removing Resident #6's psych meds due to the resident refusing. The Administrator said based on the information she learned about Resident #6, it was not appropriate for the resident to have a roommate due to him being a danger to others. She said failure to investigate the correct resident could place residents at risk of injury. In an interview on 05/18/23 at 12:56, the Psychiatric NP said Resident #6 had history of aggression and she was never informed of the incidents of abuse between Resident #6 and Resident #2 that occurred on 03/31/23. She said Resident #6 had been refusing all his medications including his psych medications so her plan was to GDR to discontinue all his medications. The Psychiatric NP said the facility was expected to notify her of any cases of physical aggression in any residents being followed but it would not have mattered in this case because Resident #6 had refused all his medication so she could not make any pharmaceutical interventions and the therapist handled non-pharmaceutical interventions. When asked how Resident #6's behaviors would be controlled and if his lack of medication would place others in danger the Psychiatric NP said if Resident #6 was deemed to be a risk to himself or others then he would have to be sent out to a behavioral hospital. Resident #9 Record review of Resident #9's face sheet, dated 05/23/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: dementia and bipolar disorder with psychotic features. Record review of Resident #9's Quarterly MDS, dated [DATE], revealed severely impaired cognition as indicated by a BIMS score of 00 out of 15, total dependence on most ADLs and always incontinent of both bladder and bowel. Record review of Resident #9's Care Plan, dated 05/25/23, revealed Focus- Resident #9 had a potential to be verbally/physically aggressive behaviors related bipolar disorder; interventions- analyze key times, places, circumstances, triggers and what de-escalates behaviors and document. Record review of Resident #9's Psychiatric Subsequent Assessment, dated 12/16/22, signed by the Psychiatric NP, revealed, mental status examination- risk of aggression: physical. Record review of Resident #9's Psychiatric Subsequent Assessment, dated 01/12/23, signed by the Psychiatric NP, revealed, mental status examination- risk of aggression: physical. Record review of Resident #9's Progress Notes, dated 02/10/23, and signed by LVN B, revealed the housekeeper stated she saw Resident #9 being hit by his roommate (Resident #2). Resident #6 was moved out from the room immediately, a head to toe assessment was performed and no bruising or bleeding was noted. Record review of Resident #9's Psychiatric Subsequent Assessment, dated 03/13/23, signed by the Psychiatric NP, revealed mental status examination- risk of aggression: physical. Collateral Information: no mood or behavior changes reported by staff. Resident #10 Record review of Resident #10's face sheet, dated 05/23/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, partial traumatic amputation level between knee and ankle and chronic pain syndrome. Record review of Resident #10's quarterly MDS, dated [DATE], revealed severely impaired cognition as indicated by a BIMS score of 00 out of 15, no behaviors, total dependence on most ADLs. Record review of Resident #10's, undated, Care Plan, printed 05/25/23, revealed, focus- below the right knee amputation. There was no documentation of any behaviors or aggression in Resident #10's care plan. Record review of Resident #10's 02/2023 Progress Notes revealed, no documentation of Resident #10 being hit by Resident #2. Record review of Resident #10's Census List, printed 05/18/23, revealed Resident #10 was in room [ROOM NUMBER]-A from 02/11/23 to 02/23/23. In an interview on 05/17/23 at 11:22 AM, LVN B said Resident #2's behaviors involved throwing himself on the floor, throwing himself on roommates, hitting residents and staff. She said Resident #2 would always instigate altercations with his roommates and she felt like Resident #2 should be in a room by himself because of his behaviors. She said Resident #2 was a fall risk and the idea from administration was to place him with a roommate that could watch him and report any falls or injuries Resident #2 may suffer. LVN B said Resident #2 had multiple altercations with different roommates like Resident #6, Resident #9 and Resident #10. LVN B said Resident #2 had a severe intellectual disability and could not control his behaviors, and he did not do it intentionally and did not understand what he was doing to others. In an interview on 05/18/23 at 12:43 PM, Resident #31 said his roommate Resident #2 had a history of hitting other residents. He said prior to rooming with Resident #2 the resident had hit him in the hallway so he was concerned about rooming with him in case he hit him, but he guessed the facility put them together so he could look out for Resident #2 since he falls. Resident #31 said so far he had not had any issues with Resident #2 because the resident was sick. He said Resident #2 would get on the floor and just stare at him, roll off his bed blocking the door. Resident #31 said he had not had any issues with Resident #2 so far but if he did he would hurt Resident #2. In an interview on 05/18/23 at 12:56, the Psychiatric NP said Resident #2 admitted to the facility with a diagnosis of severe IDD. She said his behaviors included jumping off the bed, hitting and touching others and she could see him instigating altercations with other residents. She said these behaviors were his baseline and it could be troublesome to his roommates. When asked if Resident #2 was appropriate for a roommate, the Psychiatric NP would not answer. Resident #7 Record review of Resident #7's face sheet, dated 05/23/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: dementia without behavioral disturbance, psychotic disturbance, depression and anxiety. Record review of Resident #7's quarterly MDS, dated [DATE], revealed moderately impaired cognition as indicated by a BIMS score of 10 out of 15, no potential indicators of psychosis such as hallucinations and delusions. No behavioral symptoms directed towards others, no verbal behavioral symptoms directed towards others, no behavioral symptoms not directed towards others, supervision needed for locomotion on the unit, supervision needed for location off the unit and use of a manual wheelchair. Record review of Resident #7's, undated, Care Plan revealed, focus- have verbal aggressive behavior (cussing staff) related to dementia. Focus- Resident #7 has been physically aggressive; goal- Resident #7 would demonstrate effective coping skills through the review date. Record review of Resident #7's Incident by Incident Type Report from 11/01/22 to 05/23/23, revealed Resident #7 initiated 3 separate incidents of physical aggression on 11/19/22, 05/03/23 and 05/17/23. Record review of Resident #7's Psychiatric Subsequent Assessment, dated 11/18/22, and signed by the Psychiatric NP, revealed reason for referral: verbal aggression and resistance to care. Collateral information: staff reports patient behaviors have not worsened, patent calmer since medication changes. Mental Status Examination- risk of aggression: none. Record review of Resident #7's Progress Notes, dated 11/19/22 at 9:56 PM, revealed Resident #7 assaulted another resident (Resident #8) outside in the smoking area. He punched him on the mouth which resulted in a laceration on the lip, the residents were separated and the provider, DON and Administrator were notified. Record review of Resident #7's Progress Notes, dated 11/21/22 at 11:16 AM, and signed by DON C revealed Resident #6 had a history of assaulting people and due to his institutionalized mentality he would continue to strike out physically and he was not appropriate for the facility. Resident #6 was unapologetic about his behavior and repeatedly stated if he says anything to me I will hit him again. Staff continued to make frequent rounds monitoring Resident #6's interactions with others. Record review of Resident #7's Progress Notes, dated 11/21/22 at 02:09 PM, and signed by the Social Worker B, RP notified Resident #7 was not appropriate for continued stay in the interest of safety for others. During past months since admission Resident #7 had significant physically aggressive behaviors towards other residents. Record review of Resident #7's 'Psychiatric Subsequent Assessment, dated 12/03/22, revealed patient admits he recently had an altercation with another resident and stated it wasn't his fault. Collateral Information: staff reports patient recently punched another resident in the face. Reports there was an altercation in the smoking area. Record review of Resident #7's Fair Hearing Medicaid Nursing Facility Discharge letter, dated 01/12/23, revealed the facility could not discharge Resident #7 based on events that occurred on or prior to a discharge letter issued on 11/29/22 because, the hearing officer did not receive evidence from the facility prior to the hearing and a representative from the facility was not present at the hearing on 12/28/22 to explain or support the facility's actions to discharge Resident #7 so the Hearings Officer closed the record without a response from the facility. Record review of Resident #7's Progress Notes, dated 05/03/23 at 05:15 AM, revealed Resident #7 struck another resident in the dining area, the resident was escorted back to his room and both parties were divided. Record review of Resident #7's Physician's Notes, dated 05/15/23, revealed Resident #7 continued to be receptive to supportive care and there were no changes in moods or behaviors. There were no complaints at this time. Record review of Resident #7's Progress Notes, dated 05/17/23 at 10:36 PM, revealed at 07:30 AM Resident #8 was brought to the nursing station and told the nurse Resident #7 hit him in the face and the chest. Resident #7 said Resident #8 called him a derogatory term and that was the reason he punched him in the face. Record review of Resident #7's Social Worker A, dated 05/18/23 at 10:44 AM, revealed Resident #7 hit another resident (Resident #8) late in the evening yesterday. Resident would benefit from emergency psych evaluation as he was a current threat to other residents due to his disorientation and confusion. An observation and interview on 05/17/23 at 09:55 AM revealed Resident #7 lying in bed well-groomed and in no immediate distress. He said a white man in a wheelchair hit him in the back so he came back and hit him back. He said Resident #8 talked about his mother and that was why he hit him. He said he had not had any other issues with any other residents and no other issues with Resident #7. In an interview on 05/24/23 at 01:16 PM, the Assistant Administrator said there was no incident report on record for the incident involving Residents #7 and #8 on 11/19/22. He said following any accident/incidents which include resident to resident altercations, an accident/incident report must be completed to detail the event but he did not know why the incident had not been document Resident #8 Record review of Resident #8's face sheet, printed 06/15/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: paraplegia (paralysis of the legs and lower body), history of traumatic brain injury, type 2 diabetes, mood disorder, assault by unspecified firearm. Record review of Resident #8's quarterly MDS, dated [DATE], revealed intact cognition as indicated by a BIMS score of 15 out of 15, no signs of delirium or hallucinations, no physical behavioral symptoms directed toward others, no verbal behavioral symptoms directed towards others, no other behavioral symptoms not directed toward others, no rejection of care, total dependence on most ADLs and use of a wheelchair. Record review of Resident #8's, undated, Care Plan revealed, focus- Resident #8 was a smoker with potential for injury. Record review of Resident #8's Incident/Accident Report, dated 11/18/22 at 07:30 PM, revealed Resident #8 punched Resident #7 in the mouth at 07:00 PM which resulted in a laceration to the lip while outside in the smoke area. Record review of Resident #8's Progress Notes, dated 11/19/22 at 07:03 AM, revealed Resident #7 punched Resident #8 on 11/18/22 at 07:00 PM in the mouth when both of them were in the smoking area and Resident #8 had a deep laceration to his lip. Resident #8 stated Resident #7 punched him because he told him to stop assaulting staff because of cigarettes. Resident #8 was assessed and MD was notified about the laceration and gave orders for the resident to be sent out to the hospital for sutures. Resident #8 was sent to the hospital on 11/18/22 at 07:00 PM. Record review of Resident #8's Progress Notes, dated 11/19/22 at 07:33 AM, revealed Resident #8 returned from the Hospital on 11/19/23 at 04:00 AM. Record review of Resident #8's Progress Notes, dated 11/19/22 at 11:31 AM, revealed Resident #8 said Resident #7 pointed a finger at him and was yelling at him. Resident #8 was escorted out of the dining room to go out during smoke time. Record review of Resident #8's Physician Note dated 11/22/22 revealed, Resident #8 was reportedly punched in the face by another resident (Resident #7). Resident #8 sustained a laceration to the lip, he was sent to the ER however he did not have any sutures placed. Record review of Resident #8's Progress Note, dated 05/03/22, revealed Resident #8 got hit by another resident (Resident #7) on his chest in the dining room. Resident #8 said he was yelling for someone to adjust him properly in his chair and Resident #7 got irritated, wheeled close to him and hit him in the chest. Head to toe assessment completed and Resident #8 had no bruising or swelling noted. Record review of Resident #8's Progress Notes, dated 05/17/23 at 07:30 PM, revealed Resident #8 got into a fight with Resident #7 on the smoking patio but the incident was not witnessed. Resident #7 hit Resident #7 on the lips, check and neck. Resident #8 was observed to have bruised lips, a purple bruise on the neck/throat area from trauma and Resident #8 reported Resident #7 burned him with a cigarette to which a blister was observed. Record review of Resident #8's Physician Note, dated 05/23/23, signed by MD A revealed chief complaint: follow up for coffee burn, cigarette burn, sunburn and trauma to neck. MD A was notified by staff on 05/23/23 that Resident #8 was in a fight with another resident in which he was punched in the jaw/neck and sustained a cigarette burn to his right arm. Resident #8 still had a bruise to his neck but the cigarette burn was almost healed. An observation and interview on 05/21/23 at 06:27 PM revealed, Resident #8 sitting in his wheelchair in his room, well-groomed and in no immediate distress. Resident #8 said he had multiple altercations with Resident #7 and he didn't feel safe in the facility when Resident #7 was there. He said Resident #7 always cursed at him in the hallways , the dining room and in the smoking area every day. Resident #8 said the facility made no efforts to move Resident #7 so they don't meet in the hallway, change their dinning or smoking breaks and did not ensure they were separated or supervised during meals in the dining room or smoke breaks in the courtyard even though he had made multiple complaints. Resident #8 said Resident #7 punched him in the chest and lip on multiple occasions causing him to bleed and get stitches. He said in the last incident Resident #7 burned him on his arm with a cigarette. He said the facility have taken no action to ensure he was safe from Resident #7. In an interview on 05/17/23 at 08:45 AM, the Assistant Administrator said on 05/03/23 he heard Resident #8 screaming and observed Resident #7 pushing back. He said the nurses reported Resident #7 hit Resident #8 twice in the chest because Resident #8 was screaming which agitated Resident #7 and caused him to hit him in response. The Assistant Administrator said the residents were separated and there were no incidents since then. He said there had been previous incidents between Resident #7 and Resident #8 in the smoking area, when Resident #8 took up for the staff so Resident #7 hit him in the face. The Administrator said he believed Resident #8 was triggered by loud noises. In an interview on 05/22/23 at 04:00 PM, the Assistant Administrator said following the incident on 05/18/23 Resident #7 was sent out to a behavioral hospital and he would not be returning. He said Resident #7 and Resident #8 had multiple altercations in the smoking area and the dining area. He said Resident #7 and Resident #8 normally took their smoking break or dining area together and to his knowledge there had never been measures in place to ensure these two residents were separated. He could not provide a reason why interventions were not put into place or why additional supervision was not provided to Resident #7 or Resident #8 to prevent further altercations. In an interview on 05/16/23 at 09:00 AM, the Administrator said she was the abuse coordinator and she was responsible for reporting and investigating all allegations of abuse and neglect. She said when there was a resident to resident altercation nursing staff were expected to separate the resident's immediately to ensure their safety, complete head to toe assessments and then notify the family, the MD and then the facility administration. She said if residents had a history of physical aggression they should be supervised or separated from others to ensure they were not a danger to others. The Administrator said failure to provide adequate supervision following an allegation/incident of abuse placed residents at risk of further abuse and injury. In an interview on 05/16/23 at 09:05 AM, DON A said following a resident to resident altercation residents must be immediately separated for safety, a head to toe assessment must be completed and documented. She said at no point in time should a resident be returned to the same room as the assailant and in the long term the residents should not be left alone unsupervised in the same area for safety. In an interview on 05/18/23 at 10:30 AM, the Administrator said she was the facility abuse coordinator and was responsible for investigating all allegations of abuse. The Administrator was unable to describe what action or supervision was provided to prevent abuse with Resident #2, Resident #6, Resident #7, Resident #8, Resident #9 and Resident #10. Record review of the facility policy titled Nursing Policies and Procedures- Abuse/Neglect [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 6 of 25 residents ( Resident #1, Resident #2, Resident #3, Resident #4, Resident #5 and Resident #6) reviewed for ADL care. 1. The facility failed to provide nail care for Resident #1 who suffered from contractures which resulted in overgrown nails that became embedded into his skin. The resident developed a skin infection which required antibiotic treatment and surgical intervention to remove the nail. 2. The facility failed to provide nail care to Resident #2, Resident #3, Resident #4 and Resident #5 who had contractures which resulted in nail lengths approximately ranging from 1/4- 1/2 inch. 3. The facility failed to provide nail care to Resident #6, which resulted in soiled nails and nail lengths of approximately 1/2 inch. These failures could place residents at risk of decreased quality of life, skin infections, bone infections and ultimately amputation. Findings included: Resident #1 Record review of Resident #1's face sheet, dated 05/16/23, revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of: type 2 diabetes and contracture of the unspecified hand. Record review of Resident #1's Annual MDS, dated [DATE], revealed severely impaired cognition as indicated by a BIMS score of 03 out of 15, extensive to total assistance for most ADLs, total dependence on staff for personal hygiene and always incontinent of both bladder and bowel. Record review of Resident #1's Care Plan, dated 03/16/23, revealed focus- potential impairment to skin integrity of the (bilateral hands) related to contractures; goal- resident will be free from injury (bilateral hands) and other body parts, resident will maintain or develop clean and intact skin; intervention- follow facility protocols for treatment if injury, keep skin clean and dry. Record review of Resident #1's NP Progress Note, signed 05/04/23, revealed Patient seen today while in his room. He is awake and comfortable. His vitals are acceptable and he shows no signs of acute distress There was no mention of Resident #1's overgrown fingernails. Record review of Resident #1's Progress Notes, dated 05/06/23 at 01:08 PM, written by Agency Nurse A, revealed, upon applying palm guard to the resident's left hand as ordered the patient was observed to have 4th and 5th fingers on his right hand contracted with fingernails curling into the skin, wet and smelling. The 4th finger was swollen and mild bleeding was observed. Agency Nurse A left a notification in the MD binder for the provider to follow up. Record review of Resident #1 Physician's Order, dated 05/09/23, revealed, Bactrim DS Oral 800-160 mg, an antibiotic, give 1 tablet by mouth every 12 hours for nail infection to right 4th and 5th finger for 7 days. Record review of Resident #1's NP Progress Notes, signed 05/11/23, revealed Patient seen today while in his room. His right hand is swollen, mainly around the fourth and fight digit. The fingers are red and swollen with some bleeding present. The nails are ingrown and infected and infection will be treated. Otherwise, his current pain is managed, and he is currently afebrile . Skin- 4th/5th digit ingrown nail on right hand, erythematous (red), bleeding, swollen. Diagnoses/Assessment/Plan: Infection, nail, ingrowing . begin Bactrim DS BID for 7 days. Record review of Resident #1's NP Progress Notes, signed 05/13/23, revealed Resident #1 was started on Bactrim secondary to ingrown nails. His bleeding has improved, but the swelling and tenderness remain. Record review of Resident #1's Hand Surgeon Progress Note, dated 05/17/23, revealed, Assessment: Nail deformity, cellulitis of finger of right hand. Treatment- the affected digit was washed with Betadine (an antiseptic) and saline. Patient will need surgery to remove the overgrown nail. Patient was stated on Augmentin (an antibiotic). Record review of Resident #1's Hand Surgeon Surgery Information Sheet, dated 05/17/23, revealed procedure- debridement of necrotic (dead) tissue right ring. Description of medical care and surgical procedures: cellulitis (bacterial infection of the skin), nail deformity and abscess (a pocket of pus); Irrigation and debridement of necrotic tissue of the right ring finger and palm. Record review of Resident #1's MD Progress Notes, signed 05/18/23, revealed, Patient was seen due to concern of finger infection. Patient has severe contractures of the right hand and fingers and has an elongated nail that is curved along the base of the finger and is now cutting into the same finger causing bleeding and swelling, redness, and pain of that finger. I am unclear how long his fingers have been in the contracted state for. Patient refuses any attempts at having a cue tip placed between his fingers to allow me to see the wound due to the pain. He was started on Bactrim about one week prior by NP. Musculoskeletal: right 4th finger with severe contracture with elongated nail with puncture wound of the same finger with bleeding and associated swelling, redness and tenderness. Diagnosis/Assessment/Plan: Cellulitis of fingernail of right, plan- cellulitis of fingernail of right hand-continue with Bactrim and treat for 14 days. Record review of Resident #1's Progress Notes from 01/01/2023 to 05/16/23, revealed no documentation of continuous refusal of nail care for Resident #1. Record review of Resident #1's Skin Observations from 01/01/23 to 05/16/23, revealed no documentation of overgrown nails or indications of skin infection. An observation on 05/16/23 at 12:00 PM revealed, Resident #1 sitting in a wheelchair in the hallway in front of his room. The resident had right and left hand contractures, a palm guard was on the left hand and no palm guard was on the right hand. Resident #1's right 4th and 5th finger were severely contracted on his right hand and blood was observed on the side of his 4th finger. His 4th fingernail was deformed, overgrown at approximately 1 inch long, embedded in the skin on the tip of his finger, curved and contouring down his finger. An observation on 05/16/23 at 12:35 PM revealed, Resident #1's fingernails were dirty on both hands with thick brown debris were underneath his nails, with the ring (4th) finger and pinky (5th) finger contracted. Resident #1's nails on the 4th and 5th finger were long until the nails had curled underneath digging into the resident's skin resembling bird claws. There was red dry drainage on the inner aspect of the 4th finger and the resident's right hand had a foul smelling odor. Resident #1 was unable to fully extend his 4th and 5th finger because he said it hurt and when he attempted to extend the two fingers a deep indention on the palm of the hand was observed where the small finger was resting. An additional observation of Resident #1's left had revealed, the hand was contracted with thick brown debris under his nails. In an interview on 05/16/23 at 12:40 PM, Resident #1 said he observed blood on his finger when he woke up the morning of 05/16/23. He said the nursing staff had not provided any care to his bleeding finger. In an interview on 05/16/23 at 12:45 PM, CNA A said he was Resident #1's assigned CNA. He said the resident did not have a dressing on his finger when he provided care to him in the morning but did not remember if there was blood on Resident #1's finger. In an interview on 05/16/23 at 01:35 PM, CNA A said CNAs did not provide nail care to residents with contractures, he said nurses were responsible for cleaning/filing/trimming of the nails of residents with contractures. He said he had only provided care to Resident #1 for 1 week and during that time he had observed a foul odor coming from the resident's right hand as well as the resident's overgrown and heavily soiled fingernails. CNA A said he notified Resident #1's nurse of his observation, and the only hand hygiene he performed on the resident was wiping the resident's hands clean with a wet paper towel due to the resident's contractures. In an interview on 05/16/23 at 02:05 PM, the Director of Rehab said Resident #1 did not receive current PT/OT services. He said Resident #1 had contractures on both hands and in residents with contractures palm guards were used to protect the resident's palms from skin breakdown. The Director of Rehabilitation said he saw Resident #1 a week ago and the resident had a palm guard on his left hand and he did not know if Resident #1 had orders for his right hand. He said long nails in residents with contractures placed them at risk for skin damage and there was a potential for infection. In an interview on 05/16/23 at 07:02 PM, Family Member #1 said she was not notified by the facility that the resident declined nail care or that the resident had ingrown nails that required antibiotic treatment. In an interview on 05/17/23 at 09:36 AM, the NP said she assessed Resident #1's right hand and his 4th and 5th nails were well overgrown. She said she received notification in the physician binder on the prior week that nursing staff observed bleeding and swelling to Resident #1's finger. The NP said when she visited the Resident #1 his nail was embedded to the skin, and his finger was swollen, she prescribed Bactrim, an antibiotic, and ordered a podiatrist consult. The NP said prior to that notification she had not been notified of the facility having any issues with Resident #1's fingernails or any refusal of care. She said Resident #1's nails should not have gotten that long, they were well overgrown. and had not received prior notification the resident having excessively long nails or any signs of infection. The NP said Resident #1 should have had palm guards on his right hand and that in addition to proper nail care would have prevented Resident #1's infection of his 4th and 5th fingers. In an interview on 05/17/23 at 10:20 AM, Agency Nurse A said she worked with Resident #1 on 05/06/23. She said Resident #1 had an order for the application of palm guards to the left hand and after applying the guard as ordered she observed the resident had contractures on his right hand but didn't have orders so she inspected Resident #1's right hands. She said Resident #1's right hand had a fouls smell, his fingers were swollen, had mild bleeding with drainage so she tried to clean it as much as possible. Agency Nurse A said Resident #1's fingernails were so long they had bent over taking the shape of his contracted finger, they had not been cut for a long time. She said she reviewed Resident #1's chart and there were no notes, so she took the initiative to investigate. Agency Nurse A said she notified the therapy department, who said they would assess the patient on the next Monday and she completed a notification to the NP in the provider notification binder. In an interview on 05/17/23 at 01:55 PM, MD A said Resident #1's hand contractures were so severe that it made it hard to cut his nails leaving his nails overgrown. He said he had received no previous notifications of issues with the resident's fingernails prior to the NP identifying the infection. The MD said based on the level of contractures Resident #1 should have had palm guards on both his hands. He said he did not have specific instructions for nail care in residents with contractures but expected nursing staff provided nail care to maintain a short length and prevent the nail from embedding in the skin. In an interview on 05/19/23 at 10:58 AM, the Hand Surgeon said he assessed Resident #1 on 05/17/23 and he observed Resident #1's finger nails to be excessively long and it was impossible to cut without surgical intervention because the resident would need a nerve block to cut the fingernail. He said Resident #1's fingers were inflamed infected and very painful so the patient would first complete a course of antibiotics which would help the inflammation. The Hand Surgeon said Resident #1's cellulitis and a soft tissue infection of the palm was as a result of overgrown nails in a resident with contractures that became embedded in the skin. In an interview on 06/15/23 at 12:00 PM, the Corporate Nurse said the facility could not locate shower sheets for Resident #1. Resident #2 Record review of Resident #2's face sheet, dated 05/23/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: unspecified dementia, depression, difficulty swallowing, G-tube (a tube that goes into the stomach to provide food and medications), anxiety disorders, left hand contractures, right hand contractures and severe intellectual disabilities. Record review of Resident #2's Quarterly MDS, dated [DATE], revealed unclear speech, rarely understood, sometimes understands, severely impaired cognition as indicated by a BIMS score of 00 out of 15, no response to resident mood interview questions, no documented behavioral symptoms (physical behaviors directed towards others, verbal behavioral symptoms directed to others or other behavioral symptoms not directed towards others), no rejection of care, no wandering, total dependence on all ADLs, use of a wheelchair, always incontinent of both bladder and bowel, non-traumatic brain dysfunction and left and right hand contractures. Record review of Resident #2's, undated, Care Plan revealed no focus area addressing Resident #2's contractures or nail care. An observation on 05/17/23 at 08:13 AM revealed, Resident #2 was asleep in bed with the left hand contracted and the right hands wore hand rolls with the finger nails approximately 1/4 inch long. The resident was not interviewable. Resident #3 Record review of Resident #3's face sheet, dated 5/18/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), Hemiplegia (paralysis of one side of the body), Contracture of muscle, Left Hip, Left knee, Left upper arm and Right upper arm. Record review of Resident #3's MDS dated [DATE] revealed, the resident had severely impaired cognition as indicated by a BIMS score of 00 out of 15, extensive to total assistance for most ADLs, total dependence on staff for personal hygiene and always incontinent of both bladder and bowel. Record review of Resident #3's Care Plan, dated 5/10/2023, revealed focus- potential impairment to skin integrity of the bilateral hands, bilateral lower extremities related to contractures; goal- resident will be free from injury (bilateral hands, bilateral lower extremities) and other body parts, resident will maintain or develop clean and intact skin; intervention- follow facility protocols for treatment if injury, keep skin clean and dry. An observation on 5/17/2023 at 8:34 AM revealed Resident #3 lying in bed with the head of bed at 30 degrees, bed in a low position with a pressure relief mattress, lying on his back with his left arm/hand contracture noted. There were no palm protective barrier noted between fingers and palm of hand, fingernails approximately 1/8th of inch long. In an observation and Interview on 5/17/2023 at 12:52 DON A said Resident #3's fingernails were too long and needed to be filed. Resident #4 Record review of Resident #4's face sheet, dated 5/18/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Vascular Dementia (Vascular dementia is a form of dementia caused by brain damage resulting from restricted blood flow in the brain. It affects someone's thinking skills: such as reasoning, planning, judgement and attention), Hemiplegia (paralysis of one side of the body), Contracture of muscle, left upper arm, and acquired absence of right leg below knee. Record review of Resident #4's MDS ,dated 02/03/2023, revealed severely impaired cognition as indicated by a BIMS score of 00 out of 15, extensive assistance for ADLs, personal hygiene and was always incontinent of both bladder and bowel. Record review of Resident #4's Care Plan, dated 5/15/2023, revealed focus- potential impairment to skin integrity related to incontinence of bowel/ bladder, dementia, poor circulation; goal- resident will be free from injury and other body parts, resident will maintain or develop clean and intact skin; intervention- follow facility protocols for treatment if injury, keep skin clean and dry. An observation on 5/17/23 at 8:32 AM revealed Resident #4 observed lying in bed with the head of the bed at 30 degrees, the bed was in a low position with a pressure relief mattress in place, eyes closed, lying on left side with left hand contracture noted, no pal protective barrier noted between fingers and palm of hand, fingernails were approximately 3/16th inch long. In an observation and interview on 5/17/2023 at 12:50, DON A said Resident #4's nails were too long needed to be filed. Resident #5 Record review of Resident #5's face sheet, dated 5/18/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Hemiplegia (paralysis of one side of the body), cognitive communication deficit and unspecified lack of coordination. Record review of Resident #5's Annual MDS, dated [DATE], revealed severely impaired cognition as indicated by a BIMS score of 00 out of 15, limited to extensive assistance for most ADLs, and always incontinent of both bladder and bowel. Record review of Resident #5's Care Plan, dated 03/16/23, revealed focus- at risk for confusion, aggression and decline in ADL related to dementia; goal- be able to function in the environment safely; intervention- administer medication as ordered by MD, assist resident with ADL's. An observation on 5/16/23 at 11:10 AM revealed Resident #5 sitting in his wheelchair in the common area, left hand contracted, no palm protective barrier noted, fingernails on the left hand were 1/2 inch long. Resident #6 Record review of Resident #6's face sheet, dated 05/17/23, revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, bipolar disorder, delusional disorders, unspecified psychosis and hypertension. Resident #6 did not have a diagnosis of contractures. Record review of Resident #6's Quarterly MDS, dated [DATE], revealed severely impaired cognition as indicated by a BIMS score of 03 out of 15, no signs of delirium, no rejection of care, supervision with most ADLs, use of a wheelchair and occasionally incontinent of both bladder and bowel. Record review of Resident #6's, undated, Care Plan, printed 05/17/23, revealed focus-- Resident #6 has displayed frequent episodes of refusal of medications and ADL cares and is at risk for injury; Interventions- keep MD/NP informed of resident's refusal of medications and/or ADL care. Focus initiated on 10/28/21 and revised on 04/20/22- diagnoses of schizophrenia, bipolar disorder, psychosis, delusional disorder. Sometimes became aggressive with facility properties and staff. Focus- ADL self-care deficits and was at risk for further decline in ADL functioning and injury; intervention- Resident #6 will be well dressed, groomed and clean; intervention- 1on1 for personal hygiene. An observation and interview on 05/18/23 at 12:00 PM revealed Resident #6 lying in bed in no immediate distress. Resident #6's nails were over 1/2 long on both hands with heavy dark debris under his nails. Resident #6 said he wanted his nails cut, had no problems with the staff cutting his nails and he could not remember when his nails were last cut. Resident #6 was not observed to have any contractures. In an Interview on 5/17/2023 at 12:55 PM, the Director of Nurse stated nail care was important in residents with contractures to prevent the nail from becoming embedded in the skin. She stated she was not previously aware of any resident with nail care issues including residents with contractures. The Director of Nursing stated aides were responsible for filling nails, had to provide nail care to residents with contractures and nail care needs were monitored during the shower schedule. In an interview on 05/17/23 01:55 PM, MD A said he did not have specific orders for nail care in residents with contractures but expected nursing staff to provide nail care to maintain a short length and prevent the nail from embedding in the skin. He said nail care was an expected nursing duty. MD A said he was not aware/informed of any facility residents with significant issues regarding nail care. In an interview on 05/18/23 at 12:17 PM, the DON A said nail care was important in residents with contractures because overgrown nails could become embedded in the skin causing skin infections. She said CNAs were responsible for nail care and nurses should help aides with nail care in residents with contractures. The DON A said there was no policy specifically for nail care and nail care was monitored with the shower schedule. In an interview on 05/23/23 at 04:36 PM, the Administrator said the facility did not have a policy that specifically addressed nail care in residents with contractures. Record review of the facility's, undated, policy titled Nursing Policies and Procedures: Nail Care revealed, it is the policy of this facility that the facility staff will assist the residents with nail care as needed. Residents who are unable to care for their own finger or toenails require staff assistance in keeping nails clean and trimmed.

Based on interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice the comprehensive person-centered care plan and the residents choices 2 of 12 residents (Resident #11 and Resident #12) reviewed for quality of care. 1. The facility failed to take appropriate action following Resident #11's fall by picking the resident up before completing an assessment and starting neurological checks 3 hours after the fall. 2. The facility failed to ensure Resident #12, who had suffered from a hip fracture and did not walk which resulted in the resident suffering from pain and discomfort and was unable to receive dialysis. 3. The facility failed to assess Resident #12 after returning to the facility after she was denied dialysis due to being too ill. These failures could place residents at risk for a delay of care or treatment, pain and suffering. Findings include: Resident # 11 Record review of Resident #11's face sheet, dated [DATE], revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: fracture of the left thumb, skin infection, type 2 diabetes, depression and unspecified intellectual disabilities. Record review of Resident #11's Annual MDS, dated [DATE], revealed serious mental illness, intellectual disability, moderately impaired cognition as indicated by a BIMS score of 08 out of 15, total dependence on most ADLs, use of a wheelchair and always incontinent of both bladder and bowel. Record review of Resident #11's Care Plan, printed [DATE], revealed a focus of- high risk for falls related to diabetes, not aware of the safety need, and history of falls and ambulating without assistance. Interventions- encourage Resident #11 to accept assistance from staff with ambulation and transfers; follow facility fall protocol. Record review of Resident #11's Progress Notes, dated [DATE] and printed on [DATE], at 04:48 PM revealed, no reported falls on [DATE]. Record review of Resident #11's Neurological Record, dated [DATE], revealed neurological checks were not started on Resident #11 until 10:45 PM. Record review of the facility submitted email to CII dated [DATE] at 08:33 PM revealed, Resident #11's family member reported she found the resident on the floor and he told her he fell taking himself to the bathroom because no one would. Resident #8's family member claimed an agency nurse told him you gonna stay on the floor, I am not gonna pick you up, and then closed the door to silence his cries for help. Record review of Resident #11's Clinical Assessments, printed on [DATE] at 04:55 PM, revealed no skin or fall assessments were completed after Resident #11's fall on [DATE]. In an interview on [DATE] at 04:18 PM revealed Resident #11's family member said when she arrived at the facility on [DATE] she found the resident on the floor so she began to scream for help. She said the nurse never came to help pick Resident #11 off the floor and she was instead helped by a Janitor to place Resident #11 back in bed. Resident #11's family member said the nurse never assessed the resident following the fall. In an interview on [DATE] at 09:00 AM the Administrator said Resident #11 reported to his family that Agency Nurse B would not help the resident go to the bathroom and he had an unwitnessed fall. She said Resident #11 said the nurse closed the door on him as he lay on the bathroom floor in order to mute his cries for help. She said Resident #11 was not sent out to the hospital because the Resident could recall what happened. The Administrator said when she was notified about the allegation against Agency #2 she immediately so she sent the nurse home. An observation and interview on [DATE] at 11:15 AM revealed, Resident #11 well dressed and in no immediate distress sitting in wheelchair in right outside of his door, the resident had were no visible bruises or injuries Resident #11 said he fell on [DATE] and [DATE], hit his head on both occasions but only went to the hospital on [DATE]. He said the nursing staff picked him up and he felt safe in the facility. In an interview on [DATE] at 08:26 AM, Agency Nurse B when she arrived for her evening shift at around 6:30 AM she did a cursory inspection of her residents and she observed Resident #11 in his wheelchair. Agency Nurse B said no more than 20 minutes after her arrival to her shift she heard Resident #11's family member scream and when she went to investigate she found the resident on the floor of the bathroom. She said she immediately left to get a Hoyer lift and extra assistance but there was no one on the floor so by the time she returned to Resident #1 and his family member had a member of the floor staff helping Resident #11 up. Agency Nurse B could not identify the floor staff that helped Resident #1 up. She said she was unable to initiate any assessments before the resident was picked up off the floor. Agency Nurse B said she was not trained on the facility fall policy prior to working at the facility so she was overwhelmed by the incident. She said due to the family members complaint, she was told to leave the facility shortly after the incident so she did not get to document anything and did not start Neuros. In an interview on [DATE] at 08:56 AM, RN C said Agency Nurse B informed her Resident #11 was on the floor so they both went to look for a CNA but by the time they returned to Resident #11 a member of the dietary [NAME] had helped the resident up. She Said Agency Nurse B was responsible for ensuring the facility fall protocol was followed following Resident #11's fall and she did not know what the agency nurse did or did not do. She said shortly after the incident Agency Nurse B said she was sent home by the Administrator and left a little after 07:00 PM. RN C said she contacted the Unit Manager at 07:15 PM for coverage when the Agency Nurse left and the Unit Manager did not arrive at the facility until 10:36 PM. She said during that time between Agency Nurse B leaving and the Unit Manager arriving she was not assigned to take care of Agency Nurse B's patients and she did not perform any assessments on Resident #11 or any other residents. RN C said there was no nurse coverage for Agency Nurse B's residents. In an interview on [DATE] at 09:11 AM, the Unit Manager said she received a call from the Administrator stating Resident #11's family member reported that when the resident fell and the Agency Nurse shut the door to silence his screams, the Administrator told Agency Nurse B to go home after completing her witness statement and she (unit manager) would have to cover. The Unit Manager said she arrived at the facility at 10:30 PM and started neurological checks on Resident #11 at 10:45 PM. She said to her knowledge no neuro checks were initiated prior to her arrival, there was no documentation of any assessments and no one was covering the patients between Agency Nurse B's departure and her arrival. She said the failure to assess patients before moving them could place them at risk for further injury and a delay in the initiation of neuro checks could result in late identification of a neurological problem. In an interview on [DATE] at 12:10 PM, DON B said after a resident fell nursing staff were expected to assess the patient prior to moving to prevent further injury, initiate neurological checks and notify the NP especially if the resident could not tell staff how the fall occurred. She said failure to assess residents timely could result in a delay in care. Record review of the facility policy titled Fall Management, revised ,d+[DATE], revealed in the event of a fall: 1- the resident will not be moved until a nurse evaluates the resident's condition. 2- the resident will be checked for any abnormalities i.e., confusion, level of consciousness. 3- obtain vital signs; 4- complete Range of Motion; 5- initiate neurological checked when residents hit their head or have an unwitnessed fall. 11- document all appropriate information in the medical record. Follow- up documentation is required for 72 hours post fall. Resident #12 Record review of Resident #12's face sheet, dated [DATE], revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included, [NAME], left hip fracture and dependence on renal dialysis. The Resident discharged from the facility on [DATE] due to cardiac arrest. Record review of Resident #12's, undated, Care Plan revealed, Focus- dialysis, Resident #12 is at risk for SOB, chest pain; interventions- give medications as ordered, observe feet and hands for edema during rounds. The care plan did not address if Resident #12 was non-weight bearing for her hip fracture or her method of ambulation. Record review of Resident #12's Progress Notes from admission ([DATE]) to discharge ([DATE]) printed on [DATE] at 12:55 PM revealed: - [DATE], there were no notes on Resident #12 to reflect her status. - [DATE] at 06:43 PM, revealed Resident #12 did not receive her dialysis on that day because transportation company organized by the facility to take the resident to the facility picked Resident #12 up and dropped her off late. There was no documentation of the Resident #12 being unable to get dialysis because she was too ill. -[DATE], there were no notes on Resident #12 to reflect her status. -[DATE] at 04:40 AM, Resident #12 received 1 tablet of Hydrocodone ,d+[DATE] mg due to complaints of pain. -[DATE] at 12:45 PM sgined by LVN H, nurse was notified by CNA of resident unresponsive. Upon entering patient room patient noted torso laying supine with legs on floor. Unresponsive. No pulse. Warm. Patient moved to floor and CPR initiated at 1155. 911 called. Blood sugar 213. AED applied by EMS no shock advised CPR continued by EMS. Patient history and meds provided to EMS and sheriff deputy. Patient transferred to the hospital and family notified. There were no other notes between 04:40 AM and 12:45 PM on [DATE] to reflect Reisdent #12's status. Record review of Resident #12's Clinical Assessments from admission ([DATE]) to discharge ([DATE]) printed on [DATE] at 12:55 PM revealed, there were no clinical assessments documented after Resident #12 was refused dialysis due to her pain and shortness of breath. Record review of Resident #12' PT Evaluation and Plan of Treatment signed on [DATE] revealed, current referral- Resident #12 was referred to PT due to new onset of decrease in functional mobility, decrease ins strength, decreased coordination, falls/fall risk, fracture, reduced balance when moving, reduced balance when still and pain. Ambulation: required supervision or touching assistance to walk 10 feet, Resident #12's PLOF was independent. The PT assessments for walking 50 feet with two turns, walking 150 feet, walking 10 feet on uneven surfaces and 1 step (curb) were not attempted due to medical conditions or safety concerns. Pain Assessment: intermittent achy pain rated at 6 out of 10 (0 being no pain and 10 being unspeakable pain) when at rest and intermittent achy pain rated at 8 out of 10 when in motion. Record review of facility email correspondence dated [DATE] at 09:31 AM written by the transportation agency to the facility Regional Director of Operations revealed, the transit driver said Resident #12 exited her room with her walker maybe about 25 to 30 feet then they decided she would take too long to get to the front door so they put her in a wheelchair and I took her from there. Record review of facility email correspondence dated [DATE] at 09:31 AM written by the transportation agency to the facility Regional Director of Operations revealed, the transit driver reported that when Resident #12 arrived at the dialysis center they were informed the resident did not have an appointment, the dialysis center said they would not dialyze her and that Resident #12 had to come back (to the dialysis center) via stretcher in order to be seen. Record review of Resident #12's EMR revealed, no documented assessments for Resident #12 after returning from dialysis because she was too ill to receive treatment. In an interview on [DATE] at 11:15 AM, the Administrator said he did not know why Resident #12 was denied her dialysis treatment. In an interview on [DATE] at 11:20 AM, the Admissions Coordinator said on [DATE] Resident #12 was walking slowly to the transport to receive dialysis and by the time she arrived at her appointment the dialysis staff said she was not appropriate for dialysis. She said since Resident #12 was too ill to receive dialysis the team sent her back. The Admissions Coordinator could not describe Resident #12's symptoms and could not name who she notified of the reason Resident #12 was denied dialysis. In an interview on [DATE] at 11:31, LVN G said she did not remember specifics about how Resident #12 ambulated and she was not informed that the resident was refused dialysis due to pain and SOB. In an interview on [DATE] at 10:39 AM, the Dialysis Center Administrator said when Resident #12 arrived for dialysis on [DATE] she was ill. The resident was walking into the center with a walker and to their knowledge she was supposed to be on a stretcher due to her fracture, so the dialysis staff placed her in a wheelchair but the resident was in too much pain. The Dialysis Center Administrator said their facility did not have the kind of mediation to control Resident #12's pain, the resident was experiencing heavy breathing and Resident #12 told the nurse she could not sit through dialysis because she was in pain. She said the nurse asked Resident #12 if she would like to go to the hospital, which Resident #12 said no. The Dialysis Center Administrator said she attempted to call the facility but no one answered so she sent a note with the driver advising of the situation. She said Resident #12 should not be walking due to her fracture and the pain prevented Resident #12 from receiving dialysis was as a result of her walking. In an interview on [DATE] at 10:17 AM, the PT Director said Resident #12 was very pleasant and cooperative. He said Resident #12 was not safe to walk because she was not weight bearing on her left leg and the resident should not have been walking on her own without direct supervision. The PT Director said Resident #12 experienced pain rated on a scale of 08 out of 10 due to ambulation and when she got tired she experienced SOB. He said Resident #12 walking put her at risk for compromised healing. In an interview on [DATE] at 01:55 PM, MD A said he was not notified that Resident #12 did not receive her dialysis or the resident was too ill to receive dialysis. He said he expected nursing staff to notify him of any change of conditions in Resident #12 and the resident be assessed immediately in order to identify and treat any acute health conditions. MD A said if Resident #12 was found to be unstable the resident would have been sent out to the ER for further evaluation but the resident would have been treated in the facility if she was determined to be stable. In an interview on [DATE] at 06:01 PM, LVN H said she did not remember specific details about Resident #12's ambulation or refusal of dialysis. In an interview on [DATE] at 01:05 PM, DON B said she was not aware of the details surrounding Resident #12's dialysis or her ambulation but a resident who had been assessed as being unsafe to walk by PT should not be walking because of a risk for pain. She said residents should be evaluated based on their symptoms and if Resident #12 could not have dialysis due to SOB and Pain, nursing staff should have assessed her when she returned to the facility to identify any acute health conditions The DON said a delay in dialysis could result in SOB, discomfort or the resident could code. In an interview on [DATE] at 12:10 PM, DON B said all residents should be assessed when they had a change of condition and the NP should be notified. She said the NP/provider could then give new orders for treatment or to send the resident out to the hospital for further evaluation. She said nursing staff should have assessed Resident #12 upon her return to the facility since she was noted to be to ill and failure to assess the residents for change of condition like that experienced by Resident #12 could result in worsening of condition.

Based on interview, and record review the facility failed to ensure each resident environment remains free of accident hazards and receives adequate supervision and care to prevent accidents for one (CR #1) of eight residents reviewed for accidents, hazards, and supervision. The facility failed to ensure that CR#1 who had a behavior of ingesting non-food items including chewing on his bedsheets and blanket was not provided appropriate and effective interventions to prevent accident. The facility failed to ensure CR#1's care plan reflected his behavior of ingesting non-food items and failed to identify and implement interventions that ensured CR#1 was frequently monitored for his behavior. This failure effected 1 resident and placed 38 other residents on the memory care unit at risk for injury and possible death. Findings Included: CR#1 Record review of CR#1's admission Face Sheet, dated [DATE], revealed he was a [AGE] years-old male who was admitted to the facility on [DATE]. His diagnoses included dementia without behavioral disturbances (impairment of brain functions such as memory loss), encephalopathy (brain disease that alters brain function), non-Hodgkin lymphoma (cancer that starts in the lymphatic system), history of falling, traumatic subdural hemorrhage, insomnia, hypertension (high blood pressure), gastro-esophageal reflux disease (a condition in which acidic gastric fluid flows backwards into the esophagus) and depressive disorder. Record review of CR#1's Quarterly Minimum Data Set (MDS) dated [DATE] revealed for cognition skills for daily decision making he was coded as modified independence. For behaviors he was coded as having no behavior symptoms. Rejection of care and wandering he was coded as having this type of behavior every 1 to three days. Record review of the nurse's notes dated [DATE] at 9:41am documented that CR#1 was found in his bed non-responsive at 5:45AM. CPR was applied by the nurse and 911 was called, they pronounced the resident deceased at 6:10am. In an interview on [DATE] at 10:30am with RN C regarding CR#1 she said she always work with CR#1 and he had a behavior of chewing on his sheet and blanket, but she never saw him chewing on socks. She said she was not the nurse working when the incident happened. At that point RN C was asked if CR#1's behaviors were documented, and she said that the behaviors should be documented in the nurse's note or on the 24 hour report. In an interview on [DATE] at 10:35am with MD B he said he was aware of CR#1's behavior of chewing on his blanket and sheet, but he was not aware of him chewing on his socks. At that point he was asked if he had any documentation regarding the behavior. He said he did not document CR#1's behavior. In an interview with CNA B on [DATE] at 10:55AM she said worked with CR#1 and he was not an aggressive resident. She said he had behavior of chewing on his blanket, sheet, straws, and napkins. She said at mealtime he was not given a straw because he would chew on the straw. She said whenever he was chewing on non-food items and they would redirect him. She said CR#1's chews on non-edible food items daily. In an interview with LVN A on [DATE] at 4:00PM she said that she did rounds on [DATE] at about 4:40am and the resident was asleep, and his breathing was normal. Asked how she was sure the resident was sleeping. She said she turn the light on to make sure residents were okay when she did rounds. She said at 5:45AM, CNA D call her to come to the room because CR#1 was non- responsive. She said she went to the room and the resident was placed on the floor and CPR was initiated and 911 was called. She said she checked the resident mouth and she saw what looked like food and she put her finger in the resident's mouth to clean it and that was when she pulls out a sock that was saturated with mucus from his mouth. She said 911 came quickly and took over and pronounced CR#1 dead at 6:10 AM. Further interview with LVN A revealed that CR#1 would chew on his blanket and sheet, but he never chewed on his socks. She said at times on her shift she would make sure CR#1 was asleep before she would cover him with his blanket. She said he was not an aggressive resident and he could be redirected if he was doing anything inappropriate At that point she was asked if CR#1's behavior was documented, and she said yes. Record review of CR#1's nurses notes dated [DATE] to [DATE] revealed no documentation of the CR#1 chewing on non-edible food items, sheet or blanket. Further record review of the nurse's notes revealed the last documented behavior of consuming non-edible food items was dated [DATE]. In an interview on [DATE] at 8:55am with CNA D she said she worked with CR#1 on the night he was found non-responsive. She said she checked on him around 3:00am and he was ok, he was breathing normal. She said at about 5:00AM she was doing her last round and she got to CR#1 around 5:30am -5:45 am and realized he was not responding, she only heard gargling sound. CNA D said she screamed for the nurse and the nurse came and she and another coworker put him to the floor and LVN A initiated CPR. She said while the resident was on the floor LVN A took a sock out of his mouth and it was saturated with mucus and blood. She said the Paramedic came and took over and she left the room. Further interview with CNA D revealed that CR#1 was always chewing on non-edible stuff. Record review of CR#1's Comprehensive Care Plan, initiated [DATE] and revised [DATE], revealed that his care plan did not address any behavior of chewing on non-edible items. Further record review of the Care plan revealed no care plan to address resident behavior nor was there any documented intervention in place. In an interview with CR#1's family member on [DATE] at 5:10PM she said that the facility was aware of CR#1's behavior of chewing on non-edible food items. The family member said he was chewing on blanket and sheets. The family member also said they use to bring business magazine for him to look at and the facility staff told the family not to bring any magazines because he was chewing on them. Record review of Occupational Therapy notes dated [DATE], [DATE] [DATE] and [DATE] to set items outside of plastic wrapping, such as straws in cup, utensils unwrapped placed in patient's hand. Caregivers educated to keep non-edible small items away from patient when unsupervised due to history of eating non-edible food items. Record review of Speech therapy's notes dated [DATE] and [DATE], revealed documentation where staff was to remove all non-edible items (i.e. straws, paper napkins salt and pepper packets) from patient's meal tray to minimize risk of choking on these items. In an interview with LVN K on [DATE] at 2:45PM she said she always work with CR#1 and he was not an aggressive resident. She said he had a behavior of chewing on non-edible food items (such as straws, magazines, napkins, blanket, and his sheet. She said this behavior happens daily. However, he was easily directed. She was asked if the behavior was documented, and she said it should be documented. She was unable to pull up any recent documentation of behavior. Further interview with the Social Worker on [DATE] at 2:40PM regarding Speech and Occupational Therapy notes she said she did not see the notes. She then said she would look at her computer and then said she could not access those notes from PCC. She said that was why she did not address CR#1's behavior. In an interview with on [DATE] at 4:30pm with the ADON she said they were not aware of CR#1's behavior and did not put anything in place to address the behavior. She said moving forward they will be discussing residents plan of care and the team would include the floor nurse. She said prior to this new management, floor nurses were not a part of their morning meeting. In an interview with the Speech Therapy on [DATE] at 11:16PM she said when she does assessments, she usually asked the aides or nurses questions regarding the resident's behaviors especially those on the Memory Care unit. She said the aides told her about CR#1's behavior of chewing on non-edible food items. She said she always remind them not to place non-edible food items on the tray during meal times. Record review of the Nursing Policies and Procedures dated ,d+[DATE] read in part . Subject: Safety Systems Policies: Staff will use safe practices when delivering care to patient/residents.

Based on observation, interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (CR #1) of six residents reviewed for quality of care. The facility failed to ensure that CR#1 G-Tube site was properly assessed to promptly identify signs of infections. CR#1's G-Tube site was found to be infested with maggots. The facility staff failed to obtain physician's orders to ensure that CR#1's G-tube site was assessed and monitored to ensure patency and no infection at the site. An Immediate Jeopardy (IJ) situation was determined to have existed on 02/11/2022 at 3:30PM. While the IJ was removed on 02/15/2022 at 3:35PM, the facility remained out of compliance at actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of a pattern due to the facility's needs to evaluate the effectiveness of the corrective systems. These failures affected one resident and placed all residents with G-tubes at risk for infection of G-tube sites. Findings Included: CR#1 Record review of CR#1's clinical record revealed CR#1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The CR#1 was discharged to the hospital via ambulance on 12/19/2021. Record review of CR#1's quarterly MDS dated [DATE] he was coded for Cognitive Skills for Daily Decision Making as modified independence (some difficulty in new situations only). For Functional Status she was coded For Transfer as activity occurring only once or twice a week with two plus person's physical assist. For dressing she was extensive assistance with two plus person's physical assist. For eating she was coded as total independence with one-person physical assist. For toileting and bathing she was total dependence with two plus person's physical assist and for personal hygiene she was extensive assistance with one-person physical assist. The resident was coded as incontinent of bowel and bladder and Nutritional Approaches CR#1 was coded as has been fed via a feeding tube. Record review CR#1's physician's order recapitulation order for 12/01/2021-12/31/2021 revealed no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR#1's clinical records/MAR/TAR dated 12/2021 revealed no documentation of assessment done regarding CR#1's G-Tube site. Record review of CR#1's nurse's notes dated 12/19/2021 at 8:10PM revealed CR#1's G-Tube site was noted with redness and drainage, the site was cleaned with normal saline, [MEDICATION(S)] was applied. Nurse Practitioner was notified, and orders given for the resident be sent to the hospital for G-Tube replacement. Record review of CR#1's hospital notes dated 12/19/2021 at 10:43PM read in part . Chief Complaint: Infected G-Tube site. Per NH staff, noted drainage and Maggots coming from the G-Tube site. Further record review documented NH concern for drainage of NG tube noted tonight with report of maggot. On arrival at hospital, it was noted G-Tube had a clean dressing dated 12/20/21. A single maggot was noted on dressing removal. Record review of CR#1's hospital notes dated 12/20/21 revealed reason for consult: Infected G tube replacement: Assessment: Infected PEG tube with Maggot presence. History of [CONDITION(S)], status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Attempts were made on 2/08/2022 at 2:30PM to contact the Hospital physician but they did not answer a message was left but they did not return the call. In an interview with RN B on 2/8/2022 at 3:10PM she said the night of the incident she was called in by CNA B because of the drainage at CR#1's G-Tube when she was providing incontinent care to CR#1. She said when she was assessing the site, she noticed it was swollen and red with drainage. She said the tubing was indented in the stoma. She said at that time she called the Nurse Practitioner and left a message. She said she cleaned the site and applied [MEDICATION(S)] and a clean dressing. She said later the Nurse Practitioner return her call and gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she then called 911, the DON and the family informing them CR#1 was sent to the hospital. RN B said there were no maggot in the G-tube site, but the site was looking bad. In an interview on 2/8/2022 at 3:30PM with the DON he was not aware that there was a maggot at the G-Tube site of CR#1 until the nurse liaison called from the hospital and told him that they found maggots at the site. He said there was no documentation in the nurse's notes prior to 12/19/2021 of any redness or drainage. He said the only issue that CR#1 had was the tube getting clogged. He said a few days prior to the resident being sent to the hospital the resident had some clogging issues and he assessed it and cleared the clogging and he did not see any redness, swelling or drainage. In an interview on 2/8/2022 at 4:45PM with LVN G she said she did not provide care to CR#1's G-Tube site the night she worked as there was no drainage to the dressing. She said she did not see any reddened areas around the dressing. In an interview with the DON on 2/8/2022 at 5:30PM, regarding CR#1's G-Tube site and if he had gone to the hospital to see the resident. He said that he did not go to the hospital because the resident's family did not want the resident to come back to the facility. He was asked if he had investigated the allegation regarding CR#1's G-tube site having maggots. He said he did not do a formal investigation, but he took some statements from the nurses who took care of CR#1 prior to her going to the hospital and they all said they did not see any redness, swelling or drainage. Further interview with the DON regarding the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the statement from the nurses dated 12/21/2022 titled PEG Tube Status. Documentation of statement taken from LVN T, LVN L and LVN G revealed they took care of CR#1 and they did not see any redness, swelling or drainage at CR#1's site when they took care of him. In an interview on 2/09/2022 at 2:00PM with the Medical Director he said he was aware of CR#1's infected G-tube site. He said he will be having a meeting with the facility administration to figure out how to address the issues surrounding the G-Tube site and how to resolve resident's care issues. Interview on 2/10/2021 at 8:23AM with CNA B she said she was providing care to CR#1 and she noticed that the G-Tube site was saturated with brown liquid and she did not want the gown to be messed up, so she called RN B. She said, RN B came and started providing care to CR#1's g-tube site. She said when the nurse was changing the dressing and cleaning the site, she saw maggots crawling at the site. She said, the nurse continued to clean the site until she did not see any more maggots. She said she did not report it to anyone because the nurse was aware of the maggots. During an interview on 2/10/2022 at 3:30PM with the DON he said he did not have a specific staff who routinely checked on residents with G-Tube, because they did not have any issues with any resident G-Tube site prior to CR#1's infection. He said that the only problem CR#1 had was the G-tube clogging issues. He said the issue with the infection of CR#1's G-Tube site was that the nurses were not doing proper assessment of the G-Tube site 48 hours prior to 12/19/2021 when they found the maggots. He said if the nurses had done proper assessment, they would have identified the signs and symptoms of infection before it got worse. He said infection just do not happened like that, it took at least 48 hours to get to the point where the site was swollen red with drainage and had to be sent to the hospital. Interviews conducted on 2/10/2022 with the nursing staff on the day shift revealed they did not see any redness, drainage or swelling of CR#1 G-Tube site. They said the night shift was responsible for G-tube site dressing change. Interview on 2/10/2022 with the staff on the night shift they said the night they work they did not notice and any swelling, redness of drainage on CR#1 G-tube site. Record revealed no documentation that the facility had conducted QAPI /RCA to identify what happened to CR#1's insertion site. Further record review no documentation that the facility had put any policy or procedures in place to identify and prevent an infection that could lead to maggot infestation from happening again. Record review of Nursing Policies and Procedures dated 6/2019 titled Gastrostomy Tube Site read in part . Policy: Gastrostomy tube site will be done daily. Note: Jejunal tubes, PEG Tubes and non-balloon type gastrostomy tubes (tubes without a balloon port indicate that there is a bumper immobilizer in the stomach) site care will be done per physician's order and manufacturer's specifications. Procedures: 6. Inspect surrounding skin for redness, tenderness, swelling, irritation, purulent drainage or gastric leakage. Note centimeter marking of skin disc/bolster on the gastrostomy tube. Contact the physician if irregularities are noted. 8. Clean under disc/bolster with cotton applicator moisten with water. Allow to dry thoroughly. 9. Apply ointment if ordered. 10. It is recommended that the area be left open to air. A dressing under the bolster may promote increase pressure on the shin and lead to skin maceration, breakdown or infection. CAUTION: If the tube has an internal bumper, a dressing by its thickness may cause increased pressure of the internal bumper against the gastric wall, and cause necrosis. 13. If dressing applied date, time and initial. 14. Document in the nursing progress notes. a. Date and time of care b. Condition of the insertion site and skin c. Centimeter (cm) marking of skin disc/bolster. d. Patient/resident tolerance of the procedure The Administrator was notified on 2/11/2022 at 3:30 PM an Immediate Jeopardy (IJ) situation was identified due to the above failures The template was provided at this time. The Plan of Removal was submitted by the facility and was accepted on 02/12/2022 at 11:56AM and included: Plan of Removal CR#1 was discharged to the hospital on December 19th, 2021 and has not returned to facility. Return to facility is not anticipated. All residents with G-tubes have been identified. Their G-Tubes and insertion sites have been assessed for patency and assessed for signs and symptoms of infection by Director of Nursing, Unit Managers and Wound Care Nurse on 2/11/2022. All findings were documented in resident records and all concerns will be brought to the ad hoc QAPI meeting to be held 2/12/2022. No concerns were identified. All residents with G-tubes have had their charts audited by the Director of Nursing, Unit Managers and Wound Care Nurse on 2/11/2022. Audits were completed to ensure there are physician orders and orders are added to the TARs to monitor and assess patency and for signs and symptoms of infections at and around the insertion site every shift and PRN and to ensure there are orders for g-tube site care and dressing changes every shift and PRN. Every shift dressing changes and assessments will be documented in PCC. Care Plans will be audited by Director of Nursing, Unit Managers and MDS Nurse to ensure the inclusion of G-tube assessments and care orders. Care plan audit will be completed by 2/12/2022. All Licensed nurses will be in-serviced on identifying signs and symptoms of infection of G-tube, wounds, and surgical sites by Director of Nursing and/or designee by 2/15/22. All Licensed nurses and CNAs will be in-serviced to identify s/s of infection to include warm to touch, swelling, redness, pain to site, pus, saturated dressing, and odor from site. All Licensed Nurses and CNAs will be in-serviced by Director of Nursing and/or designee on reporting requirements after identifying a change of condition such as signs and symptoms of infection by 2/15/22. CNAs will be in-serviced to immediately report and s/s of infection their supervising nurse. LVNs will be in-serviced to report any s/s of infection to Director of Nursing and/or Unit Managers, to notify the resident's physician and notify resident's family/responsible party. Any staff not scheduled to work before 2/15/22 or new employees will be in-serviced prior to or on their first day of work/return to work. We currently have no agency use in our facility and have not for many months. Monitoring Ad hoc QAPI held 2/12/22 with NHA, DON and Medical Director. Action Plan created and to be carried out immediately. Director of Nursing or designee will visually verify compliance of dressing changes and site cleansing of g-tube sites every shift Monday through Friday as well as random weekend checks for a period of 4 weeks. Director of Nursing or designee will continue dressing changes audits Weekly thereafter. Results of audits will be brought before QAPI and issues addressed as needed. Environmental assessment focused on pest control, flies, insects and/or roaches will be conducted by Perfect Pest Control Services if possible, on 2/12/2022. If not available, then an environment assessment will be conducted by Maintenance Director, Maintenance Assistant and Administrator on 2/12/2022. Perfect Pest Control Services will conduct a facility-wide assessment at the earliest date available, which is 2/14/2022. Needed changes/additions to pest control services will be evaluated at conclusion of assessment of Perfect Pest Control Services. Inservice of all facility staff on reporting of flies, roaches, insects, pests to be completed by Maintenance director and or designee by 2/15/2022. Any employees not working and new employees will be in-serviced prior to or on first day of return to work. Person Responsible for Correction: Director of Nursing/Administrator and/or designee. Completion Date 2/15/2022 Surveyor Verification of Plan of Removal was as follows: Record review of in-service records dated 2/12/2022 revealed RN's and LVN's were in-serviced on assessing PEG Tubes for signs/symptoms of infections. Assessed for redness, foul or unusual smell, swelling, rash, fever and pain. Documentation in-service dated 2/12/2022 addressing dressing change and G-tube Patency and initialing of dressing. Record review revealed documentation that an Ad hoc QAPI held 2/12/22 with NHA, DON and Medical Director. Further record review revealed that G-Tube sights assessment, cleaning and dressing change was done on each shift. Record review of residents with feeding tube revealed physician's orders for assessment and care of feeding tube sites and the care plans reviewed and updated. In an interview on 2/13/2022 at 2:50PM with DON he said that the assessment will continue for four weeks until all staff are trained. He said after they will be doing weekly and random audits to ensure continued compliance. In an interview conducted on 2/14/2022 at 4:30PM with CNA F she said she was in-service on G-Tube site and who to report to if there were drainage, foul odor and if the resident express pain. The staff was able to demonstrate understanding of training. In an interview conducted on 2/14/2022 at 4:40PM with LVN B she said she was in-service on G-Tube site, assessment of the stoma and signs and symptoms of infection. The staff was able to demonstrate understanding of training. In an interview conducted on 2/14/2022 at 5:10PM with LVN C she said she was in-service on G-Tube site, assessment of the stoma and signs and symptoms of infection. The staff was able to demonstrate understanding of training. In an interview conducted on 2/14/2022 at 5:13PM with LVN D she said she was in-service on G-Tube site, assessment of the stoma and signs and symptoms of infection. The staff was able to demonstrate understanding of training. Interview conducted on 2/15/2022 at 6:15PM with LVN F revealed she was in-serviced on PEG Tube site and signs and symptoms of infections and reporting to the DON / Unit Manager. The staff was able to demonstrate understanding of training Interview conducted with RN G on 2/15/2022 at 6:20PM revealed they were in-serviced on who to report signs and symptoms of infection, documentation, infection and assessment. The staff demonstrated understanding of the training. Interview conducted with LVN G on 2/15/2022 at 6:35PM revealed they were in-serviced on assessment of G-tube site, signs and symptoms of infection, documentation and dating of dressing change. The staff demonstrated understanding of the training. Record review of in-service training for CNA's dated 2/11/2022 addressing signs and symptoms of infection, that is redness, swelling, pain and pus. If any sign or symptoms observed, they should report to the DON or the nurse. Further record review revealed a sign in sheet revealed CNA's signatures indicating they were in-serviced on the signs and symptoms of infection. Interview conducted on 2/15/2022 at 6:42PM with CNA K revealed she was in-serviced on signs and symptoms of infection and to report to the nurse. She said they were also in-serviced on pest control and to report any roaches, flies, gnats and insects to maintenance. The staff demonstrated understanding of the training. Observation on 2/15/2022 at 6:55PM revealed LVN F providing care to a Resident #5s G-Tube site. Assessment of the G-Tube site was observed. Staff demonstrated proficiency in providing care to the G-Tube site. The Administrator and DON were notified the IJ was removed on 2/15/2022 3:35 PM. However, the facility remained out of compliance at a severity of level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility needing more time to monitor the plan of correction's effectiveness.

Based on observation, interview and record review the facility failed to ensure residents were free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion for 1 of 5 residents reviewed for abuse and neglect (Resident #1). The facility failed to protect Resident # 1 when RN A hit him in the face. The alleged perpetrator was allowed to continue working on a different floor for 8 hours. This failure affected 1 resident and had the potential to affect the 66 residents residing in hallway 100 at the facility by failing to protect residents from further abuse, neglect, or exploitation. The findings include: Resident # 1 Record review of Resident # 1's face sheet revealed he was admitted on [DATE]. His [DIAGNOSES REDACTED]. He was [AGE] years old. Record review of Resident # 1's quarterly MDS dated [DATE] revealed he scored a 15 of 15 (cognitively intact) possible correct answers on the BIMS. Resident #1 did not have behaviors potential indicators of [MEDICAL CONDITION] or behavioral symptoms. He required supervision for bed mobility and transfer and limited assistance for toilet use and extensive assistance for dressing, and personal hygiene. He was occasionally incontinent of bladder and always continent of bowel. Further record review revealed that Resident #1 was on pain management and received as needed medications for occasionally pain. Resident #1 rated his pain 6 out of 10. Record review of the facility's Provider Investigation Report dated 11/04/2016 revealed in part . -Description of the Allegation: According to Resident #1, RN A refused to give him his [MEDICATION NAME] ([MEDICATION NAME]) along with his pain medication. There was an altercation with both Resident #1 and RN A. -Description of injury: On the left side of Resident #1's mouth there was some reddened area around the mouth. On the upper lip there was a reddened area by the lip that is approx a dime size shape. The lower lip there was a smaller reddened area approx. half the size of the upper with an abrasion that was recently healed. In the lower lip there was blue discoloration and on the upper [MEDICATION NAME] (oral) area next to the upper teeth there was an open wound. -Investigation Summary: According to Resident #1, RN A refused to give him his [MEDICATION NAME] along with his pain medication and Resident #1 got upset. Resident #1 admits at becoming upset and became verbally aggressive with RN A. RN A got in front of Resident #1 and entered the resident's room before Resident #1. Resident #1 went out the room calling for help and his roommate (Resident #4) left. When Resident #1 reentered the room, RN A was still waiting for him in the room. According to Resident #1, the door closed behind him and at this time, RN A hit Resident #1 on the left side of the mouth. According to RN A, Resident #1 has always given him trouble in giving him his medications. RN A stated that it was not time for Resident #1 to have his [MEDICATION NAME] and that Resident #1 became verbally hostile yelling at him. According to RN A, Resident #1 run him over his feet several times with his wheelchair. RN A went to Resident #1 to give him medications and Resident #1 cornered him in the room. Resident #1 became both physical and verbally aggressive. RN A moved Resident #1 out of the way to get out of the room. Based on the interviews the stories collaborated each other until both Resident #1 and RN A were in the room with one another. There was incident that occurred that resulted with Resident #1 sustaining an open wound to his left upper [MEDICATION NAME] area. Based on the investigation, it does conclude that Resident #1 sustained a wound during this encounter with RN A. -Investigation findings: confirmed. RN A has been terminated Record review of a document with title Resident event dated 11/4/2016 and prepared by RN A revealed in part: . -Claimant name: Resident #1 -Date of incident: 11/03/2016 at 10:15 p.m. -Location: Resident's room. -Incident type: Employee Abuse (alleged) -Incident/Accident description findings: Resident #1 asked for his as needed pain medication at about 10:30 p.m. This nurse provided the pill. Resident #1 refused the pill saying that he needed [MEDICATION NAME] with the [MEDICATION NAME]. This nurse informed the resident that time for [MEDICATION NAME] was not due yet. At that point Resident #1 flared up, started cursing and several times used his wheelchair to bump into the feet of the nurse, asking him to leave his room. All attempts to calm him down fell on deaf ears. Eventually the nurse made to exit the room. At this point Resident #1 sped up his wheelchair to run over the nurse viciously. In his desperation to escape from the room, the nurse was caught in the wheelchair attack, and I had to push Resident #1 and wheelchair to escape from the room. Five minutes later Resident #1 emerged from his room shouting that the nurse busted his lips. Resident #1 is a lying bully Record review of Resident #1's nurse's notes by RN B revealed in part: Late entry. Type: SBAR Summary: Vital signs. Blood pressure 133/70, pulse 78, respirations 18 and temperature 98.6. Noted bleeding from the oral cavity inside left check. Monitored closely. Resident #1 gargled with salt and water and felt comfortable. The bleeding stop. Offered Tylenol ([MEDICATION NAME] for pain) 350 mg by mouth 2 tablets. MD notified on 11/04/2016 at 12 a.m. Unable to reach family . Further record review of nurse's notes revealed in part; -11/4/2016 at 2:01 p.m. Resident #1 has remained in bed all day. Upon inspection of inside of left upper lip, there is a small cut, no bleeding noted, no pain at this time. When asked if he would like to go to the hospital, he refused and said that he was doing salt water rinses and that it was helping him and said my mother showed me how to do this when I was a boy . Cut inside of left upper lip is closing, no swelling noted. He denies any tooth involvement . -11/4/2016 at 2:23 p.m. by DON Resident #1 stated 'Yes, I got mad and began cursing at him but he had no right to hit'. Upon skin assessment it was noted that there was some reddened area on the right side of his mouth. Resident #1's right upper lip seems reddened but also has some crust around the area. His right lower has a reddened scab to the area. Resident #1 then opened his mouth, it was noted that there was a bluish discoloration on the right side of his [MEDICATION NAME] that aligned with his lower teeth. In the upper [MEDICATION NAME] it was noted that there was trauma that was aligned with his upper teeth. His hands had not trauma or redness. The police was called and notified of the situation -11/4/2016 at 8:06 a.m. by RN B Late entry from 11/4/2016 Resident #1 approached me on the middle hallway during change of shift and asked me to take a picture of his mouth. There was a moderate amount of bleeding from his mouth. Resident #1 was claiming RN A closed the door on his room and punched him. Resident #1 asked me if his wound might need stitches. He opened his mouth and there was a laceration. I took Resident #1 to RN A and requested for him to call the MD for Resident #1's bleeding. LVN C was also informed of the incident and she informed DON and RN D Record review of RN A's punch detail report revealed in part; -11/3/2016 Start time 2:58 p.m. -End date and time; 11/4/2016 at 8:35 a.m. Further record review of Resident #1's orders dated November 2016 revealed in part; --12/29/2015 [MEDICATION NAME] tablet, give one tablet by mouth every 8 hours as needed for [MEDICATION NAME]. --09/28/2015 [MEDICATION NAME] table 10-325 mg (narcotic) give one table by mouth every 6 hours as needed for pain. In an interview on 11/15/2016 at 9:45 a.m. with Resident #1, he stated RN A would not give me my medications, we argued and he got in front of me on my room and he punched me on my top left lip with his right fist. He used to be nice, then he started acting like a bully. On the day of the incident, it was a Thursday night at around 11:45 p.m., I asked for my pain medication and he would not give me my pain medications. I was in pain. It felt like I had to argue with him in order to get my medications. That day, he was at the station and we argued again. He then followed me to my room. We were cussing each other around, but I was tired and I was in pain. When I went inside of my room, the door closed behind me and RN A was already inside of the room and I told him to leave more than 3 times. He then got in front of me, did not say anything and just sucker punched me on my left lip with his right fist. I had to be on antibiotics due to the cut inside my mouth. After RN A punched me, I started bleeding from my mouth and RN A just left the room without saying anything. I bleed for like an hour . Further interview and observation at that time, Resident #1 opened his mouth and lifted his left lip. There was a closed linear laceration to his left upper lip approx 0.5 cm long. No swelling noted. At that time, Resident #1 stated is healed already . Continued interview at that time, Resident #1 said that 5 minutes after the incident, RN A came back inside his room with C.N.A. E and asked him if he needed something like he did not know what had happened and that at that time, he told RN A hell No. You did enough and asked both employees to leave. Resident #1 further said that RN D came later on the night to the facility and saw him and took his statement of what had happened and that she then moved RN A to the other wing of the facility to continued working his shift. Further interview on 11/15/2016 at 10:10 a.m. with Resident #1, he stated that he was not sure what his roommate (Resident #4) witnessed during the incident on 11/3/2016 and then said The DON took pictures the next morning. Police came 24 hours after the incident . Resident #1 continued saying I already have a lot of sufferings with the physical conditions that I have, I don't need additional sufferings. This situation made me feel really bad. Record review of Resident # 4's face sheet revealed he was admitted on [DATE]. His [DIAGNOSES REDACTED]. He was [AGE] years old. Record review of Resident # 4's quarterly MDS dated [DATE] revealed he scored a 8 of 15 (moderate cognitive impairment) possible correct answers on the BIMS. Resident #4 did not have behaviors potential indicators of [MEDICAL CONDITION] or behavioral symptoms. He required supervision for bed mobility, transfer and locomotion. He was independent on walking in room and walking in corridor. In an interview on 11/15/2016 at 10:18 a.m. with the DON, he stated that he received a call on 11/4/2016 at around 1:00 a.m. by RN D because she was the on call supervisor and that she told him that there was an altercation between Resident #1 and RN A. DON further said that RN D told him that there was a problem related to Resident #1's medications and that RN D also informed him that Resident #1 was bleeding due to a tooth extraction. When asked to elaborate about the altercation between Resident #1 and RN A, DON stated that he was told that Resident #1 was upset and was after RN A. DON further said that he told RN D to move RN A to a different floor to continued working because he was under the impression that it was just an argument about the medications and that the bleeding was due to a tooth extraction. Further interview on 11/15/2016 at 10:30 a.m. with the DON, he said that the next morning he went to see Resident #1 and that the story was different and that he then learned that RN A had hit Resident #1. DON continued saying that he assessed Resident #1's mouth and that on top of his lip there was a trauma wound inside the [MEDICATION NAME] area and that the open wound was approx. 1.5 x 1.5 c.m. and that Resident #1's left upper lip and lower lip were red in color. DON then said that Resident #1 told him RN A punched me. Continued interview with the DON at that time, he said that he then talked to RN A and that RN A had told him that Resident #1 got verbally and physically aggressive towards RN A and that RN A was trying to leave Resident #1's room and that he had to pushed Resident #1 to be able to get out of the room. DON then said that RN A told him that when he pushed Resident #1 and that RN A placed one hand on his chair and the other hand on Resident #1's shoulder while he pushed Resident #1. DON then said that when police came to the building on 11/4/2016 at around 4:00 p.m. police took pictures of Resident #1's mouth and that Resident #1 did not want to file charges against RN A. In an interview on 11/15/2016 at 11:10 a.m. with RN D, she stated that she was the Staff Development Manager and that she was at home when she received a call on 11/4/2016 at around 1:00 a.m. by LVN C and that she told her that Resident #1 had told her that RN A had hit him during an argument. RN D then said that she then came to the facility and that upon arrival to the facility she saw Resident #1 holding a small towel that had blood on it. RN D then said that Resident #1 told her that RN A would not give his [MEDICATION NAME] and [MEDICATION NAME] (narcotic) for pain and that further said he gave me a right fist. RN D then said that she assessed Resident #1 and that she saw a 2.0 x 1.0 c.m. laceration to the left lower check and that at that time Resident #1 said RN A hit me. Further interview at that time with RN D, she stated that she then called the DON right after she assessed Resident #1 and that she told the DON that Resident #1 had said that he was punched in his left side of his face by RN A and further said I told the DON that Resident #1 was punched by RN A and that Resident #1 had a bleeding laceration. DON told me to remove RN A from that unit and to have him continue to work on the opposite site of the facility. So, I moved RN B to the wing of Resident #1 and had RN A worked on the 100 hallway. Continued interview with RN D on 11/15/2016 at 11:46 a.m. she stated that RN B had also reported to her at that time of her investigation that Resident #1 had said that RN A had hit him in the face. In an interview on 11/15/2016 at 12:03 p.m. with the DON, he said that he believed Resident #1 had a recent tooth extraction but he was not able to verify that information. In a phone interview on 11/15/2016 at 1:30 p.m. with C.N.A. E, she stated that on 11/3/2016 at around 11:20 p.m. or 11:30 p.m. Resident #1 showed her the inside of his mouth and told her that RN A hit him because he cursed at him for not giving his medications. C.N.A. E then said Resident #1 was holding a towel and the towel had blood and he showed me a cut on the inside of his mouth, to the left side. Don ' t remember the size. When I saw Resident #1 he wanted to cry. I then went outside and told RN A what Resident #1 had said and he told me that he did not hit Resident #1. C.N.A. E then said that RN A asked her at that time to go with him inside Resident #1 to give his medications. C.N.A. E continued saying when we went inside Resident #1's room, he stated to RN A 'I told you I don't want you and you are still here working' . C.N.A. E then said that both left the room. In an phone interview on 11/15/2016 at 1:52 p.m. with RN A, he stated that on 11/3/2016 Resident #1 wanted some [MEDICATION NAME] and that it was not time for him to have the medication. RN A then said that Resident #1 started to scream at him and that at the nursing station, Resident #1 tried to run him over with his wheelchair and that he (RN A) tried to give him the pain medication and that he followed Resident #1 to his room and that while inside Resident #1's room, Resident #1 told him to get out, not to come to his room and that he then tried to leave the room and that the roommate (Resident #4) also tried to leave the room. RN A then said that Resident #1 became very aggressive and that at that time, Resident #1 tried to run him over again with his wheelchair and that Resident #1 cornered him on the room so then RN A pushed Resident #1's shoulders with one hand and with his other hand tried to push the wheelchair to try to escape out of the room. Further interview on 11/15/2016 at 2:00 p.m. with RN A, he then said that 10 minutes after he left Resident #1's room, Resident #1 came out of the room and said that I hit him on his lips. Resident #1 then later went to the other nursing station and said that I hurt him. I did not hit him. I only pushed him to escape. In an interview on 11/15/2016 at 2:15 p.m. with Resident #4 and Resident #4's RP, the RP said that she visits Resident #4 frequently. RP then said that on 11/4/2016 when she visited Resident #4, he immediately told her the male nurse hit my roommate (Resident #1). I saw it. RP further said Resident #4 told me that the nurse came inside the room and that he would not give the medications to Resident #1, then both started cursing at each other saying bad words and then the male nurse hit Resident #4. Resident #4 told me that he was very nervous during the altercation because it happened inside of the room and he (Resident #4) was kind of in the middle of the fight. Resident #4 said that he was trying to get out of the room but got very nervous of the situation and was very scared when he saw the male nurse hitting Resident #1. I even kept asking him, are you sure? And he kept saying yes. Further interview at that time, Resident #4 said I kind of remember, but I usually tell her right away. I was very nervous when that happened. In an interview on 11/15/2016 at 4:55 p.m. with the DON and the Administrator, the Administrator, who is the Abuse/Neglect Coordinator stated that she had 2 missed calls on 11/4/2016 at around 1:00 a.m. but that she was not able to wake up and that until the morning of 11/4/2016 when she woke up and saw the messages, she forward the message to the DON because she had requested the day off. Administrator then said that one call was from RN D which she did not leave a message and the other call was from LVN C that said that Resident #1 had alleged that a nurse had hit him and that he had some bleeding on his mouth. Administrator continued saying that what was supposed to happened was to remove the alleged perpetrator away from the resident pending investigation. DON then said I thought it was a behavioral issue. RN D was here and she knows the policy. I assumed it was a behavior issue. I was under the impression that the bleeding was due to a dental situation. When I spoke with the nurses in the morning, they told me that RN A had hit Resident #1 to his face. RN B said that she went to work on the station of Resident #1 and told me she saw the bleeding on Resident #1's mouth and said that Resident #1 told her that he was punched by RN A. Administrator continued saying I feel it was a misunderstanding. DON said that he was under the impression that it was a behavioral issue and my impression was that Resident #1 was upset because he did not get the medications. In a phone interview on 11/15/2016 at 5:25 p.m. with LVN C, she stated that she was informed on 11/3/2016 at around 11:30 p.m. by other staff members that Resident #1 had said that RN A had punched him in the mouth. She then said that she went to see Resident #1 and that he showed her a towel with blood and that she saw a laceration to his mouth to the left inside jaw area. LVN C continued saying that the laceration appeared to be like a tooth puncture. LVN C then said that she went out of the room and that she saw the nurses trying to call the on call person and that she was the one that got in touch with RN D and told her about the allegation and what she saw. Attempted to call RN B on 11/15/2016 at 5:32 p.m. and she did not respond to surveyor. Record review of the facility's revised September 2016 policy titled Abuse and Neglect Prohibition revealed in part; . Each resident has the right to be free from mistreatment, neglect, abuse. Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator and/or Director of Nursing. The facility responds immediately to such allegations in accordance with stated and federal law. Abuse means the willful infliction of injury with resulting harm, pain or mental anguish. -Protection: 1.- The facility will protect residents from harm during the investigation. 2.- Any employee alleged to be involved in an instance(s) of abuse will be suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated . According to the facility's roster there were 66 residents residing in hallway 100.

Based on observation, interview and record review, the facility failed to implement their written policy and procedures that prohibit abuse for one of five residents (Resident #1) reviewed for abuse. The facility failed to immediately suspend RN A when Resident # 1 reported to facility staff that RN A punched him in the face. RN A was allowed to continue working on a different floor for 8 hours. This failure affected 1 resident and had the potential to affect the 66 residents residing in hallway 100 at the facility by failing to protect residents from further abuse, neglect, or exploitation. The findings include: Record review of the facility's revised September 2016 policy titled Abuse and Neglect Prohibition revealed in part; . Each resident has the right to be free from mistreatment, neglect, abuse. Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator and/or Director of Nursing. The facility responds immediately to such allegations in accordance with stated and federal law. Abuse means the willful infliction of injury with resulting harm, pain or mental anguish. -Protection: 1.- The facility will protect residents from harm during the investigation. 2.- Any employee alleged to be involved in an instance(s) of abuse will be suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated . Resident # 1 Record review of Resident # 1's face sheet revealed he was admitted on [DATE]. His [DIAGNOSES REDACTED]. He was [AGE] years old. Record review of Resident # 1's quarterly MDS dated [DATE] revealed he scored a 15 of 15 (cognitively intact) possible correct answers on the BIMS. Resident #1 did not have behaviors potential indicators of [MEDICAL CONDITION] or behavioral symptoms. He required supervision for bed mobility and transfer and limited assistance for toilet use and extensive assistance for dressing, and personal hygiene. He was occasionally incontinent of bladder and always continent of bowel. Further record review revealed that Resident #1 was on pain management and received as needed medications for occasionally pain. Resident #1 rated his pain 6 out of 10. Record review of the facility's Provider Investigation Report dated 11/04/2016 revealed in part . -Description of the Allegation: According to Resident #1, RN A refused to give him his [MEDICATION NAME] ([MEDICATION NAME]) along with his pain medication. There was an altercation with both Resident #1 and RN A. -Description of injury: On the left side of Resident #1's mouth there was some reddened area around the mouth. On the upper lip there was a reddened area by the lip that is approx a dime size shape. The lower lip there was a smaller reddened area approx. half the size of the upper with an abrasion that was recently healed. In the lower lip there was blue discoloration and on the upper [MEDICATION NAME] (oral) area next to the upper teeth there was an open wound. -Investigation Summary: According to Resident #1, RN A refused to give him his [MEDICATION NAME] along with his pain medication and Resident #1 got upset. Resident #1 admits at becoming upset and became verbally aggressive with RN A. RN A got in front of Resident #1 and entered the resident's room before Resident #1. Resident #1 went out the room calling for help and his roommate (Resident #4) left. When Resident #1 reentered the room, RN A was still waiting for him in the room. According to Resident #1, the door closed behind him and at this time, RN A hit Resident #1 on the left side of the mouth. According to RN A, Resident #1 has always given him trouble in giving him his medications. RN A stated that it was not time for Resident #1 to have his [MEDICATION NAME] and that Resident #1 became verbally hostile yelling at him. According to RN A, Resident #1 run him over his feet several times with his wheelchair. RN A went to Resident #1 to give him medications and Resident #1 cornered him in the room. Resident #1 became both physical and verbally aggressive. RN A moved Resident #1 out of the way to get out of the room. Based on the interviews the stories collaborated each other until both Resident #1 and RN A were in the room with one another. There was incident that occurred that resulted with Resident #1 sustaining an open wound to his left upper [MEDICATION NAME] area. Based on the investigation, it does conclude that Resident #1 sustained a wound during this encounter with RN A. -Investigation findings: confirmed. RN A has been terminated Record review of a document with title Resident event dated 11/4/2016 and prepared by RN A revealed in part: . -Claimant name: Resident #1 -Date of incident: 11/03/2016 at 10:15 p.m. -Location: Resident's room. -Incident type: Employee Abuse (alleged) -Incident/Accident description findings: Resident #1 asked for his as needed pain medication at about 10:30 p.m. This nurse provided the pill. Resident #1 refused the pill saying that he needed [MEDICATION NAME] with the [MEDICATION NAME]. This nurse informed the resident that time for [MEDICATION NAME] was not due yet. At that point Resident #1 flared up, started cursing and several times used his wheelchair to bump into the feet of the nurse, asking him to leave his room. All attempts to calm him down fell on deaf ears. Eventually the nurse made to exit the room. At this point Resident #1 sped up his wheelchair to run over the nurse viciously. In his desperation to escape from the room, the nurse was caught in the wheelchair attack, and I had to push Resident #1 and wheelchair to escape from the room. Five minutes later Resident #1 emerged from his room shouting that the nurse busted his lips. Resident #1 is a lying bully Record review of Resident #1's nurse's notes by RN B revealed in part: Late entry. Type: SBAR Summary: Vital signs. Blood pressure 133/70, pulse 78, respirations 18 and temperature 98.6. Noted bleeding from the oral cavity inside left check. Monitored closely. Resident #1 gargled with salt and water and felt comfortable. The bleeding stop. Offered Tylenol ([MEDICATION NAME] for pain) 350 mg by mouth 2 tablets. MD notified on 11/04/2016 at 12 a.m. Unable to reach family . Further record review of nurse's notes revealed in part; -11/4/2016 at 2:01 p.m. Resident #1 has remained in bed all day. Upon inspection of inside of left upper lip, there is a small cut, no bleeding noted, no pain at this time. When asked if he would like to go to the hospital, he refused and said that he was doing salt water rinses and that it was helping him and said my mother showed me how to do this when I was a boy . Cut inside of left upper lip is closing, no swelling noted. He denies any tooth involvement . -11/4/2016 at 2:23 p.m. by DON Resident #1 stated 'Yes, I got mad and began cursing at him but he had no right to hit'. Upon skin assessment it was noted that there was some reddened area on the right side of his mouth. Resident #1's right upper lip seems reddened but also has some crust around the area. His right lower has a reddened scab to the area. Resident #1 then opened his mouth, it was noted that there was a bluish discoloration on the right side of his [MEDICATION NAME] that aligned with his lower teeth. In the upper [MEDICATION NAME] it was noted that there was trauma that was aligned with his upper teeth. His hands had not trauma or redness. The police was called and notified of the situation -11/4/2016 at 8:06 a.m. by RN B Late entry from 11/4/2016 Resident #1 approached me on the middle hallway during change of shift and asked me to take a picture of his mouth. There was a moderate amount of bleeding from his mouth. Resident #1 was claiming RN A closed the door on his room and punched him. Resident #1 asked me if his wound might need stitches. He opened his mouth and there was a laceration. I took Resident #1 to RN A and requested for him to call the MD for Resident #1's bleeding. LVN C was also informed of the incident and she informed DON and RN D Record review of RN A's punch detail report revealed in part; -11/3/2016 Start time 2:58 p.m. -End date and time; 11/4/2016 at 8:35 a.m. Further record review of Resident #1's orders dated November 2016 revealed in part; --12/29/2015 [MEDICATION NAME] tablet, give one tablet by mouth every 8 hours as needed for [MEDICATION NAME]. --09/28/2015 [MEDICATION NAME] table 10-325 mg (narcotic) give one table by mouth every 6 hours as needed for pain. In an interview on 11/15/2016 at 9:45 a.m. with Resident #1, he stated RN A would not give me my medications, we argued and he got in front of me on my room and he punched me on my top left lip with his right fist. He used to be nice, then he started acting like a bully. On the day of the incident, it was a Thursday night at around 11:45 p.m., I asked for my pain medication and he would not give me my pain medications. I was in pain. It felt like I had to argue with him in order to get my medications. That day, he was at the station and we argued again. He then followed me to my room. We were cussing each other around, but I was tired and I was in pain. When I went inside of my room, the door closed behind me and RN A was already inside of the room and I told him to leave more than 3 times. He then got in front of me, did not say anything and just sucker punched me on my left lip with his right fist. I had to be on antibiotics due to the cut inside my mouth. After RN A punched me, I started bleeding from my mouth and RN A just left the room without saying anything. I bleed for like an hour . Further interview and observation at that time, Resident #1 opened his mouth and lifted his left lip. There was a closed linear laceration to his left upper lip approx 0.5 cm long. No swelling noted. At that time, Resident #1 stated is healed already . Continued interview at that time, Resident #1 said that 5 minutes after the incident, RN A came back inside his room with C.N.A. E and asked him if he needed something like he did not know what had happened and that at that time, he told RN A hell No. You did enough and asked both employees to leave. Resident #1 further said that RN D came later on the night to the facility and saw him and took his statement of what had happened and that she then moved RN A to the other wing of the facility to continued working his shift. Further interview on 11/15/2016 at 10:10 a.m. with Resident #1, he stated that he was not sure what his roommate (Resident #4) witnessed during the incident on 11/3/2016 and then said The DON took pictures the next morning. Police came 24 hours after the incident . Resident #1 continued saying I already have a lot of sufferings with the physical conditions that I have, I don't need additional sufferings. This situation made me feel really bad. Record review of Resident # 4's face sheet revealed he was admitted on [DATE]. His [DIAGNOSES REDACTED]. He was [AGE] years old. Record review of Resident # 4's quarterly MDS dated [DATE] revealed he scored a 8 of 15 (moderate cognitive impairment) possible correct answers on the BIMS. Resident #4 did not have behaviors potential indicators of [MEDICAL CONDITION] or behavioral symptoms. He required supervision for bed mobility, transfer and locomotion. He was independent on walking in room and walking in corridor. In an interview on 11/15/2016 at 10:18 a.m. with the DON, he stated that he received a call on 11/4/2016 at around 1:00 a.m. by RN D because she was the on call supervisor and that she told him that there was an altercation between Resident #1 and RN A. DON further said that RN D told him that there was a problem related to Resident #1's medications and that RN D also informed him that Resident #1 was bleeding due to a tooth extraction. When asked to elaborate about the altercation between Resident #1 and RN A, DON stated that he was told that Resident #1 was upset and was after RN A. DON further said that he told RN D to move RN A to a different floor to continued working because he was under the impression that it was just an argument about the medications and that the bleeding was due to a tooth extraction. Further interview on 11/15/2016 at 10:30 a.m. with the DON, he said that the next morning he went to see Resident #1 and that the story was different and that he then learned that RN A had hit Resident #1. DON continued saying that he assessed Resident #1's mouth and that on top of his lip there was a trauma wound inside the [MEDICATION NAME] area and that the open wound was approx. 1.5 x 1.5 c.m. and that Resident #1's left upper lip and lower lip were red in color. DON then said that Resident #1 told him RN A punched me. Continued interview with the DON at that time, he said that he then talked to RN A and that RN A had told him that Resident #1 got verbally and physically aggressive towards RN A and that RN A was trying to leave Resident #1's room and that he had to pushed Resident #1 to be able to get out of the room. DON then said that RN A told him that when he pushed Resident #1 and that RN A placed one hand on his chair and the other hand on Resident #1's shoulder while he pushed Resident #1. DON then said that when police came to the building on 11/4/2016 at around 4:00 p.m. police took pictures of Resident #1's mouth and that Resident #1 did not want to file charges against RN A. In an interview on 11/15/2016 at 11:10 a.m. with RN D, she stated that she was the Staff Development Manager and that she was at home when she received a call on 11/4/2016 at around 1:00 a.m. by LVN C and that she told her that Resident #1 had told her that RN A had hit him during an argument. RN D then said that she then came to the facility and that upon arrival to the facility she saw Resident #1 holding a small towel that had blood on it. RN D then said that Resident #1 told her that RN A would not give his [MEDICATION NAME] and [MEDICATION NAME] (narcotic) for pain and that further said he gave me a right fist. RN D then said that she assessed Resident #1 and that she saw a 2.0 x 1.0 c.m. laceration to the left lower check and that at that time Resident #1 said RN A hit me. Further interview at that time with RN D, she stated that she then called the DON right after she assessed Resident #1 and that she told the DON that Resident #1 had said that he was punched in his left side of his face by RN A and further said I told the DON that Resident #1 was punched by RN A and that Resident #1 had a bleeding laceration. DON told me to remove RN A from that unit and to have him continue to work on the opposite site of the facility. So, I moved RN B to the wing of Resident #1 and had RN A worked on the 100 hallway. Continued interview with RN D on 11/15/2016 at 11:46 a.m. she stated that RN B had also reported to her at that time of her investigation that Resident #1 had said that RN A had hit him in the face. In an interview on 11/15/2016 at 12:03 p.m. with the DON, he said that he believed Resident #1 had a recent tooth extraction but he was not able to verify that information. In a phone interview on 11/15/2016 at 1:30 p.m. with C.N.A. E, she stated that on 11/3/2016 at around 11:20 p.m. or 11:30 p.m. Resident #1 showed her the inside of his mouth and told her that RN A hit him because he cursed at him for not giving his medications. C.N.A. E then said Resident #1 was holding a towel and the towel had blood and he showed me a cut on the inside of his mouth, to the left side. Don ' t remember the size. When I saw Resident #1 he wanted to cry. I then went outside and told RN A what Resident #1 had said and he told me that he did not hit Resident #1. C.N.A. E then said that RN A asked her at that time to go with him inside Resident #1 to give his medications. C.N.A. E continued saying when we went inside Resident #1's room, he stated to RN A 'I told you I don't want you and you are still here working' . C.N.A. E then said that both left the room. In an phone interview on 11/15/2016 at 1:52 p.m. with RN A, he stated that on 11/3/2016 Resident #1 wanted some [MEDICATION NAME] and that it was not time for him to have the medication. RN A then said that Resident #1 started to scream at him and that at the nursing station, Resident #1 tried to run him over with his wheelchair and that he (RN A) tried to give him the pain medication and that he followed Resident #1 to his room and that while inside Resident #1's room, Resident #1 told him to get out, not to come to his room and that he then tried to leave the room and that the roommate (Resident #4) also tried to leave the room. RN A then said that Resident #1 became very aggressive and that at that time, Resident #1 tried to run him over again with his wheelchair and that Resident #1 cornered him on the room so then RN A pushed Resident #1's shoulders with one hand and with his other hand tried to push the wheelchair to try to escape out of the room. Further interview on 11/15/2016 at 2:00 p.m. with RN A, he then said that 10 minutes after he left Resident #1's room, Resident #1 came out of the room and said that I hit him on his lips. Resident #1 then later went to the other nursing station and said that I hurt him. I did not hit him. I only pushed him to escape. In an interview on 11/15/2016 at 2:15 p.m. with Resident #4 and Resident #4's RP, the RP said that she visits Resident #4 frequently. RP then said that on 11/4/2016 when she visited Resident #4, he immediately told her the male nurse hit my roommate (Resident #1). I saw it. RP further said Resident #4 told me that the nurse came inside the room and that he would not give the medications to Resident #1, then both started cursing at each other saying bad words and then the male nurse hit Resident #4. Resident #4 told me that he was very nervous during the altercation because it happened inside of the room and he (Resident #4) was kind of in the middle of the fight. Resident #4 said that he was trying to get out of the room but got very nervous of the situation and was very scared when he saw the male nurse hitting Resident #1. I even kept asking him, are you sure? And he kept saying yes. Further interview at that time, Resident #4 said I kind of remember, but I usually tell her right away. I was very nervous when that happened. In an interview on 11/15/2016 at 4:55 p.m. with the DON and the Administrator, the Administrator, who is the Abuse/Neglect Coordinator stated that she had 2 missed calls on 11/4/2016 at around 1:00 a.m. but that she was not able to wake up and that until the morning of 11/4/2016 when she woke up and saw the messages, she forward the message to the DON because she had requested the day off. Administrator then said that one call was from RN D which she did not leave a message and the other call was from LVN C that said that Resident #1 had alleged that a nurse had hit him and that he had some bleeding on his mouth. Administrator continued saying that what was supposed to happened was to remove the alleged perpetrator away from the resident pending investigation. DON then said I thought it was a behavioral issue. RN D was here and she knows the policy. I assumed it was a behavior issue. I was under the impression that the bleeding was due to a dental situation. When I spoke with the nurses in the morning, they told me that RN A had hit Resident #1 to his face. RN B said that she went to work on the station of Resident #1 and told me she saw the bleeding on Resident #1's mouth and said that Resident #1 told her that he was punched by RN A. Administrator continued saying I feel it was a misunderstanding. DON said that he was under the impression that it was a behavioral issue and my impression was that Resident #1 was upset because he did not get the medications. In a phone interview on 11/15/2016 at 5:25 p.m. with LVN C, she stated that she was informed on 11/3/2016 at around 11:30 p.m. by other staff members that Resident #1 had said that RN A had punched him in the mouth. She then said that she went to see Resident #1 and that he showed her a towel with blood and that she saw a laceration to his mouth to the left inside jaw area. LVN C continued saying that the laceration appeared to be like a tooth puncture. LVN C then said that she went out of the room and that she saw the nurses trying to call the on call person and that she was the one that got in touch with RN D and told her about the allegation and what she saw. Attempted to call RN B on 11/15/2016 at 5:32 p.m. and she did not respond to surveyor. According to the facility's roster there were 66 residents residing in hallway 100.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to prevent the development or worsening of pressure ulcers and to promote the healing of pressure ulcers for 4 of 29 residents (Resident #18, 19 and 56, and 46) who were reviewed for pressure ulcer care and management as evidenced by: -The facility failed to repositioned Resident #18 for five hours while he was seated in his wheelchair. -The facility failed to provide timely incontinent care to Resident #18. Resident #18 developed two stage three pressure sores that were not identified by the facility. -The facility failed to identify three new wounds to Resident #19's scrotum area. -The facility failed to prevent in house pressure ulcers for Resident # 19. Resident # 19's weekly skin assessment dated [DATE] revealed that his skin was intact. Resident #19's skin assessment dated [DATE] documented a deep tissue injury to his right heel and a deep tissue injury to his left heel. -The facility failed to provide preventative pressure sore measures to Resident #19's right heel until surveyor intervention. -The facility failed to prevent the development and worsening of a facility acquired pressure ulcer for Resident # 56 who had a stage IV pressure ulcer to her right heel that was identified as a deep tissue injury on 10/14/15 and was an unstageable pressure ulcer on 10/28/15. -Resident # 46 assessment record revealed conflicting documentation of pressure ulcer for assessment, monitoring, and prevention. These failures further resulted in an identification of an Immediate Jeopardy (IJ) 12/09/15 . While the IJ was removed on 12/11/2015, the facility remained out of compliance at the severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures affected 4 residents and placed the 23 additional residents that were identified at risk for pressure ulcers at risk for a decline in health and need for additional treatment. Findings Include: Resident # 18 Record review of the medical record face sheet revealed Resident # 18 was admitted on [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years old. Record review of Resident #18's Plan of Care initiated 9/10/2015 revealed in part: Focus: Resident #18 requires assistance with ADL's related to Dementia. -Goal: Resident #18 will have grooming and [MEDICATION NAME] needs met with staff assistance of extensive assistance of 2 staff. -Intervention: Provide assistance as required for completion of ADL tasks. Further record review -Pressure ulcer Actual problem related to sensory perception, moisture/incontinence, decreased activity, impaired mobility, friction and shear. Has stage three pressure ulcers to bilateral heels. -Goal: Free of further breakdown through next review. Target date 3/6/2016. -Interventions: Provide incontinence care after each incontinent episode, reposition in chair/bed frequently for comfort and pressure reduction. Turn and reposition frequently to decrease pressure. Braden scare 16 - At risk. Record review of Resident #18's Braden Scale - Predicting Pressure Score Risk revealed on 11/25/2015 his score was an 13 (moderate risk). Record review of Resident # 18's quarterly MDS assessment with 12/04/2015 ARD date revealed his Cognitive Skills for Daily Decision Making was assessed as severely impaired. He required extensive assistance of two staff support with bed mobility, transfers, dressing and extensive assistance of one staff support for locomotion, eating, toilet use and personal hygiene and was totally dependent on staff for bathing. He was assessed as having a range of motion impairment on both sides of his upper and lower extremities. He was always incontinent of bowel and bladder. The skin condition section of the assessment revealed he had two stage three pressure ulcers that were present upon admission/entry or reentry. Further record review revealed that he was at risk of developing pressure ulcers, had a pressure reducing device for chair and for bed and was not on a turning/repositioning program. An observation on 12/08/2015 at 3:20 pm revealed that Resident # 18's room had strong urine odor to the outside of his room. Further observation revealed as surveyor entered Resident #18's room that the curtain was half way closed and Resident #18 was slouched in his chair with the buttocks at the edge of the chair behind the closed curtain. Resident #18 tried to reach surveyor with his right hand and softly said help me with a soft voice while grimacing his face. Resident #18's pants were observed to be wet from his waist down to his buttocks area, his right heel protector had come off form his right foot and there was a strong odor of urine in his room. At that moment surveyor exited the room and brought LVN Q immediately to the room as she was at the nursing station. Further observation and interview at that time while LVN Q entered Resident #18's room, she stated as she pulled Resident #18's shirt up his gastrostomy tube is closed, but he is wet, he usually goes to bed after lunch, let me go out and get somebody. LVN Q exited the room, Resident #18 grimaced his face and tried to move himself up in the chair with his right hand unsuccessfully and tried to reach surveyor with his right hand and softly moaned again help me. Observation and interview on 12/08/2015 at 3:34 p.m. revealed that LVN Q, RN G, CNA UU and CNA U entered the room as Resident #18 was still trying to reach surveyor for help and his face was grimaced. LVN Q stated as she got closer to Resident #18 he is uncomfortable, he is going to bed, he has been up since 9:00 a.m. At that time, LVN Q and RN G repositioned Resident #18 back to his chair while Resident #18's face continued to be grimaced. Continued observation at that time revealed that as CNA U removed Resident #18's shirt, LVN Q stated is wet, is gross. Further observation while CNA U and CNA UU removed Resident #18's brief, the brief was noted heavily saturated with urine, brownish in color and had several spots of blood on the brief on the buttocks area. Resident #18's wheelchair cushion appeared to be totally indented and wet. LVN Q was asked if the cushion from Resident #18's wheelchair was wet and she responded Yes, is very wet. Further observation and interview at that time revealed Resident #18's scrotum area was very reddened and as Resident #18 was turned to his side, his buttocks areas appeared very reddened with open areas on each of his buttocks. LVN Q stated as she looked at the buttocks of Resident #18 This is skin breakdown, he didn't have it before. I see some black tissue with redness around, necrotic tissue to his right buttocks. LVN Q further said that she told CNA EE to take care of Resident #18 before the end of the shift and that she thought Resident #18 was OK. Continued observation and interview at that time, RN G said I will assess the wounds now and stated as he measured Resident #18's right buttock's wound the lower right buttock, is 1.0 x 1.0 c.m. is thickness loss of the skin, wound base is pink and surrounding site is blackish, necrotic tissue. Left inner buttocks, has a width of 4.0 c.m. and length of 1.5 c.m. with wound base skin peeled off and red and has an area of 1.0 x 1.0 c.m. of darker color in the middle, like brownish, blackish in color. RN G said it happened today, is fresh. I worked yesterday and nothing was reported, need to get wound consult, that's a new area. Record review of Resident # 18's SBAR Communication Form and Progress Note dated 12/08/2015 read in part: -Situation: New abrasion area noted on left buttock (1cm x 4cm) small open skin on right buttock (1x1 cm) -Things that make condition or symptom worse are: Limited bed and chair mobility. -Things that make the condition or symptom better are: turning and repositioning, keep clean, dry. -Nursing notes: New skin abrasion/breakdown on left buttock and right buttock. Additional Nursing notes as applicable: New skin abrasion/breakdown on left buttock (4x1 c.m.) and right buttock (1x1c.m.). Wound base is pink with dark spot in center. New order to apply triple antibiotic ointment and dry dressing until wound consult. Record review of Resident #18's physician's orders [REDACTED]. -Wound consult for left and right buttock skin breakdown -Clean left and right buttock wound with NS, pat dry, apply triple antibiotic ointment and cover with dry dressing daily until wound consult. Record review of Resident #18's wound assessment report dated 12/09/2015 revealed in part: Left Ischium: 0.9 x 0.7 x 0.2 c.m. ( LxWxD) Wound type: Pressure. Stage: Three. In house, new Right buttock: 3.7 x 1.6 x 0.1 c.m. ( LxWxD) Wound type: Pressure. Stage: Three. In house, new Right heel: 1.7 x 1.6 x 0.4 c.m. ( LxWxD) Wound type: Pressure. Stage: Three Left heel: 0.7 x 0.6 x 0.4 c.m. ( LxWxD) Wound type: Pressure. Stage: Three In an interview on 12/08/2015 at 5:00 p.m. with ADON A and LVN K, both stated that Resident #18 did not have wounds to his buttocks before and that open areas to his buttocks were new. In an interview on 12/08/2015 at 5:05 p.m. with CNA U, she stated that she was the afternoon shift aide and that she started her shift at 3 p.m. and that nobody gave her report about Resident #18 and that she did not know how long he was up in his chair or if he needed to go to bed until LVN Q called her. In a phone interview on 12/9/2015 at 1:00 p.m. with CNA EE, she stated that she worked with Resident #18 on 12/08/2015 during the 7 - 3 p.m. shift and that the only skin problems were the pressure sores to his heels. CNA EE further said that the last time she checked on Resident #18 was at 2:40 p.m. because LVN Q told her to change his clothing and that she changed his shirt only because his brief was dry. CNA EE continued saying that she did incontinent care to Resident #18 at around 10:00 a.m. and that she did not see any open areas to his buttocks and that at that time, she got Resident #18 up in his chair and that Resident #18 remained on his chair until she left at 3:00 p.m. and that he did not get further incontinent care because when she checked him at 2:40 p.m. Resident #18 was dry. When asked how did she check Resident #18's brief for wetness, she replied I looked at the front of his pants and the brief looked dry. When asked if Resident #18 was on a repositioning program, CNA EE responded Not that I know. When patients are in bed, they get turned every 2 hours but when Resident #18 was on his chair, I was not aware that he needed to be repositioned in his chair. When asked how often do residents get checked for incontinent care, CNA EE responded every 2 hours. When asked why Resident #18 was not checked for incontinent care between 10 a.m. and 2:40 pm., CNA EE responded I had to complete showers, got everybody up, then by that time it was lunch time and then I was in the dining room assignment. I did not leave the dining room until around 1:15 p.m. I had 13 residents. I usually do only 2 rounds, but depends because sometimes we have only 4 C.N.A's and we are supposed to have 5 CNA's. When asked if she got report about which residents needed to be turn and repositioned, CNA EE responded No, staff figure it out on their own. Continued interview at that time, CNA EE stated that whenever they see any new skin problem on the residents, they report it to the nurses verbally and further said everything you want to report about the skin has to be done verbally because you can not even put the information on point of click (computer) because there is no way of doing it. When asked if she reported any new skin problem about Resident #18 on 12/08/2015 during the 7 - 3 shift, she responded no because he did not have any new skin problem and the last time I did incontinent care at 10:00 a.m. he did not have signs of skin breakdown. Interviews on 12/10/2015 at 8:55 a.m. with CNA BB and CNA RR, both stated that skin conditions are reported to nurses verbally only, that the facility did not have any skin sheet or showers sheets to report any skin conditions. CNA BB further said The computer system point click does not ask for skin conditions or skin breakdown. Resident #19 Record review of the medical record face sheet revealed Resident # 19 was admitted on [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years old. Record review of Resident #19's Braden Scale - Predicting Pressure Score Risk revealed on 11/17/2015 his score was an 17 (at risk). Record review of Resident # 19's admission MDS assessment with 11/24/2015 ARD date revealed his Cognitive Skills for Daily Decision Making was assessed as moderate impaired. He required extensive assistance of two staff support with bed mobility and transfers and extensive assistance of one staff support for locomotion, dressing, toilet use and personal hygiene and was total dependent on staff for bathing. He was assessed as having a range of motion impairment on both sides of his lower extremities. He was always incontinent of bowel and bladder. The skin condition section of the assessment revealed he had one venous and arterial ulcer present. Further record review revealed that he was at risk of developing pressure ulcers and had no pressure sores and had a pressure reducing device for chair and bed and was not on a turning/repositioning program. Record review of Resident #19 ' s Skin - head to Toe checks dated: -12/07/2015 revealed that his skin was intact. No skin problems were identified. -12/09/2015 new pressure ulcer. -Describe new or existing issues: Resident #19 has Deep Tissue Injury to bilateral heels. -Right heel pressure 5.0 x 3.5 c.m. and Left heel pressure 6.0 x 4.0 c.m. Record review of Resident #19's Plan of Care initiated 11/24/2015 revealed in part: -Focus: Resident #19 has diabetes mellitus and has an arterial/ischemic ulcer of the left distal first toe and second toe. -Interventions: Check all of body for breaks in skin and treat promptly as ordered by doctor, check feet daily. An observation on 12/10/2015 at 9:03 am revealed that Resident # 19 was lying on his bed with a heel bootie to his left foot and the right foot heel was resting on the bed mattress. Further observation and interview, CNA BB stated that she was assigned to work with Resident #19 and that he did not have any skin problems that she was aware of. Continued observation revealed that Resident #19's left heel had a large black discoloration covering the entire heel that was approx 6 x 5 c.m. and there was an open area on the middle of the black discoloration that was approx 1.0 x 1.0 c.m. Further observation and interview revealed that Resident #19's right heel was resting on the mattress and he had a dark purple/black area on the right heel that was approx 4.0 x 5.0 c.m. and Resident #19 stated it's been there for a while already. When asked CNA BB if she was aware that Resident #19's heels had dark discolorations, she responded No. When asked if she knew of any precautions to take with Resident #19's heels, she responded No. In an interview on 12/10/2015 at 9:15 a.m. with LVN S, she stated that she remembered that Resident #19 already had purple discolorations to his left heel before and that it looked like a pressure ulcer and that there were no orders for the left heel because the skin was not open but did not remember if the information was of Resident #19's skin assessment and further said For the right heel, this is my first time seeing it, I did not know he had any problems to his right heel and the left heel looks different because the skin was not open before. Further observation and interview at that time, LVN S and CNA BB were asked to observe the perineal area of Resident #19 after Resident #19 gave permission. When CNA BB touched the scrotum area of Resident #19, he screamed ouuuch. Continued observation revealed that Resident #19 had 3 open areas to his scrotum area. LVN S then measured the open areas as follows: -Right lateral side of scrotum open area was 2.0 x 1.0 c.m. and superior aspect of wound had an area with yellow slough that measured 0.8 x 1.0 c.m. -Inferior side of scrotum open area was 2.0 x 1.5 c.m. with wound base red. -Left lateral side of scrotum open area was 1.0 x 1.2 c.m. with wound base red Further interview at that time with LVN S, she stated that she was not aware of Resident #19's scrotums' open areas and that CNA's were supposed to report any skin problems immediately and that she was going to call the MD to get orders. When asked if Resident #19 was supposed to have any special precautions to his heels and if CNA BB was made aware, LVN S did not respond and immediately offloaded the heels of Resident #19 with pillows. Record review of Resident #19's SBAR Communication form and Progress note dated 12/09/2015 revealed in part: -Situation: Resident #19 has Deep Tissue Injury to bilateral heels -Things that make the condition or symptom worse: pressures to areas -Other relevant information: Resident #19 has heel booties in place. Record review of Resident # 19's SBAR Communication Form and Progress Note dated 12/10/2015 at 9:55 a.m. read in part: -Situation: Resident #19 was noted with an open skin to his left heel posteriorly and three skin ulcers to his testicles. Reported to NP on 12/10/2015 at 10:20 a.m. Further record review of Resident #19's Plan of Care initiated 12/10/2015 and revised 12/11/2015 revealed in part: -Focus: Resident #19 has Deep Tissue Injury to bilateral heels actual impairment to skin integrity of the bilateral heels related to suspected deep tissue injury. Resident #19 has potential/Actual skin issues related to excoriation under genitals. -Interventions: Off load heels, turn and reposition and check for incontinence every 2 hours. Use pillows to decrease pressure and off load heels. In an interview on 12/10/2015 at 10:20 a.m. with Resident #19, he stated that the sores to his scrotum had been there for about a week and that they hurt a lot when the staff would clean him. In an interview with LVN K, wound care nurse, conducted on 12/10/2015 at 11:40 am, he reported he became aware of Resident # 18's buttocks pressure ulcers on 12/08/2015 when the afternoon shift nurse reported to him and that the wound care doctor had already evaluated Resident #18 and that the MD said that both were stage three pressure sores and had obtained wound care orders already. LVN K continued saying that he was not aware of any problems with Resident #19 ' s heels and that he had just learned today about the open areas to his scrotum and that the charge nurse had already call the MD for orders. LVN K further said that the charge nurses on the floor are supposed to supervise the CNA's to make sure they turn and reposition the residents and do incontinent care and that CNA's were supposed to report skin problems as soon as possible to the charge nurse or the wound care nurse. LVN K continued saying that the charge nurses are supposed to give a report to the CNA's about skin problems and interventions. In an interview on 12/10/2015 at 3:30 p.m. with MDS A (LVN), she stated that she conducted the skin assessment to Resident #19 on 12/09/2015 and that she found Deep Tissue Injury to both of his heels. When asked if she checked his scrotum area, MDS A responded No, I did not look at his scrotum, we are supposed to look at the entire body when doing body assessments including the under breast, under arms and scrotum area for males. I think I was just so tired, did the body assessment late last night. In an interview on 12/11/2015 at 9:30 a.m. with the DON, he stated that Aides were supposed to report to nurses immediately any changes in the skin and that CNA's did not have any papers to document skin condition but that they could in put the information on the computer when doing their ADL's. DON further said that staff were supposed to report skin conditions on the beginning of the problem like stage one pressure sores and not wait until residents have stage three or deep tissue injuries and said If residents are at risk to develop pressure sores, the charge nurses are supposed to communicate with the CNA's the information and residents are supposed to be turned and repositioned every 2 hours even when they are on their chairs . The DON stated that incontinent care is supposed to be done every 2 hours and that nurses on the floor were in charge of monitoring the CNA's to make sure the residents were being checked for incontinent care every 2 hours and said I don't expect that residents are found soaking wet with wound on the skin . The DON stated that charge nurses were in charge of performing the weekly skin assessments of the residents and that they were supposed to include the perineal areas when doing the body assessments. Resident # 56 Record review of Resident # 56's medical records revealed she was admitted on [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident # 56's significant change MDS assessment dated [DATE] revealed her cognitive skills for daily decision making was moderately impaired. She was totally dependent with two person assistance with bed mobility, transfers, and toileting; totally dependent with one person assistance for locomotion, eating, and bathing, and required extensive two person assistance with dressing and personal hygiene. She was always incontinent of bowel and bladder and received nutrition through [DEVICE] feeding. She had one stage IV pressure ulcer, was at risk for developing pressure ulcers, had pressure reducing device for chair and bed, and was not on a turning/repositioning program. Observation of Resident # 56 on 12/07/15 at 3:59 PM revealed she was asleep on her back with the head of bed elevated and the [DEVICE] infusing. Observation of Resident # 56 on 12/08/15 at 8:29 AM revealed she was asleep on her back with the head of bed elevated and the [DEVICE] infusing. She was observed to have heel protectors on both feet under the covers. Observation of Resident # 56 on 12/09/15 at 5:20 PM revealed she was asleep and turned toward her right side. Observation of Resident # 56 on 12/10/15 at 8:33 AM revealed she was asleep on her back with the head of bed elevated and the [DEVICE] infusing. She was observed to have heel protectors on both feet under the covers and had a standard mattress on the bed. Further review of Resident # 56's medical records revealed a Weekly Pressure Ulcer Record dated 8/12/15 read she had an existing pressure ulcer to her left buttocks acquired at the facility on 8/10/15. Measurements documented were 4.9 x 2.4 x 0.1 cm, Stage II. Further review of Resident # 56's medical records revealed a Head to Toe Skin Check dated 10/12/15 read Intact Skin. Record review of a Weekly Pressure Ulcer Record dated 10/14/15 read that Resident # 56 had a new pressure ulcer to her right heel acquired in the facility on 10/14/15. Measurements documented were 2.4 x 3.6 cm (no depth) Stage: Suspected deep tissue injury . The Description of the Site read black wound bed and black wound edges. The Specialty Interventions were pillow for off loading. Record review of a Weekly Pressure Ulcer Record dated 10/16/15 revealed it read that the right heel pressure ulcer measured 2.4 x 3.6 cm (no depth) Stage: Suspected deep tissue injury. Record review of a Weekly Pressure Ulcer Record dated 10/28/15 revealed it read that the right heel pressure ulcer measured 5.1 x 6.5 x 0.4 cm and was unstageable. Record review of a Weekly Pressure Ulcer Record dated 11/25/15 revealed it read that the right heel pressure ulcer measured 4.7 x 5.2 x 1.4 cm and was a Stage IV. Record review of a Weekly Pressure Ulcer Record dated 12/02/15 revealed it read that the right heel pressure ulcer measured 3.1 x 3.8 x 0.7 cm and was a Stage IV. Record review revealed no other Weekly Pressure Ulcer Records were noted in Resident # 56's medical records. No documentation from the wound care doctor was found in the resident's medical records. Record review of Resident # 56's Care Plans revealed a care plan dated 10/07/15 read, (Resident # 56) has DTI ulcer development r/t immobility, revised on 10/20/15 with target date 11/20/15. Interventions included Administer treatments as ordered and observe for effectiveness .Complete a full body check weekly and document Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning .Follow facility policies/protocols for the prevention/treatment of [REDACTED].# 56) requires the bed as flat as possible to reduce shear. The resident prefers to be repositioned with 2 person assist. Record review of the Braden Scale For Predicting Pressure Sore Risk revealed the following assessments for 2015: -3/11/15 score = 10 - High Risk - with total score of 12 or less representing high risk, -4/8/15 score = 13 - Moderate Risk, -11/2/15 - score = 10 - High Risk, -11/17/15 - score = 10 - High Risk, -12/09/15 - score = 9.0 - Very High Risk. Record review of Resident # 56's lab results revealed the following: -5/27/15 - [MEDICATION NAME] low at 3.4 (Expected Range - 3.5-5.7) -10/15/15 - [MEDICATION NAME] low at 3.0 -11/12/15 - [MEDICATION NAME] low at 2.9 Record review of Resident # 56 ' s December physician's orders [REDACTED]. -NPO (Nothing by Mouth) diet; -Enteral Feed Order every shift [MEDICATION NAME] 1.2 per [DEVICE] via pump @ 65 mls/hour x 22 hours/day, to provide 1718 calories per 24 hours, start date 9/30/15; -Heel protectors on bilateral feet or float on pillow off bed every shift, start date 8/01/15; -Vitamin C tablet 500 mg ([MEDICATION NAME] Acid) Give 1 tablet via [DEVICE] in the morning for pressure sore, start date 10/15/15; -Zinc Sulfate Capsule 220 mg, Give 1 tablet via [DEVICE] in the morning for pressure sore, start dated 10/15/15; -Santyl Ointment 250 unit/gm ([MEDICATION NAME]) Apply to R Heel topically every day shift for pressure sore - Clean with ns, pat dry, apply santyl, cover with dry dressing, start date 10/29/15. Record review of Resident # 56's 2015 physician orders [REDACTED]. Record review of the nutrition notes revealed a note dated 9/25/15 read, Nutrition Intervention: Quarterly, NOP [MEDICATION NAME] 1.2 @ 70 ml/hr x 22 hrs flush with 30 ml of water per hr x 22 hrs. = 1848 Kcal, 85.4 gm pro., 1242 ml water. 9/15 wt. 169.9 resident shows a 4.8 % wt gain in 30 days, BMI 27.4 overweight, IBW 130 + -10% .Recommend decrease feeding to 65 ml/hr x 22 hrs flush with 25 ml/hr x 22 hrs, flush meds as protocol. 1718 Kcal. 79.3 gm of pro, 1154 ml water . Record review of a Nutrition Status Review,Quarterly dated 12/9/15 revealed it read, NPO on [MEDICATION NAME] 1.2 @ 65 ml/hr x 22 hrs flush with 30 ml of water/hr x 22 hrs, 12/15 wt. 174.8, wt. continues increasing, resident shows a 7.5% wt. gain in 180 day. Resident is on 20 mg [MEDICATION NAME] per day. Noted stage 4 wound to right heel, getting better per 12/7/15 report .1) Continue current feeding, 2) notified MD of wt. gain resident is only getting 21 Kcal/KBW, Res is on 20 mg of [MEDICATION NAME] per day, 3) Rec. 30 ml promod per day x 30 day .Promote wound healing . Both assessments were signed by the RD. In an interview with LVN K on 12/8/15 at 11:50 AM he stated that Resident # 56 had a sacrum pressure ulcer that had cleared up. He stated a suspected deep tissue injury was discovered on Resident # 56's right heel on 10/14/15. He stated because it was a suspected deep tissue injury they used [MEDICATION NAME] on it to dry it up. LVN K stated, Then it opened up. He stated they began using santyl ointment on it then. He stated the wound care doctor later came and debrided the wound. He stated he wasn ' t sure exactly when the wound care doctor looked at it. In an interview with ADON A on 12/10/15 at 9:57 AM she stated Resident # 56 should be turned and repositioned every 2 hours. She stated Resident # 56 can ' t move her body. She stated she can move her arms and hands, but that is all. She stated she would never be able to turn over by herself. When asked why she thought she developed the pressure ulcer on her heel, she stated, She might have had breakdown there before. ADON A then stated she did not know. In an interview with the RD on 12/11/15 at 2:48 PM she stated when a resident has any abnormal labs such as low [MEDICATION NAME] the facility lets her know and she assesses the resident. She stated she looks at how well they eat and if they eat well she does not recommend any supplements. When asked about her assessment of Resident # 56 on 9/25/15, she stated Resident # 56 is on [DEVICE] feeding. She stated a resident on [DEVICE] feeding should be getting enough protein in the formula, so she would not recommend any supplements. She stated, It just means that something else is going on with the body to cause the pressure ulcers. The RD was asked about the assessment she did on Resident # 56 on 12/09/15 and if she had recommended Promod 30 ml per day x 30 days. She stated she did recommend the Promod on that date. She stated Promod is a liquid protein. She was asked if she did think then that Resident # 56 needed more protein. The RD responded, At that moment. Yes. Resident # 46 Record review of Resident # 46's face sheet revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident # 46's quarterly MDS assessment records dated 11/17/15 revealed a BIMS score of 15 indicating her cognition was intact. Record review of Resident # 46's care plan dated 11/18/15 revealed the resident had a stage 3 pressure ulcer develop due to a history of pressure ulcers. The care plan was initiated on 7/24/15. Further review of the care plan revealed the resident had physical limitations and immobility. Record review of Resident # 46's clinical records revealed Braden Scale report for predicting pressure Sores Risk for Resident # 46 with the following documentation on 12/9/14 a score of 16, on 12/16/14 a score of 16, on 12/23/14 a score of 16, and on 12/30/14 a score of 16. According to this assessment, a total score of 15-18 equals a mild risk of developing pressures ulcers. Record review of weekly pressure ulcer record dated 1/5/15 revealed a wound to the sacral area site midline sacrum date on onset 1/5/15 re-opened. Record review of facility weekly pressure ulcer log dated 11/17/15 revealed Resident # 46 acquired a stage 3 pressure ulcer while in the facility. An Observation of wound care treatment f

Based on interview, and record review, the facility failed to provide pharmaceutical services and procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 9 of 25 residents reviewed for pharmacy services (Resident #'s 76, 67, 34, 46, 20, 32, 73, 106, 26): -The facility failed to administer Resident #76 his Levothyroxine 125 mcg for [DIAGNOSES REDACTED] for 39 days. Resident #76 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. -The facility failed to respond to the pharmacy Consult Report from October 1, 2015 where the pharmacist had made a recommendation to ensure that facility notify the MD that Resident #76 had missed doses of several medications including Levothyroxine 125 mcg. -The facility failed to order from the pharmacy Levothyroxine 125 mcg for Resident #76 and the medication was not available at the facility. - Resident #67 did not receive 5 physician ordered medications (Atorvastatin Calcium 40mg, Calcium Acetate 667mg, Citalopram Hydrobromide 20mg, Lisinopril 10mg, and Ranolazine ER 500mg) between 11/27/2015 and 12/8/2015. - Resident #67's medications were held on some days in October and November 2015 when she was away at dialysis without a physician's orders [REDACTED]. - Resident #34's MARs for the months of October and November 2015 revealed undocumented/blank spaces for physician ordered medications. - Resident #46's MARs for the months of October and November 2015 revealed undocumented/blank spaces for physician ordered medications. - Resident #20 received their Levothyroxine 88 mcg tablet only on October 2, 8, 11, 14, 15, 16, 18, 20, 21, 22, 23, 24, 25, 26, 28, 29 and 31. - Resident #32 received their Levothyroxine 25 mcg only on October 8, 11, 16, 18, 21, 24, 28 and 30, and November 3,4, 7,8,12,13,16,18,21,22,23,25,26,and 30. - Resident #73 received their Levothyroxine 25 mcg tablet only on October 7 and was not administered in November. - Resident #106 did not receive Levothyroxine 75mcg on any day during the month of November 2015, and on 23 days of October 2015. - Resident #106's MARs for month of November 2015 revealed undocumented/blank spaces for physician ordered medications. - Resident #26's MARs for the months of October and November 2015 revealed undocumented/blank spaces for physician ordered medications. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 12/09/15 at 12:32 PM. While the IJ was removed on 12/11/15 at 4:35 PM, the facility remained out of compliance at a severity of actual harm that is not IJ with a scope identified as pattern because the facility was still monitoring the effectiveness of the Plan of Removal. This deficient practice affected 9 residents and could place 117 additional residents at risk for adverse side effects, long lasting medical complications, unnecessary hospitalization s and death. The Findings Include: Resident #76 Record review of the facility face sheet revealed Resident #76 was a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with the following [DIAGNOSES REDACTED]. Record review of the quarterly MDS dated [DATE] revealed Resident #76 was moderate cognitive impaired and was able to make self understood and was able to understand others. Record review of Resident #76's physician orders [REDACTED]. Levothyroxine 125 mcg tablet, give one tablet orally one time a day related to unspecified [DIAGNOSES REDACTED]. Record review of the pharmacy Shipment summary dated 10/09/2015 at 2:43 a.m. revealed a delivery of 15 tablets of Levothyroxine 125 mcg for Resident #76. Record review of Resident #76's eMAR (Electronic Medication Administration Record) dated 10/01/2015 to 10/31/2015 revealed the following: -Levothyroxine 125 mcg tablet, give 1 tablet orally one time a day related to unspecified [DIAGNOSES REDACTED]. Further record review revealed that Levothyroxine 125 mcg tablet was administered only on October 4, 5, 7, 8, 11, 12 and 15. Continued record review revealed that eMAR did not have a reason why doses were missed. Record review of facility's pharmacy consultation report dated October 1, 2015 through October 14, 2015 revealed in part: .(Resident #76) To: DON. (Resident #76) has missed doses of several medications according to the medication administration record (MAR), but the reason why doses were missed was not documented. -Recommendation: Please ensure that the prescriber has been made aware of these missed doses, and remind nursing staff to record appropriate documentation describing why doses were missed Record review of Resident #76's eMAR (Electronic Medication Administration Record) dated 11/01/2015 to 11/30/2015 revealed the following: -Levothyroxine 125 mcg tablet, give 1 tablet orally one time a day related to unspecified [DIAGNOSES REDACTED]. Further record review revealed that Levothyroxine 125 mcg tablet was not administered from November 1 to November 23rd 2015 and the eMAR did not have a reason why doses were missed. Record review of the Resident #76's Progress notes dated 11/23/2015 at 8:42 p.m. revealed in part Resident #76's family member was called around 6:00p.m. and informed that Resident #76 was admitted at the Hospital and will not be back tonight. Record review of Resident #76's hospital's history and physical dated 11/23/2015 at 8:51 p.m. revealed in part .Resident #76 presents from the clinic after being found to be bradycardic (slow heart rate under 60 beats per minute) to 36 and hypotensive (low blood pressure) to 77/56. Bradycardia: Likely secondary to [DIAGNOSES REDACTED] (TSH 14.8).(Expected range 0.270 - 4.20 uIU/mL). Restart levothyroxine. [DIAGNOSES REDACTED]: TSH 14.8. Possibly due to not getting appropriate dosage at the nursing home. Further record review of Resident #76's hospital discharge note and final assessment and plan dated 11/25/2015 revealed in part: [AGE] year old male with history of [DIAGNOSES REDACTED]. Found to have a TSH (Thyroid-Stimulating Hormone) level of 14.8 on admission, which was the likely cause of his bradycardia. He was started on levothyroxine dose (.125 mg daily) with improvement in heart rate (30s - 50s with low of 29 overnight on day of admission and 50s to 70s with low of 39 on day of discharge). Given acute improvement, there is concern that Resident #76 was not getting his appropriate dose of levothyroxine in the nursing home. In an interview on 12/7/2015 at 12:29 p.m. with ADON A, she stated that she was responsible for the reconciliation of medications at the end of each month and that she would usually compare the old orders with the new orders and would check the orders against the Medication Administration Record. When asked if she was aware that Resident #76 received his Levothyroxine 125 mcg only 7 times in the month of October 2015 and did not receive his Levothyroxine 125 mcg from November 1st to November 23rd when he was admitted to the hospital, she responded yes, we knew from Resident #76 and his family member when he came back from the hospital, everybody knew that his medications were not given. When asked if she had checked the eMAR in October 2015 while doing the reconciliation of orders, she responded I don't remember. In an interview on 12/7/2015 at 2:50 p.m. with the DON, he stated that they had found a problem on the computer system and that it was the reason why they had moved from electronic MAR to paper MAR on 12/2/2015. DON continued saying that it was a configuration system problem that before he was a DON (approx 5 months ago), there were missing room assignments on the computer system and further said it goes by room numbers and the mechanism would be triggered by the room numbers, so if the number of the room was not there, the medication would not come on the screen. Surveyor requested the room numbers that were affected by the configuration system problem. DON continued saying that the facility was made aware on November 25th that Resident #76 did not received his Levothyroxine medication as ordered and that it was the reason that his TSH levels were high and the heart rate low at 36 because the medication was not given. The requested room numbers were not provided by the time of exit from the facility. Further interview at that time, surveyor asked DON if incident involving Resident #76's Levothyroxine medication not given as ordered and Resident #76 ending in the hospital was reported to DADS and the DON stated No, because the (family member) said she had already reported it to the State office and also the VA nurse. They told me it was going to be reported. Continued interview with the DON, he stated that the facility started charting on August 1st on the eMAR system and that it was around September 2015 that staff started complaining of orders not appearing on the screen of the eMAR and that the facility provided training on using the eMAR system and entering orders. DON continued saying that he believed that the configuration problem had been resolved until he heard the problem of the medication with Resident #76. DON further said that he spoke with LVN D about Resident #76's medication Levothyroxine not given and that he questioned her why the medication Levothyroxine was last ordered on [DATE] where 15 doses were sent only and that LVN D said that the medication would not appear on the screen sometimes. In an interview on 12/8/2015 at 9:15 a.m. with ADON B, he stated that he was also responsible of consolidating physician orders [REDACTED]. He said that he would only compare the previous physician orders [REDACTED]. In an interview on 12/08/2015 at 9:25 a.m. with LVN Q, she stated that she would occasionally see problems with the eMAR system in which orders would not appear on the screen and heard that some nurses would write orders in the computer Point Click Care (electronic clinical records) and then the order would not show on the eMAR. She further said that ADON's and DON had been made aware of the problems since the problems were happening back in October and November. In a phone interview on 12/08/2015 at 10:21 a.m. with RN C, he stated that he worked on the afternoon and the night shift and would give the thyroid medications to residents at around 6:00 a.m. whenever he would work on the night shift. He further stated that sometimes the medications would not come on the eMAR computer screen and that he had been reporting problem since a couple of months ago. RN C continued saying that he did remember Resident #76's medication Levothyroxine was not available at one point and that he was not able to order the medication on the computer and that he reported the information to the incoming nurse to let the ADON know about it. RN C did not remember the date when the medication was not available or who did he spoke to about it. In an interview on 12/08/2015 at 12:35 p.m. with Resident #76, he said They failed to give me one of my pills. I asked them about it and they told me that they did not have it, then I went to the VA hospital. They facility did not have it on the computer. Resident #76 further said I do not receive medications from the VA hospital, the VA hospital only pays for my medications here at the facility. Further interview on 12/08/2015 at 12:44 p.m. with the DON, he stated that on December 2nd, 2015 the facility went on paper MAR because the facility did not know what was happening on the computer system and further said last 3 months, there were so many residents with holes in the MARs well a couple. DON continued saying the holes in the eMAR means that the medications were not given at that time. We are checking all residents, we are in the process. It was a computer error. When asked who was supposed to checked the eMARs to make sure residents were getting their medications, the DON said we just started having the nurses and CMA's checking the MARs for holes. The ADONs were supposed to check the eMARs before. DON further said that he trained the staff on October 2015 because he looked at few eMARs and noticed some holes and that he thought it was a training issue. DON continued saying that he called the VA pharmacy on December 2, 2015 and that he was told that the facility was supposed to provide medications for the residents and that they would only provide the high value medications. In an interview on 12/08/2015 at 2:20 p.m. with LVN C, she stated that she has reported to ADON A that some medications would not appear on the computer screen. LVN C continued saying that it has been a problems since the facility started using the computer system and that the DON was made aware already and that people from the Corporation were in the facility approx 2 weeks ago and that it was reported to them that some medications would not show up on the computer screen. In a phone interview on 12/08/2015 at 3:10 p.m. with Pharmacist at VA hospital, she stated they had just recently provided 30 tablets on November 25, 2015 for Resident # 76. The Pharmacist stated that prior to that the last time they sent Levothyroxine for Resident #76 was in 2012. In an interview on 12/09/2015 at 8:15 a.m. with LVN D, she stated that she worked the night shift with Resident #76 and that she had been having problems with medications at 6:00 a.m. not showing up on the screen and further said staff would give medications to the residents that would come on the screen, the system would highlight the medications that were due to give at certain time and that was one of the problems. LVN D continued saying that the problem had been since August 2015 and that she was told recently that it was a glitch problem and that that was the reason the facility had moved to paper MARs. LVN D further said that the Levothyroxine for Resident #76 was not coming up on the system and that she thought that the medication had been discontinued because it would not come up on the system at 6:00 a.m. LVN D said that she talked to ADON A about Resident #76's medication not showing on the screen and that ADON A said OK and that she believed that she was looking into it and further said I told her several times. When the medication was coming up on the screen, Resident #76 was getting his medication but once it didn't come on the system, he did not get it and we did not have it. If a medication was not signed, was not given. No medications were coming up on the screen for Resident #76 at 6:00 a.m. and Levothyroxine was a medication due to be given at 6:00 a.m. In continued interview with LVN D, she continued saying that she gave a letter to ADON A with the name of 4 other residents that medications were not showing on the screen but she did not remember the names of those residents or when did she give her the list. LVN D further said that she tried to re-order Levothyroxine but couldn't do it so she reported the information to the LVN C. When asked if she checked the physician orders [REDACTED]. In an interview on 12/09/2015 at 9:00 a.m. with RN K, she stated that she only works PRN night shift in the facility and that she did noticed an issued with the Levothyroxine medication of Resident #76 and further said Resident #76 told me that he was supposed to get his morning pill and I went to look at his MAR on the computer and there was nothing scheduled for him so he did not get the Levothyroxine medication because nothing was showing up on the computer screen. In an interview on 12/09/2015 at 10:15 a.m. with the DON and the DDO, the DDO stated that the Administrator was on vacation since the day after thanksgiving and that he came to the facility on November the 28th. The DDO further said that during a previous state investigation on 12/2/2015, he was told about the incident with Resident #76's medication, and that facility had an ad hoc meeting on 12/02/2015 and that eMAR was changed to paper MAR. DON continued saying that he noticed there were some omissions on the eMARs and that he thought it was a training issue and that he trained the staff. DON further said that LVN D had told him that she had administered the Levothyroxine medication to Resident #76 even thought it was not documented. DON continued saying LVN D told me that the medication was here from VA pharmacy in a bottle. DON further said that the MARs are supposed to be checked periodically by the unit managers who are the ADONs and said If we see there is something going on, we need to implement something. When asked how many residents could potentially be affected, the DON responded Do not know, but everybody with an omission could be potential. In an interview on 12/10/2015 at 10:25 a.m. with ADON A, she stated that LVN D told her at around the beginning of October that some medicines would not come on the screen and that she told her to check the nurse's MAR and then the MA's MAR and that LVN D did not report further problems and that she assumed everything was OK. ADON A further said LVN D said that she has always given the medicine Levothyroxine to Resident #76 from the blister packet, the one we received from our pharmacy and not from the VA bottle. ADON A further said that she never received any list of residents with problems during the night shift from anybody in the facility and that no nurses or MA's had reported to her any problems with medications not available or not showing on the computer screen. Resident #67 Record review of Resident #67's medical record revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. She was [AGE] years of age. Record review of Resident #67's physician's order [REDACTED]. revealed she was prescribed the following medications: [REDACTED] - Amlodipine Besylate 5mg, give one tablet by mouth daily for hypertension - Aspirin 325mg, give one tablet by mouth daily for heart attack - Calcitriol 0.25mcg, give one tablet by mouth every day for osteoporosis - Clopidogrel Bisulfate 75mg, give one tablet by mouth once daily for antiplatelet - Famotidine 20mg, give one tablet by mouth once daily for ulcer sores - Isosorbide Mononitrate Extended Release 30mg, give one tablet once daily for hypertension - Lactulose Solution 10 gm/mL, give 30ml by mouth once daily for constipation - Levetiracetam 500mg, give one tablet by mouth once daily for seizures - Megace 40mg/mL, give 10 mL by mouth once daily for appetite - Metoprolol Tartrate 50mg, give one tablet by mouth twice daily for hypertension - Nepro Liquid, give 237 mL by mouth two times daily for renal disease - Pregabalin 25mg, give one capsule by mouth twice daily for muscle pain - Quetiapine Fumarate 25mg, give one tablet by mouth daily for psychosis - Renal Tablet, give one tablet by mouth once daily for end stage renal disease - Sucralfate Suspension 1 gm/10 mL, give 10 mL by mouth every day for stomach ulcer - Zantac 150mg, give one tablet by mouth twice daily for gastro-esophageal reflux disease Record review of Resident #67's hospital records revealed she was admitted to the hospital on [DATE] after experiencing sharp chest pains and feeling diaphoretic. She was discharged from the hospital on [DATE]. Record review of Resident #67 ' s Progress Note dated 11/18/2015 and written by LVN O revealed that she was transported to the hospital from the dialysis center. A Progress Note dated 11/21/2015 written by LVN O revealed that she returned from the hospital and the physician was notified. Record review of Resident #67 ' s Discharge- Patient Medication Report from the hospital dated 11/21/2015 revealed she was discharged from the hospital with the following new medication orders: - Aspirin 81mg, give one tablet by mouth daily - Atorvastatin 40mg (a medication for cholesterol), give one tablet by mouth at bedtime - Calcium Acetate 667mg (a medication for high phosphate) , give one tablet by mouth daily - Citalopram 20mg (a medication for depression), give one tablet by mouth daily - Lisinopril 10mg (a medication for hypertension), give one tablet by mouth daily - Ranolazine Extended Release 500mg (a medication for angina), give one tablet by mouth every 12 hours. - Sucralfate 1GM tablet (a medication for stomach ulcers), give one tablet by mouth daily Record review of Resident #67's MAR dated November 2015 revealed that on 11/21/2015, Aspirin 81mg, Atorvastatin 40mg, Calcitriol 0.25mcg, Calcium Acetate 667mg, Citalopram Hydrobromide 20mg, Famotidine 20mg, Lisinopril 10mg, Metoprolol Tartrate 50mg, Sucralfate 1gm tablet, and Ranolazine Extended Release 500mg were added to be administered. All of these medications were discontinued on 11/27/2015. Further review of Resident #67's CMA MAR dated November 2015 revealed that she continued to be administered Aspirin 325mg, Calcitriol 0.25mcg, Famotidine 20mg, and Metoprolol Tartrate 50mg between 11/21/2015 and 11/27/2015. This indicates the medications were documented as being given twice, once on the MAR and once on the CMA MAR. Record review of orders created by LVN D dated 11/27/2015 revealed that she discontinued Resident #67's Aspirin 81mg, Atorvastatin 40mg, Calcitriol 0.25mcg, Calcium Acetate 667mg, Citalopram Hydrobromide 20mg, Famotidine 20mg, Lisinopril 10mg, Metoprolol Tartrate 50mg, Sucralfate 1gm tablet, and Ranolazine Extended Release 500mg because of double entry. In an interview on 12/8/2015 at 3:30pm, ADON A said the new medications for Resident #67 ordered from the hospital should not have been discontinued. She said LVN D must have noticed there were duplicates on the MAR, and when she discontinued the duplicates, she accidentally discontinued all of the medications with an order date of 11/21/2015. She said she would call the physician to clarify the order. In an interview on 12/9/2015 at 8:00am, LVN D said when checked Resident #67 ' s MAR with the physician's order [REDACTED]. She said she discontinued the medications that were duplicates. She said she did not notice there were new medications on the MAR. She said she thought all of the medications she discontinued were duplicates because she checked it against the physician's order [REDACTED]. She said that isn't good. In an interview on 12/11/2015 at 9:20am, the DON said when a resident returns from the hospital, the admitting nurse should call the primary care physician and verify their medications. He said they should look at previous medications to ensure they are not adding duplicates. He said he could not comment on Resident #67 because he needed to look at it further. In an interview on 12/11/2015 at 3:00pm, the DON said he did not have a chance to look at Resident #67's MAR or physician's orders [REDACTED]. In an interview on 12/11/2015 at 3:35pm, LVN O said he could not remember if he was the admitting nurse when Resident #67 returned from the hospital. He said when a resident comes back from the hospital, he always calls the primary care physician to verify which orders to continue or discontinue. He said he would create all new orders on the MAR and discontinue all of the medications prior to hospital stay. When asked about Resident #67, he said he did not know why the new medications were discontinued, or why there were duplicates on the MAR. Record review of Resident #67's Care Plan dated 10/2/2015 revealed she requires dialysis and goes to a hemodialysis center on Mondays, Wednesdays and Fridays. Further review of Resident #67's physician's order [REDACTED]. Further review of Resident #67's MARs dated October and November 2015 revealed the following: - Amlodipine Besylate 5mg was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, 11/13/2015, and 11/23/2015. - Aspirin 325mg was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, 11/13/2015, and 11/23/2015. - Calcitriol 0.25mcg was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, 11/13/2015, and 11/23/2015. - Clopidogrel Bisulfate 75mg was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, 11/13/2015, and 11/23/2015. - Isosorbide Monnitrate Extended Release 30mg was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, 11/13/2015, and 11/23/2015. - Lactulose 10gm/mL was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, and 11/13/2015. - Levetiracetam 500mg was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, 11/13/2015, and 11/23/2015. - Megace 40mg/mL was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, 11/13/2015, and 11/23/2015. - Quetiapine Fumarate 25mg was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, 11/13/2015, and 11/23/2015. - Renal Tablet was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, and 11/13/2015. - Sucralfate Suspension 1gm/mL was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, 11/13/2015, and 11/23/2015. - Metoprolol Tartrate 50mg was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, 11/13/2015, and 11/23/2015 at the 9:00am scheduled time, and 11/16/2015 at the 4:00pm scheduled time. - Nepro Liquid was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, and 11/13/2015 at the 8:00am scheduled time, and 11/16/2015 at the 4:00pm scheduled time. - Pregabalin 25mg was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/14/2015, and 10/16/2015 at the 8:00am scheduled time, and 11/16/2015 at the 4:00pm scheduled time. - Zantac 150mg was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, 11/13/2015, and 11/23/2015 at the 9:00am scheduled time, and 11/16/2015 at the 4:00pm scheduled time. In an interview on 12/8/2015 at 2:30pm, LVN C said she cared for Resident #67. She said they held Resident #67 ' s blood pressure medications on the days she goes to dialysis because her blood pressure usually decreases during the procedure. She said they are supposed to get orders from the physician to hold medications on dialysis days. She said she could not find the order to hold medications for Resident #67. When asked what could happen if missing medications on those days, she said a lot could happen. In an interview on 12/8/2015 at 3:30pm, ADON A said if residents are missing medications on dialysis days, there should be an order from the physician. In an interview on 12/9/2015 at 8:20am, Resident #67 said she was about to leave for dialysis. She said on the days she goes to dialysis, she missed some of her medications. She said she did not notice any problems when she missed the medications. In an interview on 12/9/2015 at 8:25am, CMA A said she did not give blood pressure medications to Resident #67 on the days she goes to dialysis, because her blood pressure decreases on those days. She said usually, she does not give Resident #67 her 9:00am medications on Mondays, Wednesdays or Fridays because she is not in the facility. She said if she returns during her shift, she would administer the medications later in the day. She said she did not notify the nurse when she held the medications. She was aware that an order was required to hold medications, but was not sure if Resident #67 had an order to hold medications on dialysis days. In an interview on 12/9/2015 at 2:50pm, ADON A said she had just received an order from the physician to hold Resident #67's blood pressure medications on dialysis days, and said the doctor recommended changing the schedule time of the other medications to ensure she is receiving them as prescribed. In an interview on 12/11/2015 at 9:20am, the DON said some residents do not take blood pressure medications on dialysis days, but said some resident can tolerate them. He said it was dependent on the resident. He said there should be an order to hold medications. When asked about other medications with missed doses, he said, .especially seizure meds .It is important she gets it daily . Resident #34 Record review of Resident #34's medical record revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. She was [AGE] years of age. Record review of Resident #34's MAR dated November 2015 revealed the following: - Synthroid 137mcg, give one tablet by mouth in the morning for [DIAGNOSES REDACTED], was not marked as given on 11/1/2015-11/3/2015, 11/6/2015, 11/10/2015-11/12/2015, 11/17/2015, 11/22/2015, 11/27/2015, and 11/28/2015. The MAR did not indicate why the doses were missed. Record review of Resident #34's MAR dated October 2015 revealed the following:

Based on interview and record review the Administrator and the DON failed to administer the facility in a manner that enables it to use its resources effectively and efficiently resulting in system failures. Immediate jeopardy was identified in the area of Quality of Care and Pharmacy Services for 12 of 29 residents reviewed (Residents #'s 18, 19, 56, 46, 76, 67, 34, 20, 32, 73, 106, 26) The Administrator failed to: --Supervise and monitor the implementation of the new electronic medication administration system to ensure it was working correctly and would not cause medication errors, and ensure that nurses and medication aides were well trained in its use; Failed to identify and investigate system failure and implement appropriate corrective action. --Train the DON to have the skills and/or knowledge to train, supervise, and evaluate the nursing staff in both areas of medications and pressure ulcer prevention; --Supervise the DON to ensure that nursing staff completed accurate pressure sore assessments and nursing staff were monitored to ensure preventative care was provided to residents at risk for skin breakdown. The DON failed to: --Provide training and supervision to nursing staff to ensure staff were trained on medication administration, documentation, ordering medications, and on accurate reconciliation of medications monthly to ensure physician's orders [REDACTED]. --Ensure Pharmacist's recommendations were followed up on; --Supervise nursing staff to ensure monitoring of the medication administration record of residents was being conducted and issues reported were addressed timely; --Ensure the nursing staff were trained on identifying, reporting and documenting skin issues; --Monitor and supervise the nursing staff on accurate pressure sore assessment, use of pressure relieving devices, repositioning, and that preventative care was provided to residents at risk for skin breakdown; These failures resulted in an identification of two Immediate Jeopardy's (IJ) on 12/09/15 at 12:32 PM. While the IJ's were removed on 12/11/15 at 4:35 PM, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices and could place 39 residents receiving [MEDICATION NAME] for [MEDICAL CONDITION] at risk for adverse side effects, long [MEDICATION NAME] medical complications, unnecessary hospitalization s and death, and had the potential to place 27 residents at risk for developing new or worsening pressure sores, deterioration of existing ones, pain, infection and hospitalization . Findings Include: Medications Resident #76 Record review of the facility face sheet revealed Resident #76 was a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with the following [DIAGNOSES REDACTED]. Record review of Resident #76's physician orders [REDACTED]. [MEDICATION NAME] 125 mcg tablet, give one tablet orally one time a day related to unspecified [MEDICAL CONDITION]. Record review of the pharmacy Shipment summary dated 10/09/2015 at 2:43 a.m. revealed a delivery of 15 tablets of [MEDICATION NAME] 125 mcg for Resident #76. Record review of Resident #76's eMAR (Electronic Medication Administration Record) dated 10/01/2015 to 10/31/2015 revealed the following: -[MEDICATION NAME] 125 mcg tablet, give 1 tablet orally one time a day related to unspecified [MEDICAL CONDITION]. Further record review revealed that [MEDICATION NAME] 125 mcg tablet was administered only on October 4, 5, 7, 8, 11, 12 and 15. Continued record review revealed that eMAR did not have a reason why doses were missed. Record review of facility's consultation report dated October 1, 2015 through October 14, 2015 revealed in part: .(Resident #76) To: DON. (Resident #76) has missed doses of several medications according to the medication administration record (MAR), but the reason why doses were missed was not documented. -Recommendation: Please ensure that the prescriber has been made aware of these missed doses, and remind nursing staff to record appropriate documentation describing why doses were missed Record review of Resident #76's eMAR (Electronic Medication Administration Record) dated 11/01/2015 to 11/30/2015 revealed the following: -[MEDICATION NAME] 125 mcg tablet, give 1 tablet orally one time a day related to unspecified [MEDICAL CONDITION]. Further record review revealed that [MEDICATION NAME] 125 mcg tablet was not administered from November 1 to November 23rd 2015 and the eMAR did not have a reason why doses were missed. Record review of the Resident #76's Progress notes dated 11/23/2015 at 8:42 p.m. revealed in part Resident #76's daughter called around 6:00p.m. and informed that Resident #76 was admitted at the Hospital and will not be back tonight. Record review of Resident #76's hospital's history and physical dated 11/23/2015 at 8:51 p.m. revealed in part .Resident #76 presents from the clinic after being found to be bradycardic (slow heart rate under 60 beats per minute) to 36 and hypotensive (low blood pressure) to 77/56. [MEDICAL CONDITION]: Likely secondary to [MEDICAL CONDITION] (TSH 14.8).(Expected range 0.270 - 4.20 uIU/mL). Restart [MEDICATION NAME]. [MEDICAL CONDITION]: TSH 14.8. Possibly due to not getting appropriate dosage at the nursing home. Further record review of Resident #76's hospital discharge note and final assessment and plan dated 11/25/2015 revealed in part: [AGE] year old male with history of [MEDICAL CONDITION]. Found to have a TSH ([MEDICAL CONDITION]-Stimulating Hormone) level of 14.8 on admission, which was the likely cause of his [MEDICAL CONDITION]. He was started on [MEDICATION NAME] dose (.125 mg daily) with improvement in heart rate (30s - 50s with low of 29 overnight on day of admission and 50s to 70s with low of 39 on day of discharge). Given acute improvement, there is concern that Resident #76 was not getting his appropriate dose of [MEDICATION NAME] in the nursing home. Record review of the quarterly MDS dated [DATE] revealed Resident #76 was moderate cognitive impaired and was able to make self understood and was able to understand others. In an interview on 12/7/2015 at 12:29 p.m. with ADON A, she stated that she was responsible for the reconciliation of medications at the end of each month and that she would usually compare the old orders with the new orders and would check the orders against the Medication Administration Record. When asked if she was aware that Resident #76 received his [MEDICATION NAME] 125 mcg only 7 times in the month of October 2015 and did not receive his [MEDICATION NAME] 125 mcg from November 1st to November 23rd when he was admitted to the hospital, she responded yes, we knew from Resident #76 and the daughter when he came in from the hospital, everybody knew that his medications were not given. When asked if she had checked the eMAR in October 2015 while doing the reconciliation of orders, she responded I don't remember. In an interview on 12/7/2015 at 2:50 p.m. with the DON, he stated that they had found a problem on the computer system and that it was the reason why they had moved from electronic MAR to paper MAR on 12/2/2015. DON continued saying that it was a configuration system problem that before he was a DON (approx 5 months ago), there were missing room assignments on the computer system and further said it goes by room numbers and the mechanism would be triggered by the room numbers, so if the number of the room was not there, the medication would not come on the screen. Surveyor requested the room numbers that were affected by the configuration system problem. DON continued saying that the facility was made aware on November 25th that Resident #76 did not received his [MEDICATION NAME] medication as ordered and that it was the reason that his TSH levels were high and the heart rate low at 36 because the medication was not given. Further interview at that time, surveyor asked DON if incident involving Resident #76's [MEDICATION NAME] medication not given as ordered and Resident #76 ending in the hospital was reported to the State office and the DON stated No, because the daughter said she had already reported it to the State office and also the VA nurse. They told me it was going to be reported. Continued interview with the DON, he stated that the facility started charting on August 1st on the eMAR system and that it was around September 2015 that staff started complaining of orders not appearing on the screen of the eMAR and that the facility provided training on using the eMAR system and entering orders. DON continued saying that he believed that the configuration problem had been resolved until he heard the problem of the medication with Resident #76. DON further said that he spoke with LVN D about Resident #76's medication [MEDICATION NAME] not given and that he questioned her why the medication [MEDICATION NAME] was last ordered on [DATE] where 15 doses were sent only and that LVN D said that the medication would not appear on the screen sometimes. In an interview on 12/8/2015 at 9:15 a.m. with ADON B, he stated that he was also responsible of consolidating physician orders [REDACTED]. In an interview on 12/08/2015 at 9:25 a.m. with LVN Q, she stated that she would occasionally see problems with the eMAR system in which orders would not appear on the screen and heard that some nurses would write orders in point click and then the order would not show on the eMAR. She further said that ADON's and DON had been made aware of the problems since the problems were happening back in October and November. In a phone interview on 12/08/2015 at 10:21 a.m. with RN C, he stated that he worked on the afternoon and the night shift and would give the [MEDICAL CONDITION] medications to residents at around 6:00 a.m. whenever he would work on the night shift. He further stated that sometimes the medications would not come on the eMAR computer screen and that he had been reporting problem since a couple of months ago. RN C continued saying that he did remember Resident #76's medication [MEDICATION NAME] was not available at one point and that he was not able to order the medication on the computer and that he reported the information to the incoming nurse to let the ADON know about it. RN C did not remember the date when the medication was not available or who did he speak about it. In an interview on 12/08/2015 at 12:35 p.m. with Resident #76, he said They failed to give me one of my pills. I asked them about it and they told me that they did not have it, then I went to the VA hospital. They did not have it on the computer. Resident #76 further said I do not receive medications from the VA hospital, the VA hospital only pays for my medications here at the facility. Further interview on 12/08/2015 at 12:44 p.m. with the DON, he stated that on December 2nd, 2015 the facility went on paper MAR because the facility did not know what was happening on the computer system and further said last 3 months, there were so many residents with holes in the MARs well a couple. DON continued saying the holes in the eMAR means that the medications were not given at that time. We are checking all residents, we are in the process. It was a computer error. When asked who was supposed to checked the eMARs to make sure residents were getting their medications, the DON said we just started having the nurses and CMA's checking the MARs for holes. The ADONs were supposed to check the eMARs before. DON further said that he trained the staff on October 2015 because he looked at few eMARs and noticed some holes and that he thought it was a training issue. DON continued saying that he called the VA pharmacy on December 2, 2015 and that he was told that the facility was supposed to provide medications for the residents and that they would only provide the high value medications. In an interview on 12/08/2015 at 2:20 p.m. with LVN C, she stated that she has reported to ADON A that some medications would not appear on the computer screen. LVN C continued saying that it has been a problems since the facility started using the computer system and that the DON was made aware already and that people from the Corporation were in the facility approx 2 weeks ago and that it was reported to them that some medications would not show up on the computer screen. In a phone interview on 12/08/2015 at 3:10 p.m. with Pharmacist at VA hospital, she stated that the last time they sent [MEDICATION NAME] for Resident #1 was on 2012 and that they had just provided 30 tablets on November 25, 2015. In an interview on 12/09/2015 at 8:15 a.m. with LVN D, she stated that she worked the night shift with Resident #76 and that she had been having problems with medications at 6:00 a.m. not showing up on the screen and further said staff would give medications to the residents that would come on the screen, the system would highlight the medications that were due to give at certain time and that was one of the problems. LVN D continued saying that the problem had been since August 2015 and that she was told recently that it was a glitch problem and that that was the reason the facility had moved to paper MARs. LVN D further said that the [MEDICATION NAME] for Resident #76 was not coming up on the system and that she thought that the medication had been discontinued because it would not come up on the system at 6:00 a.m. LVN D said that she talked to ADON A about Resident #76's medication not showing on the screen and that ADON A said OK and that she believed that she was looking into it and further said I told her several times. When the medication was coming up on the screen, Resident #76 was getting his medication but once it didn't come on the system, he did not get it and we did not have it. If a medication was not signed, was not given. No medications were coming up on the screen for Resident #76 at 6:00 a.m. and [MEDICATION NAME] was a medication due to be given at 6:00 a.m. In continued interview with LVN D, she continued saying that she gave a letter to ADON A with the name of 4 other residents that medications were not showing on the screen but she did not remember the names of those residents or when did she give her the list. LVN D further said that she tried to re-order [MEDICATION NAME] but couldn't do it so she reported the information to the LVN C. When asked if she checked the physician orders [REDACTED]. In an interview on 12/09/2015 at 9:00 a.m. with RN K, she stated that she only works PRN night shift in the facility and that she did noticed an issued with the [MEDICATION NAME] medication of Resident #76 and further said Resident #76 told me that he was supposed to get his morning pill and I went to look at his MAR on the computer and there was nothing scheduled for him so he did not get the [MEDICATION NAME] medication because nothing was showing up on the computer screen. In an interview on 12/09/2015 at 10:15 a.m. with the DON and the DDO, the DDO stated that the Administrator was on vacation since the day after thanksgiving and that he came to the facility on November the 28th. The DDO further said that he was made aware of Resident #76's medication incident on 12/02/2015 when surveyor first came to the facility and that facility had an ad hoc on 12/02/2015 and that eMAR was changed to paper MAR. DON continued saying that he noticed there were some omissions on the eMARs and that he thought it was a training issue and that he trained the staff. DON further said that LVN D had told him that she had administered the [MEDICATION NAME] medication to Resident #76 even was not documented. DON continued saying LVN D told me that the medication was here from VA pharmacy in a bottle. DON further said that the MARs are supposed to be checked periodically by the unit managers who are the ADONs and said If we see there is something going on, we need to implement something. When asked how many residents could potentially be affected, the DON responded Do not know, but everybody with an omission could be potential. In an interview on 12/10/2015 at 10:25 a.m. with ADON A, she stated that LVN D told her at around the beginning of October that some medicines would not come on the screen and that she told her to check the nurse's MAR and then the CMA's MAR and that LVN D did not report further problems and that she assumed everything was OK. ADON A further said LVN D said that she has always given the medicine [MEDICATION NAME] to Resident #76 from the blister packet, the one we received from our pharmacy and not from the VA bottle. ADON A further said that she never received any list of residents with problems during the night shift from anybody in the facility and that no nurses or CMA's had reported to her any problems with medications not available or not showing on the computer screen. An additional 5 of 7 residents reviewed for [MEDICAL CONDITION] medication did not receive their medication as ordered by the physician in the months of October and November 2015. The facility provided a list of 39 residents who received [MEDICAL CONDITION] medication. Pressure Sores Resident # 18 Record review of the medical record face sheet revealed Resident # 18 was admitted on [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years old. Record review of Resident #18's Plan of Care initiated 9/10/2015 revealed in part: Focus: Pressure ulcer Actual problem related to sensory perception, moisture/incontinence, decreased activity, impaired mobility, friction and shear. Has stage three pressure ulcers to bilateral heels. -Goal: Free of further breakdown through next review. Target date 3/6/2016. -Interventions: Provide incontinence care after each incontinent episode, reposition in chair/bed frequently for comfort and pressure reduction. Turn and reposition frequently to decrease pressure. Braden scare 16 - At risk. Record review of Resident #18's Braden Scale - Predicting Pressure Score Risk revealed on 11/25/2015 his score was an 13 (moderate risk). Record review of Resident # 18's quarterly MDS assessment with 12/04/2015 ARD date revealed his Cognitive Skills for Daily Decision Making was assessed as severely impaired. He required extensive assistance of two staff support with bed mobility, transfers, dressing and extensive assistance of one staff support for locomotion, eating, toilet use and personal hygiene and was total dependent on staff for bathing. He was assessed as having a range of motion impairment on both sides of his upper and lower extremities. He was always incontinent of bowel and bladder. The skin condition section of the assessment revealed he had two stage three pressure ulcers that were present upon admission/entry or reentry. Further record review revealed that he was at risk of developing pressure ulcers, had a pressure reducing device for chair and for bed and was not on a turning/repositioning program. Record review of Resident # 18's SBAR Communication Form and Progress Note dated 12/08/2015 read in part: -Situation: New abrasion area noted on left buttock (1cm x 4cm) small open skin on right buttock (1x1 cm) -Things that make condition or symptom worse are: Limited bed and chair mobility. -Things that make the condition or symptom better are: turning and repositioning, keep clean, dry. -Nursing notes: New skin abrasion/breakdown on left buttock and right buttock. Additional Nursing notes as applicable: New skin abrasion/breakdown on left buttock (4x1 c.m.) and right buttock (1x1c.m.). Wound base is pink with dark spot in center. New order to apply triple antibiotic ointment and dry dressing until wound consult. Record review of Resident #18's physician's orders [REDACTED]. -Wound consult for left and right buttock skin breakdown -Clean left and right buttock wound with NS, pat dry, apply triple antibiotic ointment and cover with dry dressing daily until wound consult. Record review of Resident #18's wound assessment report dated 12/09/2015 revealed in part: Left Ischium: 0.9 x 0.7 x 0.2 c.m. Wound type: Pressure. Stage: 3. In house, new Right buttock: 3.7 x 1.6 x 0.1 c.m. Wound type: Pressure. Stage: 3. In house, new Right heel: 1.7 x 1.6 x 0.4 c.m. Wound type: Pressure. Stage: 3 Left heel: 0.7 x 0.6 x 0.4 c.m. Wound type: Pressure. Stage: 3 An observation on 12/08/2015 at 3:20 pm revealed that Resident # 18's room had strong urine odor to the outside of his room. Further observation revealed as surveyor entered Resident #18's room that the curtain was half way closed and Resident #18 was slouched in his chair with the buttocks at the edge of the chair behind the closed curtain. Resident #18 tried to reached surveyor with his right hand and softly said help me with a soft voice while grimacing his face. Continued observation at that time revealed that Resident #18's pants were wet from his waist down to his buttocks area, his right heel protector had come off form his right foot and there was a strong odor of urine in his room. At that moment surveyor exited the room and brought LVN Q immediately to the room as she was at the nursing station. Further observation and interview at that time while LVN Q entered Resident #18's room, she stated as she pulled Resident #18's shirt up his gastrostomy tube is closed, but he is wet, he usually goes to bed after lunch, let me go out and get somebody. Continued observation at that time as LVN Q exited the room, Resident #18 grimaced his face and tried to move himself up in the chair with his right hand unsuccessfully and tried to reached surveyor with his right hand and softly moaned again help me. Observation on 12/08/2015 at 3:34 p.m. revealed that LVN Q, RN G, CNA UU and CNA U entered the room as Resident #18 was still trying to reach surveyor for help and his face was grimaced. Further observation and interview, LVN Q stated as she got closer to Resident #18 he is uncomfortable, he is going to bed, he is being up since 9:00 a.m. At that time, LVN Q and RN G repositioned Resident #18 back to his chair while Resident #18's face continued to grimaced. Continued observation at that time revealed that as CNA U removed Resident #18's shirt, LVN Q stated is wet, is gross. Further observation while CNA U and CNA UU removed Resident #18's brief, the brief was noted heavily saturated with urine, brownish in color and had several spots of blood on the brief on the buttocks area. Resident #18's wheelchair cushion appeared to be totally indented and wet. Surveyor asked LVN Q if the cushion from Resident #18's wheelchair was wet and she responded Yes, is very wet. Further observation at that time revealed Resident #18's scrotum area was very reddened and as Resident #18 was turned to his side, his buttocks areas appeared very reddened with open areas on each of his buttocks. Continued observation and interview, LVN Q stated as she looked at the buttocks of Resident #18 This is skin breakdown, he didn't have it before. I see some black tissue with redness around, necrotic tissue to his right buttocks. LVN Q further said that she told CNA EE to take care of Resident #18 before the end of the shift and that she thought Resident #18 was OK. Continued observation and interview at that time, RN G said I will assess the wounds now and stated as he measured Resident #18's right buttock's wound is on the lower right buttock, is 1.0 x 1.0 c.m. is thickness loss of the skin, wound base is pink and surrounding site is blackish, necrotic tissue. Left inner buttocks, has a width of 4.0 c.m. and length of 1.5 c.m. with wound base skin peeled off and red and has an area of 1.0 x 1.0 c.m. of darker color in the middle, like brownish, blackish in color. It happened today, is fresh. I worked yesterday and nothing was reported, need to get wound consult, that's a new area. In an interview on 12/08/2015 at 5:00 p.m. with ADON A and LVN K, both stated that Resident #18 did not have wounds to his buttocks before and that open areas to his buttocks were new. In an interview on 12/08/2015 at 5:05 p.m. with CNA U, she stated that she was the afternoon shift aide and that she started her shift at 3 p.m. and that nobody gave her report about Resident #18 and that she did not know how long he was up in his chair or if he needed to go to bed until LVN Q called her. In a phone interview on 12/9/2015 at 1:00 p.m. with CNA EE, she stated that she worked with Resident #18 on 12/08/2015 during the 7 - 3 p.m. shift and that the only skin problems were the pressure sores to his heels. CNA EE further said that the last time she checked on Resident #18 was at 2:40 p.m. because LVN Q told her to changed his clothing and that she changed his shirt only because his brief was dry. CNA EE continued saying that she did incontinent care to Resident #18 at around 10:00 a.m. and that she did not see any open areas to his buttocks and that at that time, she got Resident #18 up in his chair and that Resident #18 remained on his chair until she left at 3:00 p.m. and that he did not get further incontinent care because when she checked him at 2:40 p.m. Resident #18 was dry. When asked how did she checked Resident #18's brief for wetness, she replied I looked at the front of his pants and the brief looked dry. When asked if Resident #18 was on a repositioning program, CNA EE responded Not that I know. When patients are in bed, they get turn every 2 hours but when Resident #18 was on his chair, I was not aware that he needed to be repositioned in his chair. Further interview at that time, surveyor asked her how often do residents get checked for incontinent care and CNA EE responded every 2 hours. When asked why Resident #18 was not checked for incontinent care between 10 a.m. and 2:40 pm., CNA EE responded I had to complete showers, got everybody up, then by that time was lunch time and then I was in the dining room assignment, I did not leave the dining room until around 1:15 p.m. I had 13 residents. I usually do only 2 rounds, but depends because sometimes we have only 4 C.N.A's and we are supposed to have 5 CNA's. When asked if she got report about which residents needed to be turn and repositioned, CNA EE responded No, staff figure it out on their own. Continued interview at that time, CNA EE stated that whenever they see any new skin problem on the residents, they report it to the nurses verbally and further said everything you want to report about the skin has to be done verbally because you can not even put the information on point of click (computer) because there is no way of doing it. When asked if she reported any new skin problem about Resident #18 on 12/08/2015 during the 7 - 3 shift, she responded no because he did not have any new skin problem and the last time I did incontinent care at 10:00 a.m. he did not have signs of skin breakdown. Interviews on 12/10/2015 at 8:55 a.m. with CNA BB and CNA RR, both stated that skin conditions are reported to nurses verbally only, that the facility did not have any skin sheet or showers sheets to report any skin conditions. CNA BB further said The computer system does not ask for skin conditions or skin breakdown. The facility provided a list of 27 residents at risk for pressure ulcers. The facility Administrator was notified on 12/09/15 at 12:32 PM that an IJ situation had been identified due to the above failures. The Plan of Removal was submitted by the Administrator on 12/10/15. The final Plan of Removal was accepted by the survey team on 12/11/15 at 4:35 PM. Plan to Remove Immediate Jeopardy Pharmacy Services The survey team identified that the facility failed to address omissions on the Electronic Medication Administration Record and other Pharmacy Services related concerns. The concerns identified in Pharmacy Services were the result of omissions found on the electronic medication administration record. It was determined that more technical analysis was needed to trouble shoot the problems experienced by the licensed staff who were administering medications. Woodwind Lakes made the decision to use a paper Medication Administration Record effective December 2, 2015. From that point forward a paper MAR has been used to record all medications administered by licensed staff. The first resident(Resident #76) identified as not having received the proper amount of [MEDICATION NAME] medication was retested and the results were reported to the attending physician and action was taken based on his / her instructions. TSH levels were drawn on the following patients who had orders for [MEDICATION NAME] and whose levels were outside the normal range between December 7 and December 9, 2015, results were communicated to the attending physician and action taken based on his/her instructions: The results of the 100% MAR to Cart audit conducted 12/9/2015 resulted in the following discrepancies. West Wing Nudexta not on cart and reordered 12/9/2015; received and on cart [MEDICATION NAME] 12.5 mg reordered 12/9/2015; received and on cart Lactolose 30ml not on cart and reordered 12/9/2015; received an on cart Verapmler 20mg. not on cart and reordered 12/9/2015; received and on cart [MEDICATION NAME] 10 mg not on cart and reordered 12/9/2015; r eceived and on cart [MEDICATION NAME] 30 mg not on cart and reordered 12/9/2015; received and on cart Resperdone 1 mg not on cart and reordered 12/10/2015; received and on cart East Wing [MEDICATION NAME] 12.5 mg not on cart and reordered 12/10/2015; received and on cart [MEDICATION NAME] Flex pen not on cart and reordered 12/9/2015; received and on cart Ipratrop-Albut; Reordered 12/10/2015; received and on cart Biofreeze; routinley stored in med room and moved to the cart Ducolax; Reordered 12/10/2015; received and on cart [MEDICATION NAME]; routinely stored in the med room and moved to the cart [MEDICATION NAME] A/B; routinely stored in the med room and moved to the cart [MEDICATION NAME] HCL 25 mg, [MEDICATION NAME] 2.5 mg, [MEDICATION NAME] 30 mg; routinely stored in the med room and moved to the cart; Losartan not on cart and reordered 12/10/2015, received and on cart; Ipratrop A/B request to discontinue 12/10/2015. [MEDICATION NAME] stored in E-Kit and always available Risperadal, [MEDICATION NAME] routinely stored in med room and moved to the cart [MEDICATION NAME] Flextouch not on cart and reordered 12/10/2015; received and on cart [MEDICATION NAME] not on cart and reordered 12/10/2015; received and on cart [MEDICATION NAME] not on cart and reordered 12/10/2015; reordered/not received. Follow up 12/11 Debros ear wax; routinely stored in med room and moved to the cart. In-service training for Medication Administration & Documentation and Receiving Medications from the Pharmacy began 12/09/2015 and will be completed December 11, 2015. Licensed staff will be in-serviced prior to beginning their shift if they have not already attended the required in-service. The facility will ensure continued compliance with medication administration records by a nurse to nurse review of the MAR from shift to shift to ensure

Based on interview, and record review, the facility failed to implement policies that prohibit neglect of residents, for one Resident (Resident #76) of 25 residents reviewed for neglect, in that: -The facility failed to administer Resident #76 his [MEDICATION NAME] 125 mcg for [MEDICAL CONDITION] for 39 days. -Resident #76 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. This failure affected one resident and could place the additional 38 residents receiving [MEDICATION NAME] for [MEDICAL CONDITION] at risk for adverse side effects, long [MEDICATION NAME] medical complications, unnecessary hospitalization s and death. These findings included: Record review of the facility face sheet revealed Resident #76 was a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with the following [DIAGNOSES REDACTED]. Record review of the quarterly MDS dated [DATE] revealed Resident #76 was moderate cognitive impaired and was able to make self understood and was able to understand others. Record review of Resident #76's physician orders with start date of 08/01/2015 revealed the following order: [MEDICATION NAME] 125 mcg tablet, give one tablet orally one time a day related to unspecified [MEDICAL CONDITION]. Record review of the pharmacy Shipment summary dated 10/09/2015 at 2:43 a.m. revealed a delivery of 15 tablets of [MEDICATION NAME] 125 mcg for Resident #76. Record review of Resident #76's eMAR (Electronic Medication Administration Record) dated 10/01/2015 to 10/31/2015 revealed the following: -[MEDICATION NAME] 125 mcg tablet, give 1 tablet orally one time a day related to unspecified [MEDICAL CONDITION]. Further record review revealed that [MEDICATION NAME] 125 mcg tablet was administered only on October 4, 5, 7, 8, 11, 12 and 15. Continued record review revealed that eMAR did not have a reason why doses were missed. Record review of facility's pharmacy consultation report dated October 1, 2015 through October 14, 2015 revealed in part: .(Resident #76) To: DON. (Resident #76) has missed doses of several medications according to the medication administration record (MAR), but the reason why doses were missed was not documented. -Recommendation: Please ensure that the prescriber has been made aware of these missed doses, and remind nursing staff to record appropriate documentation describing why doses were missed Record review of Resident #76's eMAR (Electronic Medication Administration Record) dated 11/01/2015 to 11/30/2015 revealed the following: -[MEDICATION NAME] 125 mcg tablet, give 1 tablet orally one time a day related to unspecified [MEDICAL CONDITION]. Further record review revealed that [MEDICATION NAME] 125 mcg tablet was not administered from November 1 to November 23rd 2015 and the eMAR did not have a reason why doses were missed. Record review of the Resident #76's Progress notes dated 11/23/2015 at 8:42 p.m. revealed in part (Resident #76's) (family member) was called around 6:00 p.m. and informed that Resident #76 was admitted at the Hospital and will not be back tonight. Record review of Resident #76's hospital's history and physical dated 11/23/2015 at 8:51 p.m. revealed in part .Resident #76 presents from the clinic after being found to be bradycardic (slow heart rate under 60 beats per minute) to 36 and hypotensive (low blood pressure) to 77/56. [MEDICAL CONDITION]: Likely secondary to [MEDICAL CONDITION] (TSH 14.8).(Expected range 0.270 - 4.20 uIU/mL). Restart [MEDICATION NAME]. [MEDICAL CONDITION]: TSH 14.8. Possibly due to not getting appropriate dosage at the nursing home. Further record review of Resident #76's hospital discharge note and final assessment and plan dated 11/25/2015 revealed in part: [AGE] year old male with history of [MEDICAL CONDITION]. Found to have a TSH ([MEDICAL CONDITION]-Stimulating Hormone) level of 14.8 on admission, which was the likely cause of his [MEDICAL CONDITION]. He was started on [MEDICATION NAME] dose (.125 mg daily) with improvement in heart rate (30s - 50s with low of 29 overnight on day of admission and 50s to 70s with low of 39 on day of discharge). Given acute improvement, there is concern that Resident #76 was not getting his appropriate dose of [MEDICATION NAME] in the nursing home. In an interview on 12/7/2015 at 12:29 p.m. with ADON A, she stated that she was responsible for the reconciliation of medications at the end of each month and that she would usually compare the old orders with the new orders and would check the orders against the Medication Administration Record. When asked if she was aware that Resident #76 received his [MEDICATION NAME] 125 mcg only 7 times in the month of October 2015 and did not receive his [MEDICATION NAME] 125 mcg from November 1st to November 23rd when he was admitted to the hospital, she responded yes, we knew from (Resident #76) and his (family member) when he came back from the hospital, everybody knew that his medications were not given. When asked if she had checked the eMAR in October 2015 while doing the reconciliation of orders, she responded I don't remember. In an interview on 12/7/2015 at 2:50 p.m. with the DON, he stated that they had found a problem on the computer system and that it was the reason why they had moved from electronic MAR to paper MAR on 12/2/2015. DON continued saying that it was a configuration system problem that before he was a DON (approx 5 months ago), there were missing room assignments on the computer system and further said it goes by room numbers and the mechanism would be triggered by the room numbers, so if the number of the room was not there, the medication would not come on the screen. Surveyor requested the room numbers that were affected by the configuration system problem. DON continued saying that the facility was made aware on November 25th that Resident #76 did not received his [MEDICATION NAME] medication as ordered and that it was the reason that his TSH levels were high and the heart rate low at 36 because the medication was not given. The requested room numbers were not provided by the time of exit from the facility. Further interview at that time, surveyor asked DON if incident involving Resident #76's [MEDICATION NAME] medication not given as ordered and Resident #76 ending in the hospital was reported to the State office and the DON stated No, because the (family member) said she had already reported it to the State office and also the VA nurse. They told me it was going to be reported. Continued interview with the DON, he stated that the facility started charting on August 1st on the eMAR system and that it was around September 2015 that staff started complaining of orders not appearing on the screen of the eMAR and that the facility provided training on using the eMAR system and entering orders. DON continued saying that he believed that the configuration problem had been resolved until he heard the problem of the medication with Resident #76. DON further said that he spoke with LVN D about Resident #76's medication [MEDICATION NAME] not given and that he questioned her why the medication [MEDICATION NAME] was last ordered on [DATE] where 15 doses were sent only and that LVN D said that the medication would not appear on the screen sometimes. In an interview on 12/8/2015 at 9:15 a.m. with ADON B, he stated that he was also responsible of consolidating physician orders at the end of the month on one side of the building. He said that he would only compare the previous physician orders and with the current physician orders but he would not check the physician orders with the eMAR. He was not aware of any holes (blank spaces) on the electronic MARs. In an interview on 12/08/2015 at 9:25 a.m. with LVN Q, she stated that she would occasionally see problems with the eMAR system in which orders would not appear on the screen and heard that some nurses would write orders in the computer Point Click Care (electronic clinical records) and then the order would not show on the eMAR. She further said that ADON's and DON had been made aware of the problems since the problems were happening back in October and November. In a phone interview on 12/08/2015 at 10:21 a.m. with RN C, he stated that he worked on the afternoon and the night shift and would give the [MEDICAL CONDITION] medications to residents at around 6:00 a.m. whenever he would work on the night shift. He further stated that sometimes the medications would not come on the eMAR computer screen and that he had been reporting problem since a couple of months ago. RN C continued saying that he did remember Resident #76's medication [MEDICATION NAME] was not available at one point and that he was not able to order the medication on the computer and that he reported the information to the incoming nurse to let the ADON know about it. RN C did not remember the date when the medication was not available or who did he speak about it. In an interview on 12/08/2015 at 12:35 p.m. with Resident #76, he said They failed to give me one of my pills. I asked them about it and they told me that they did not have it, then I went to the VA hospital. The facility did not have it on the computer. Resident #76 further said I do not receive medications from the VA hospital, the VA hospital only pays for my medications here at the facility. Further interview on 12/08/2015 at 12:44 p.m. with the DON, he stated that on December 2nd, 2015 the facility went on paper MAR because the facility did not know what was happening on the computer system and further said last 3 months, there were so many residents with holes in the MARs well a couple. DON continued saying the holes in the eMAR means that the medications were not given at that time. We are checking all residents, we are in the process. It was a computer error. When asked who was supposed to checked the eMARs to make sure residents were getting their medications, the DON said we just started having the nurses and CMA's checking the MARs for holes. The ADONs were supposed to check the eMARs before. DON further said that he trained the staff on October 2015 because he looked at few eMARs and noticed some holes and that he thought it was a training issue. DON continued saying that he called the VA pharmacy on December 2, 2015 and that he was told that the facility was supposed to provide medications for the residents and that they would only provide the high value medications. In an interview on 12/08/2015 at 2:20 p.m. with LVN C, she stated that she has reported to ADON A that some medications would not appear on the computer screen. LVN C continued saying that it has been a problems since the facility started using the computer system and that the DON was made aware already and that people from the Corporation were in the facility approx 2 weeks ago and that it was reported to them that some medications would not show up on the computer screen. In a phone interview on 12/08/2015 at 3:10 p.m. with Pharmacist at VA hospital, she stated that the last time they sent [MEDICATION NAME] for Resident #1 was on 2012. She said they had just recently provided 30 tablets on November 25, 2015. In an interview on 12/09/2015 at 8:15 a.m. with LVN D, she stated that she worked the night shift with Resident #76 and that she had been having problems with medications at 6:00 a.m. not showing up on the screen and further said staff would give medications to the residents that would come on the screen, the system would highlight the medications that were due to give at certain time and that was one of the problems. LVN D continued saying that the problem had been since August 2015 and that she was told recently that it was a glitch problem and that that was the reason the facility had moved to paper MARs. LVN D further said that the [MEDICATION NAME] for Resident #76 was not coming up on the system and that she thought that the medication had been discontinued because it would not come up on the system at 6:00 a.m. LVN D said that she talked to ADON A about Resident #76's medication not showing on the screen and that ADON A said OK and that she believed that she was looking into it and further said I told her several times. When the medication was coming up on the screen, Resident #76 was getting his medication but once it didn't come on the system, he did not get it and we did not have it. If a medication was not signed, was not given. No medications were coming up on the screen for Resident #76 at 6:00 a.m. and [MEDICATION NAME] was a medication due to be given at 6:00 a.m. In continued interview with LVN D, she continued saying that she gave a letter to ADON A with the name of 4 other residents that medications were not showing on the screen but she did not remember the names of those residents or when did she give her the list. LVN D further said that she tried to re-order [MEDICATION NAME] but couldn't do it so she reported the information to the LVN C. When asked if she checked the physician orders for Resident #76 to find any changes in orders for [MEDICATION NAME], LVN C responded I only reported the information to the ADON A. In an interview on 12/09/2015 at 9:00 a.m. with RN K, she stated that she only works PRN night shift in the facility and that she did noticed an issued with the [MEDICATION NAME] medication of Resident #76 and further said Resident #76 told me that he was supposed to get his morning pill and I went to look at his MAR on the computer and there was nothing scheduled for him so he did not get the [MEDICATION NAME] medication because nothing was showing up on the computer screen. In an interview on 12/09/2015 at 10:15 a.m. with the DON and the DDO, the DDO stated that the Administrator was on vacation since the day after thanksgiving and that he came to the facility on November the 28th. The DDO further said that during a previous state investigation on 12/2/2015, he was told about the incident with Resident #76's medication, and that facility had an ad hoc meeting on 12/02/2015 and that eMAR was changed to paper MAR. DON continued saying that he noticed there were some omissions on the eMARs and that he thought it was a training issue and that he trained the staff. DON further said that LVN D had told him that she had administered the [MEDICATION NAME] medication to Resident #76 even thought it was not documented. DON continued saying LVN D told me that the medication was here from VA pharmacy in a bottle. DON further said that the MARs are supposed to be checked periodically by the unit managers who are the ADONs and said If we see there is something going on, we need to implement something. When asked how many residents could potentially be affected, the DON responded Do not know, but everybody with an omission could be potential. In an interview on 12/10/2015 at 10:25 a.m. with ADON A, she stated that LVN D told her at around the beginning of October that some medicines would not come on the screen and that she told her to check the nurse's MAR and then the MA's MAR and that LVN D did not report further problems and that she assumed everything was OK. ADON A further said LVN D said that she has always given the medicine [MEDICATION NAME] to Resident #76 from the blister packet, the one we received from our pharmacy and not from the VA bottle. ADON A further said that she never received any list of residents with problems during the night shift from anybody in the facility and that no nurses or MA's had reported to her any problems with medications not available or not showing on the computer screen. Record review of the facility policy and procedure revised June 2013 with title Abuse and neglect prohibition revealed in part: .Each resident has the right to be free from neglect . -Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . Record review of a facility policy revised June 2008 titled, Medication Administration revealed in part: Resident Medications are administered in an accurate, safe, timely and sanitary manner. Documentation: Record the name, dose, route, and time of medication the Medication Administration Record Record review of a facility policy revised September 2011 titled, Physician orders revealed in part: .Physician orders are obtained to provide clear direction regarding the care of the resident . Record review of a facility policy revised January 2012 titled, Receiving Physician orders revealed in part: .The entire process of medication administration must be handled with the utmost degree of care. From the time that we receive an order from a physician until the time the medication is delivered to the patient, accuracy is very important . Refer to F282 and F425 for additional information related to missed medications. The DON identified 39 residents receiving [MEDICATION NAME] in the facility and the facility's CMS Form 672 revealed a census of 126.

Based on record review and interview, the facility failed to implement their written policy that prohibited neglect for 1 of 25 residents (Resident #76) reviewed for neglect, as evidenced by: -The facility failed to administer Resident #76 his [MEDICATION NAME] 125 mcg for [MEDICAL CONDITION] for 39 days. -Resident #76 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. This failure affected one resident and could place the additional 38 residents receiving [MEDICATION NAME] for [MEDICAL CONDITION] at risk for adverse side effects, long [MEDICATION NAME] medical complications, unnecessary hospitalization s and death. Findings included: Record review of the facility policy and procedure revised June 2013 with title Abuse and neglect prohibition revealed in part: .Each resident has the right to be free from neglect . -Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness .- Procedure: Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation of resident property is at risk for occurring . - The facility will investigate all patterns, trends, or incidents that suggest the possible presence of neglect, identified through analysis conducted by the committee, with intervention, reporting, or policy/procedure modifications conducted as appropriate. Record review of the facility face sheet revealed Resident #76 was a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with the following [DIAGNOSES REDACTED]. Record review of the quarterly MDS dated [DATE] revealed Resident #76 had moderate cognitive impairment and was able to make himself understood and was able to understand others. Record review of Resident #76's physician orders with start date of 08/01/2015 revealed the following order: [MEDICATION NAME] 125 mcg tablet, give one tablet orally one time a day related to unspecified [MEDICAL CONDITION]. Record review of the pharmacy Shipment summary dated 10/09/2015 at 2:43 a.m. revealed a delivery of 15 tablets of [MEDICATION NAME] 125 mcg for Resident #76. Record review of Resident #76's eMAR (Electronic Medication Administration Record) dated 10/01/2015 to 10/31/2015 revealed the following: -[MEDICATION NAME] 125 mcg tablet, give 1 tablet orally one time a day related to unspecified [MEDICAL CONDITION]. Further record review revealed that [MEDICATION NAME] 125 mcg tablet was administered only on October 4, 5, 7, 8, 11, 12 and 15. Continued record review revealed that eMAR did not have a reason why doses were missed. Record review of facility's pharmacy consultation report dated October 1, 2015 through October 14, 2015 revealed in part: .(Resident #76) To: DON. (Resident #76) has missed doses of several medications according to the medication administration record (MAR), but the reason why doses were missed was not documented. -Recommendation: Please ensure that the prescriber has been made aware of these missed doses, and remind nursing staff to record appropriate documentation describing why doses were missed Record review of Resident #76's eMAR (Electronic Medication Administration Record) dated 11/01/2015 to 11/30/2015 revealed the following: -[MEDICATION NAME] 125 mcg tablet, give 1 tablet orally one time a day related to unspecified [MEDICAL CONDITION]. Further record review revealed that [MEDICATION NAME] 125 mcg tablet was not administered from November 1 to November 23rd 2015 and the eMAR did not have a reason why doses were missed. Record review of the Resident #76's Progress notes dated 11/23/2015 at 8:42 p.m. revealed in part (Resident #76's) (family member) was called around 6:00 p.m. and informed that (Resident #76) was admitted at the Hospital and will not be back tonight. Record review of Resident #76's hospital's history and physical dated 11/23/2015 at 8:51 p.m. revealed in part .Resident #76 presents from the clinic after being found to be bradycardic (slow heart rate under 60 beats per minute) to 36 and hypotensive (low blood pressure) to 77/56. [MEDICAL CONDITION]: Likely secondary to [MEDICAL CONDITION] (TSH 14.8).(Expected range 0.270 - 4.20 uIU/mL). Restart [MEDICATION NAME]. [MEDICAL CONDITION]: TSH 14.8. Possibly due to not getting appropriate dosage at the nursing home. Further record review of Resident #76's hospital discharge note and final assessment and plan dated 11/25/2015 revealed in part: [AGE] year old male with history of [MEDICAL CONDITION]. Found to have a TSH ([MEDICAL CONDITION]-Stimulating Hormone) level of 14.8 on admission, which was the likely cause of his [MEDICAL CONDITION]. He was started on [MEDICATION NAME] dose (.125 mg daily) with improvement in heart rate (30s - 50s with low of 29 overnight on day of admission and 50s to 70s with low of 39 on day of discharge). Given acute improvement, there is concern that (Resident #76) was not getting his appropriate dose of [MEDICATION NAME] in the nursing home. In an interview on 12/7/2015 at 12:29 p.m. with ADON A, she stated that she was responsible for the reconciliation of medications at the end of each month and that she would usually compare the old orders with the new orders and would check the orders against the Medication Administration Record. When asked if she was aware that Resident #76 received his [MEDICATION NAME] 125 mcg only 7 times in the month of October 2015 and did not receive his [MEDICATION NAME] 125 mcg from November 1st to November 23rd when he was admitted to the hospital, she responded yes, we knew from (Resident #76) and his (family member) when he came back from the hospital, everybody knew that his medications were not given. When asked if she had checked the eMAR in October 2015 while doing the reconciliation of orders, she responded I don't remember. In an interview on 12/7/2015 at 2:50 p.m. with the DON, he stated that they had found a problem on the computer system and that it was the reason why they had moved from electronic MAR to paper MAR on 12/2/2015. DON continued saying that it was a configuration system problem that before he was a DON (approx 5 months ago), there were missing room assignments on the computer system and further said it goes by room numbers and the mechanism would be triggered by the room numbers, so if the number of the room was not there, the medication would not come on the screen. Surveyor requested the room numbers that were affected by the configuration system problem. DON continued saying that the facility was made aware on November 25th that Resident #76 did not received his [MEDICATION NAME] medication as ordered and that it was the reason that his TSH levels were high and the heart rate low at 36 because the medication was not given. The requested room numbers were not provided by the time of exit from the facility. Further interview at that time, surveyor asked DON if incident involving Resident #76's [MEDICATION NAME] medication not given as ordered and Resident #76 ending in the hospital was reported to the State office and the DON stated No, because the (family member) said she had already reported it to the State office and also the VA nurse. They told me it was going to be reported. Continued interview with the DON, he stated that the facility started charting on August 1st on the eMAR system and that it was around September 2015 that staff started complaining of orders not appearing on the screen of the eMAR and that the facility provided training on using the eMAR system and entering orders. DON continued saying that he believed that the configuration problem had been resolved until he heard the problem of the medication with Resident #76. DON further said that he spoke with LVN D about Resident #76's medication [MEDICATION NAME] not given and that he questioned her why the medication [MEDICATION NAME] was last ordered on [DATE] where 15 doses were sent only and that LVN D said that the medication would not appear on the screen sometimes. In an interview on 12/8/2015 at 9:15 a.m. with ADON B, he stated that he was also responsible of consolidating physician orders at the end of the month on one side of the building. He said that he would only compare the previous physician orders and with the current physician orders but he would not check the physician orders with the eMAR. He was not aware of any holes (blank spaces) on the electronic MARs. In an interview on 12/08/2015 at 9:25 a.m. with LVN Q, she stated that she would occasionally see problems with the eMAR system in which orders would not appear on the screen and heard that some nurses would write orders in the computer Point Click Care (electronic clinical records) and then the order would not show on the eMAR. She further said that ADON's and DON had been made aware of the problems since the problems were happening back in October and November. In a phone interview on 12/08/2015 at 10:21 a.m. with RN C, he stated that he worked on the afternoon and the night shift and would give the [MEDICAL CONDITION] medications to residents at around 6:00 a.m. whenever he would work on the night shift. He further stated that sometimes the medications would not come on the eMAR computer screen and that he had been reporting problem since a couple of months ago. RN C continued saying that he did remember Resident #76's medication [MEDICATION NAME] was not available at one point and that he was not able to order the medication on the computer and that he reported the information to the incoming nurse to let the ADON know about it. RN C did not remember the date when the medication was not available or who did he speak about it. In an interview on 12/08/2015 at 12:35 p.m. with Resident #76, he said They failed to give me one of my pills. I asked them about it and they told me that they did not have it, then I went to the VA hospital. The facility did not have it on the computer. Resident #76 further said I do not receive medications from the VA hospital, the VA hospital only pays for my medications here at the facility. Further interview on 12/08/2015 at 12:44 p.m. with the DON, he stated that on December 2nd, 2015 the facility went on paper MAR because the facility did not know what was happening on the computer system and further said last 3 months, there were so many residents with holes in the MARs well a couple. DON continued saying the holes in the eMAR means that the medications were not given at that time. We are checking all residents, we are in the process. It was a computer error. When asked who was supposed to checked the eMARs to make sure residents were getting their medications, the DON said we just started having the nurses and CMA's checking the MARs for holes. The ADONs were supposed to check the eMARs before. DON further said that he trained the staff on October 2015 because he looked at few eMARs and noticed some holes and that he thought it was a training issue. DON continued saying that he called the VA pharmacy on December 2, 2015 and that he was told that the facility was supposed to provide medications for the residents and that they would only provide the high value medications. In an interview on 12/08/2015 at 2:20 p.m. with LVN C, she stated that she has reported to ADON A that some medications would not appear on the computer screen. LVN C continued saying that it has been a problems since the facility started using the computer system and that the DON was made aware already and that people from the Corporation were in the facility approx 2 weeks ago and that it was reported to them that some medications would not show up on the computer screen. In a phone interview on 12/08/2015 at 3:10 p.m. with Pharmacist at VA hospital, she stated that the last time they sent [MEDICATION NAME] for Resident #1 was on 2012. She said they had just recently provided 30 tablets on November 25, 2015. In an interview on 12/09/2015 at 8:15 a.m. with LVN D, she stated that she worked the night shift with Resident #76 and that she had been having problems with medications at 6:00 a.m. not showing up on the screen and further said staff would give medications to the residents that would come on the screen, the system would highlight the medications that were due to give at certain time and that was one of the problems. LVN D continued saying that the problem had been since August 2015 and that she was told recently that it was a glitch problem and that that was the reason the facility had moved to paper MARs. LVN D further said that the [MEDICATION NAME] for Resident #76 was not coming up on the system and that she thought that the medication had been discontinued because it would not come up on the system at 6:00 a.m. LVN D said that she talked to ADON A about Resident #76's medication not showing on the screen and that ADON A said OK and that she believed that she was looking into it and further said I told her several times. When the medication was coming up on the screen, Resident #76 was getting his medication but once it didn't come on the system, he did not get it and we did not have it. If a medication was not signed, was not given. No medications were coming up on the screen for Resident #76 at 6:00 a.m. and [MEDICATION NAME] was a medication due to be given at 6:00 a.m. In continued interview with LVN D, she continued saying that she gave a letter to ADON A with the name of 4 other residents that medications were not showing on the screen but she did not remember the names of those residents or when did she give her the list. LVN D further said that she tried to re-order [MEDICATION NAME] but couldn't do it so she reported the information to the LVN C. When asked if she checked the physician orders for Resident #76 to find any changes in orders for [MEDICATION NAME], LVN C responded I only reported the information to the ADON A. In an interview on 12/09/2015 at 9:00 a.m. with RN K, she stated that she only works PRN night shift in the facility and that she did noticed an issued with the [MEDICATION NAME] medication of Resident #76 and further said Resident #76 told me that he was supposed to get his morning pill and I went to look at his MAR on the computer and there was nothing scheduled for him so he did not get the [MEDICATION NAME] medication because nothing was showing up on the computer screen. In an interview on 12/09/2015 at 10:15 a.m. with the DON and the DDO, the DDO stated that the Administrator was on vacation since the day after thanksgiving and that he came to the facility on November the 28th. The DDO further said that during a previous state investigation on 12/2/2015, he was told about the incident with Resident #76's medication, and that facility had an ad hoc meeting on 12/02/2015 and that eMAR was changed to paper MAR. DON continued saying that he noticed there were some omissions on the eMARs and that he thought it was a training issue and that he trained the staff. DON further said that LVN D had told him that she had administered the [MEDICATION NAME] medication to Resident #76 even though it was not documented. DON continued saying LVN D told me that the medication was here from VA pharmacy in a bottle. DON further said that the MARs are supposed to be checked periodically by the unit managers who are the ADONs and said If we see there is something going on, we need to implement something. When asked how many residents could potentially be affected, the DON responded Do not know, but everybody with an omission could be potential. In an interview on 12/10/2015 at 10:25 a.m. with ADON A, she stated that LVN D told her at around the beginning of October that some medicines would not come on the screen and that she told her to check the nurse's MAR and then the MA's MAR and that LVN D did not report further problems and that she assumed everything was OK. ADON A further said LVN D said that she has always given the medicine [MEDICATION NAME] to Resident #76 from the blister packet, the one we received from our pharmacy and not from the VA bottle. ADON A further said that she never received any list of residents with problems during the night shift from anybody in the facility and that no nurses or MA's had reported to her any problems with medications not available or not showing on the computer screen. The DON identified 39 residents receiving [MEDICATION NAME] in the facility and the facility's CMS Form 672 revealed a census of 126.

Based on observation, interview, and record review, the facility failed to provide services in accordance with the written Plan of Care for 4 of 25 residents (Residents # 67, 76, and 106) reviewed for compliance with physician's orders [REDACTED]. -The facility failed to administer Resident #76 his [MEDICATION NAME] 125 mcg for [MEDICAL CONDITION] for 39 days. -Resident #76 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. - Resident #106 did not receive [MEDICATION NAME] 75mcg on any day during the month of November 2015, and on 23 days of October 2015. -Resident #67 did not receive 5 physician ordered medications (Atorvastatin Calcium 40mg, Calcium Acetate 667mg, [MEDICATION NAME] 20mg, [MEDICATION NAME] 10mg, and Ranolazine ER 500mg) between 11/27/2015 and 12/8/2015. - Resident #67's medications were held on some days in October and November 2015 when she was away at [MEDICAL TREATMENT] without a physician's orders [REDACTED]. This failure affected 3 residents and placed an additional 123 residents at risk for not receiving the care and services ordered by the physician and a decline in health status. Findings Include: Resident #76 Record review of the facility face sheet revealed Resident #76 was a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with the following [DIAGNOSES REDACTED]. Record review of the quarterly MDS dated [DATE] revealed Resident #76 had moderate cognitive impairment and was able to make himself understood and was able to understand others. Record review of Resident #76's physician orders [REDACTED]. [MEDICATION NAME] 125 mcg tablet, give one tablet orally one time a day related to unspecified [MEDICAL CONDITION]. Record review of the pharmacy Shipment summary dated 10/09/2015 at 2:43 a.m. revealed a delivery of 15 tablets of [MEDICATION NAME] 125 mcg for Resident #76. Record review of Resident #76's eMAR (Electronic Medication Administration Record) dated 10/01/2015 to 10/31/2015 revealed the following: -[MEDICATION NAME] 125 mcg tablet, give 1 tablet orally one time a day related to unspecified [MEDICAL CONDITION]. Further record review revealed that [MEDICATION NAME] 125 mcg tablet was only administered on October 4, 5, 7, 8, 11, 12 and 15. Continued record review revealed that eMAR did not have a reason why doses were missed. Record review of facility's pharmacy consultation report dated October 1, 2015 through October 14, 2015 revealed in part: .(Resident #76) To: DON. (Resident #76) has missed doses of several medications according to the medication administration record (MAR), but the reason why doses were missed was not documented. -Recommendation: Please ensure that the prescriber has been made aware of these missed doses, and remind nursing staff to record appropriate documentation describing why doses were missed Record review of Resident #76's eMAR (Electronic Medication Administration Record) dated 11/01/2015 to 11/30/2015 revealed the following: -[MEDICATION NAME] 125 mcg tablet, give 1 tablet orally one time a day related to unspecified [MEDICAL CONDITION]. Further record review revealed that [MEDICATION NAME] 125 mcg tablet was not administered as ordered from November 1 to November 23rd 2015 and the eMAR did not have a reason why doses were missed. Record review of the Resident #76's progress notes from October and November 2015 revealed no indication that the MD was notified of missed medication doses. Further record review of the Resident #76's Progress notes dated 11/23/2015 at 8:42 p.m. revealed in part Resident #76's family member called around 6:00p.m. and informed that Resident #76 was admitted at the Hospital and will not be back tonight. Record review of Resident #76's hospital's history and physical dated 11/23/2015 at 8:51 p.m. revealed in part .Resident #76 presents from the clinic after being found to be bradycardic (slow heart rate under 60 beats per minute) to 36 and hypotensive (low blood pressure) to 77/56. [MEDICAL CONDITION]: Likely secondary to [MEDICAL CONDITION] (TSH 14.8).(Expected range 0.270 - 4.20 uIU/mL). Restart [MEDICATION NAME]. [MEDICAL CONDITION]: TSH 14.8. Possibly due to not getting appropriate dosage at the nursing home. Further record review of Resident #76's hospital discharge note and final assessment and plan dated 11/25/2015 revealed in part: [AGE] year old male with history of [MEDICAL CONDITION]. Found to have a TSH ([MEDICAL CONDITION]-Stimulating Hormone) level of 14.8 on admission, which was the likely cause of his [MEDICAL CONDITION]. He was started on [MEDICATION NAME] dose (.125 mg daily) with improvement in heart rate (30s - 50s with low of 29 overnight on day of admission and 50s to 70s with low of 39 on day of discharge). Given acute improvement, there is concern that Resident #76 was not getting his appropriate dose of [MEDICATION NAME] in the nursing home. In an interview on 12/7/2015 at 12:29 p.m. with ADON A, she stated that she was responsible for the reconciliation of medications at the end of each month and that she would usually compare the old orders with the new orders and would check the orders against the Medication Administration Record. When asked if she was aware that Resident #76 received his [MEDICATION NAME] 125 mcg only 7 times in the month of October 2015 and did not receive his [MEDICATION NAME] 125 mcg from November 1st to November 23rd when he was admitted to the hospital, she responded yes, we knew from Resident #76 and the daughter when he came back from the hospital, everybody knew that his medications were not given. When asked if she had checked the eMAR in October 2015 while doing the reconciliation of orders, she responded I don't remember. In an interview on 12/7/2015 at 2:50 p.m. with the DON, he stated that they had found a problem on the computer system and that it was the reason why they had moved from electronic MAR to paper MAR on 12/2/2015. DON continued saying that it was a configuration system problem that before he was a DON (approx 5 months ago), there were missing room assignments on the computer system and further said it goes by room numbers and the mechanism would be triggered by the room numbers, so if the number of the room was not there, the medication would not come on the screen. Surveyor requested the room numbers that were affected by the configuration system problem. DON continued saying that the facility was made aware on November 25th that Resident #76 did not received his [MEDICATION NAME] medication as ordered and that it was the reason that his TSH levels were high and the heart rate low at 36 because the medication was not given. The requested room numbers were not provided by the time of exit from the facility. Further interview at that time, the DON was asked if incident involving Resident #76's [MEDICATION NAME] medication not given as ordered and Resident #76 ending in the hospital was reported to the State office and the DON stated No, because (a family member) and the VA nurse said they had already reported it to the State office. They told me it was going to be reported. Continued interview with the DON, he stated that the facility started charting on August 1st on the eMAR system and that it was around September 2015 that staff started complaining of orders not appearing on the screen of the eMAR and that the facility provided training on using the eMAR system and entering orders. DON continued saying that he believed that the configuration problem had been resolved until he heard the problem of the medication with Resident #76. DON further said that he spoke with LVN D about Resident #76's medication [MEDICATION NAME] not given and that he questioned her why the medication [MEDICATION NAME] was last ordered on [DATE] where 15 doses were sent only and that LVN D said that the medication would not appear on the screen sometimes. In an interview on 12/8/2015 at 9:15 a.m. with ADON B, he stated that he was also responsible for consolidating physician orders [REDACTED]. He said that he would compare the previous physician orders [REDACTED]. He stated he would not check the physician orders [REDACTED]. In an interview on 12/08/2015 at 9:25 a.m. with LVN Q, she stated that she would occasionally see problems with the eMAR system in which orders would not appear on the screen and heard that some nurses would write orders in Point Click Care, the facility's electronic clinical records application. Then the order would not show on the eMAR. She further said that ADON's and DON had been made aware of the problems since the problems were happening back in October and November. In a phone interview on 12/08/2015 at 10:21 a.m. with RN C, he stated that he worked on the afternoon and the night shift and would give the [MEDICAL CONDITION] medications to residents at around 6:00 a.m. whenever he would work on the night shift. He further stated that sometimes the medications would not come on the eMAR computer screen and that he had been reporting problem since a couple of months ago. RN C continued saying that he did remember Resident #76's medication [MEDICATION NAME] was not available at one point and that he was not able to order the medication on the computer and that he reported the information to the incoming nurse to let the ADON know about it. RN C did not remember the date when the medication was not available or who he spoke to about it. In an interview on 12/08/2015 at 12:35 p.m. with Resident #76, he said They failed to give me one of my pills. I asked them about it and they told me that they did not have it, then I went to the VA hospital. The facility did not have it on the computer. Resident #76 further said I do not receive medications from the VA hospital. The VA hospital only pays for my medications here at the facility. Further interview on 12/08/2015 at 12:44 p.m. with the DON, he stated that on December 2nd, 2015 the facility went on paper MAR because the facility did not know what was happening on the computer system and further said last 3 months, there were so many residents with holes in the MARs well a couple. DON continued saying the holes in the eMAR means that the medications were not given at that time. We are checking all residents, we are in the process. It was a computer error. When asked who was supposed to checked the eMARs to make sure residents were getting their medications, the DON said we just started having the nurses and CMA's checking the MARs for holes. The ADONs were supposed to check the eMARs before. DON further said that he trained the staff on October 2015 because he looked at few eMARs and noticed some holes and that he thought it was a training issue. DON continued saying that he called the VA pharmacy on December 2, 2015 and that he was told that the facility was supposed to provide medications for the residents and that they would only provide the high value medications. In an interview on 12/08/2015 at 2:20 p.m. with LVN C, she stated that she had reported to ADON A that some medications would not appear on the computer screen. LVN C continued saying that it had been a problem since the facility started using the computer system. The DON was made aware and people from the Corporate office were in the facility approximately 2 weeks ago and it was reported to them that some medications would not show up on the computer screen. In a phone interview on 12/08/2015 at 3:10 p.m. with the Pharmacist at the VA hospital, she stated that the last time they sent [MEDICATION NAME] for Resident # 76 was in 2012. She stated that they had just recently provided 30 tablets on November 25, 2015. In an interview on 12/09/2015 at 8:15 a.m. with LVN D, she stated that she worked the night shift with Resident #76 and that she had been having problems with medications at 6:00 a.m. not showing up on the screen and further said staff would give medications to the residents that would come on the screen, the system would highlight the medications they were due to give at certain time and that was one of the problems. LVN D continued saying that the problem had been since August 2015 and that she was told recently that it was a glitch problem and that was the reason the facility had moved to paper MARs. LVN D further said that the [MEDICATION NAME] for Resident #76 was not coming up on the system and that she thought that the medication had been discontinued because it would not come up on the system at 6:00 a.m. LVN D said that she talked to ADON A about Resident #76's medication not showing on the screen and that ADON A said OK and that she believed that she was looking into it and further said I told her several times. When the medication was coming up on the screen, Resident #76 was getting his medication but once it didn't come on the system, he did not get it and we did not have it. If a medication was not signed, it was not given. No medications were coming up on the screen for Resident #76 at 6:00 a.m. and [MEDICATION NAME] was a medication due to be given at 6:00 a.m. In continued interview with LVN D, she said that she gave a letter to ADON A with the name of 4 other residents whose medications were not showing on the screen but she did not remember the names of those residents or when she gave ADON A the list. LVN D further said that she tried to re-order [MEDICATION NAME] but couldn't do it so she reported the information to LVN C. When asked if she checked the physician orders [REDACTED]. In an interview on 12/09/2015 at 9:00 a.m. with RN K, she stated that she only worked PRN night shift in the facility and that she did notice an issue with the [MEDICATION NAME] medication of Resident #76 and further said Resident #76 told me that he was supposed to get his morning pill and I went to look at his MAR on the computer and there was nothing scheduled for him so he did not get the [MEDICATION NAME] medication because nothing was showing up on the computer screen. In an interview on 12/09/2015 at 10:15 a.m. with the DON and the DDO, the DDO stated that the Administrator was on vacation since the day after thanksgiving and that he came to the facility on November the 28th. The DDO further said that he was made aware of Resident #76's medication incident on 12/02/2015 when a surveyor was in the facility on a previous investigation. The facility had an ad hoc meeting on 12/02/2015 and the eMAR was changed to paper MAR. DON continued saying that he noticed there were some omissions on the eMARs and that he thought it was a training issue and that he trained the staff. DON further said that LVN D had told him that she had administered the [MEDICATION NAME] medication to Resident #76 was not documented. DON continued saying LVN D told me that the medication was here from VA pharmacy in a bottle. DON further said that the MARs are supposed to be checked periodically by the unit managers who are the ADONs and said If we see there is something going on, we need to implement something. When asked how many residents could potentially be affected, the DON responded Do not know, but everybody with an omission could be potential. In an interview on 12/10/2015 at 10:25 a.m. with ADON A, she stated that LVN D told her at around the beginning of October that some medicines would not come on the screen and that she told her to check the nurse's MAR and then the MA's MAR and that LVN D did not report further problems and that she assumed everything was OK. ADON A further said LVN D said that she has always given the medicine [MEDICATION NAME] to Resident #76 from the blister packet, the one we received from our pharmacy and not from the VA bottle. ADON A further said that she never received any list of residents with problems during the night shift from anybody in the facility and that no nurses or MA's had reported to her any problems with medications not available or not showing on the computer screen. Resident #106 Record review of Resident #106's medical record revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. She was [AGE] years of age. Record review of Resident #106's Care Plan dated 7/12/2015 revealed that she had [MEDICAL CONDITION]. Interventions included .give [MEDICAL CONDITION] replacement therapy as ordered. Observe/document/report PRN any side effects and effectiveness. Observe/document/report PRN any s/sx of [MEDICAL CONDITION] due to medication . obtain and observe lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Record review of Resident #106's monthly recapitulation physician's orders [REDACTED]. The start date of the medication was 4/28/2015. Record review of Resident #106's MAR dated November 2015 revealed that the medication [MEDICATION NAME] 75mcg was scheduled at 6:00am. The medication was not marked as given on any day in November 2015. Record review of Resident #106's MAR dated October 2015 revealed that the medication [MEDICATION NAME] 75mcg was not marked as given on 10/1/2015, 10/9/2015-10/17/2015, and 10/19/2015-10/31/2015. The MAR did not indicate why the doses were missed. Record review of Resident #106's lab reports revealed the following: - On 10/23/2015, she had a TSH level of 5.16 uIU/mL, more than the expected range of 0.27-4.2 uIU/mL. - On 11/4/2015, she had a TSH level of 2.42 uIU/mL that was within the expected range. - On 12/9/2015, she had a TSH level of 2.43 uIU/mL that was within the expected range. Record review of the pharmacy Proof of Delivery report dated 12/9/2015 revealed that the facility received a delivery of Resident #106's [MEDICATION NAME] 75mcg tablets on 9/24/2015, 10/17/2015, and 11/20/2015. Each delivery contained 30 tablets of medication. An observation/interview of the medication cart on 12/9/2015 at 4:07pm revealed Resident #106 was using a blister pack of [MEDICATION NAME] 75mcg that was filled on 10/16/2015 with a quantity of 30 tablets. There were 4 tablets left in the blister packet. In an interview on 12/9/2015 at 4:07pm, MA E said if Resident #106 was taking the medication daily, .she should have ran (sic) out a month ago. She said the count did not make sense. In an observation of the medication room, there was a full blister pack of Resident #106's [MEDICATION NAME] 75mcg that was filled on 11/19/2015 with a quantity of 30 tablets. In an interview on 12/9/2015 at 4:15pm, ADON A said Resident #106 received her [MEDICATION NAME] medication in November. She said sometimes, when the medication aides pulled a new package of medication, they did not always select the oldest blister pack. She said Resident #106 must have had extra medication in the medication room. In an interview on 12/11/2015 at 9:20am, when asked if Resident #106 received her [MEDICATION NAME] medication in November, the DON said I don't know. In a telephone interview on 12/11/2015 at 2:00pm, the facility's consulting pharmacist said she visited the facility in September and November 2015. She said the pharmacist that filled in for her in October noticed documentation errors in the October MARs for some residents. She said she was not sure if the errors were omissions or documentation errors. She said she did not look at resident's MARs in November because she thought the problem was already addressed. She said she was not sure what the facility implemented to address the issue. Resident #67 Record review of Resident #67's medical record revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. She was [AGE] years of age. Record review of an admission MDS assessment dated [DATE] revealed she had a BIMS score of 11, indicating moderate cognitive impairment. Record review of Resident #67's physician's orders [REDACTED]. - [MEDICATION NAME] 5mg, give one tablet by mouth daily for hypertension - Aspirin 325mg, give one tablet by mouth daily for [MEDICAL CONDITION] - [MEDICATION NAME] 0.25mcg, give one tablet by mouth every day for [MEDICAL CONDITION] - [MEDICATION NAME] Bisulfate 75mg, give one tablet by mouth once daily for antiplatelet - [MEDICATION NAME] 20mg, give one tablet by mouth once daily for ulcer sores - [MEDICATION NAME] Extended Release 30mg, give one tablet once daily for hypertension - [MEDICATION NAME] Solution 10 gm/mL, give 30ml by mouth once daily for constipation - Levetiracetam 500mg, give one tablet by mouth once daily for [MEDICAL CONDITION] - [MEDICATION NAME] 40mg/mL, give 10 mL by mouth once daily for appetite - [MEDICATION NAME] 50mg, give one tablet by mouth twice daily for hypertension - Nepro Liquid, give 237 mL by mouth two times daily for [MEDICAL CONDITION] - Pregabalin 25mg, give one capsule by mouth twice daily for muscle pain - Quetiapine [MEDICATION NAME] 25mg, give one tablet by mouth daily for [MEDICAL CONDITION] - Renal Tablet, give one tablet by mouth once daily for end stage [MEDICAL CONDITION] - [MEDICATION NAME] Suspension 1 gm/10 mL, give 10 mL by mouth every day for stomach ulcer - [MEDICATION NAME] 150mg, give one tablet by mouth twice daily for gastro-[MEDICAL CONDITION] reflux disease Record review of Resident #67's hospital records revealed she was admitted to the hospital on [DATE] after experiencing sharp chest pains and feeling diaphoretic. She was discharged from the hospital on [DATE]. Record review of Resident #67's Progress Note dated 11/18/2015 and written by LVN O revealed that she was transported to the hospital from the [MEDICAL TREATMENT] center. A Progress Note dated 11/21/2015 written by LVN O revealed that she returned from the hospital and the physician was notified. Record review of Resident #67's Discharge- Patient Medication Report from the hospital dated 11/21/2015 revealed she was discharged from the hospital with the following new medication orders: - Aspirin 81mg, give one tablet by mouth daily - Atorvastatin 40mg (a medication for cholesterol), give one tablet by mouth at bedtime - Calcium Acetate 667mg (a medication for high [MEDICATION NAME]) , give one tablet by mouth daily - [MEDICATION NAME] 20mg (a medication for depression), give one tablet by mouth daily - [MEDICATION NAME] 10mg (a medication for hypertension), give one tablet by mouth daily - Ranolazine Extended Release 500mg (a medication for [MEDICAL CONDITION]), give one tablet by mouth every 12 hours. - [MEDICATION NAME] 1GM tablet (a medication for stomach ulcers), give one tablet by mouth daily Record review of Resident #67's MAR dated November 2015 revealed that on 11/21/2015, Aspirin 81mg, Atorvastatin 40mg, [MEDICATION NAME] 0.25mcg, Calcium Acetate 667mg, [MEDICATION NAME] 20mg, [MEDICATION NAME] 20mg, [MEDICATION NAME] 10mg, [MEDICATION NAME] 50mg, [MEDICATION NAME] 1gm tablet, and Ranolazine Extended Release 500mg were added to be administered. All of these medications were discontinued on 11/27/2015. Further review of Resident #67's MA MAR dated November 2015 revealed that she continued to be administered Aspirin 325mg, [MEDICATION NAME] 0.25mcg, [MEDICATION NAME] 20mg, [MEDICATION NAME] 50mg, and [MEDICATION NAME] Suspension 1 gm/10 mL between 11/21/2015 and 11/27/2015. This indicates the medications were documented as being given twice, once on the nurse MAR and once on the MA MAR. Record review of orders created by LVN D dated 11/27/2015 revealed that she discontinued Resident #67's Aspirin 81mg, Atorvastatin 40mg, [MEDICATION NAME] 0.25mcg, Calcium Acetate 667mg, [MEDICATION NAME] 20mg, [MEDICATION NAME] 20mg, [MEDICATION NAME] 10mg, [MEDICATION NAME] 50mg, [MEDICATION NAME] 1gm tablet, and Ranolazine Extended Release 500mg because of double entry. In an interview on 12/8/2015 at 3:30pm, ADON A said the new medications for Resident #67 ordered from the hospital should not have been discontinued. She said LVN D must have noticed there were duplicates on the MAR, and when she discontinued the duplicates, she accidentally discontinued all of the medications with an order date of 11/21/2015. She said she would call the physician to clarify the order. In an interview on 12/9/2015 at 8:00am, LVN D said when she was checking Resident #67's MAR with the physician's orders [REDACTED]. She said she did not notice there were new medications on the MAR. She said she thought all of the medications she discontinued were duplicates because she checked it against the physician's order [REDACTED]. She said that isn't good. In an interview on 12/11/2015 at 9:20am, the DON said when a resident returns from the hospital, the admitting nurse should call the primary care physician and verify their medications. He said they should look at previous medications to ensure they are not adding duplicates. He said he could not comment on Resident #67 because he needed to look at it further. In an interview on 12/11/2015 at 3:00pm, the DON said he did not have a chance to look at Resident #67's MAR or physician's orders [REDACTED]. In an interview on 12/11/2015 at 3:35pm, LVN O said he could not remember if he was the admitting nurse when Resident #67 returned from the hospital. He said when a resident comes back from the hospital, he always calls the primary care physician to verify which orders to continue or discontinue. He said he would create all new orders on the MAR and discontinue all of the medications prior to hospital stay. When asked about Resident #67, he said he did not know why the new medications were discontinued, or why there were duplicates on the MAR. Record review of Resident #67's Care Plan dated 10/2/2015 revealed she requires [MEDICAL TREATMENT] and goes to a [MEDICAL TREATMENT] center on Mondays, Wednesdays and Fridays. Further review of Resident #67 ' s physician's orders [REDACTED]. Further review of Resident #67's MARs dated October and November 2015 revealed the following: - [MEDICATION NAME] 5mg was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, 11/13/2015, and 11/23/2015. - Aspirin 325mg was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, 11/13/2015, and 11/23/2015. - [MEDICATION NAME] 0.25mcg was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, 11/13/2015, and 11/23/2015. - [MEDICATION NAME] Bisulfate 75mg was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, 11/13/2015, and 11/23/2015. - [MEDICATION NAME] Extended Release 30mg was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, 11/13/2015, and 11/23/2015. - [MEDICATION NAME] 10gm/mL was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, and 11/13/2015. - Levetiracetam 500mg was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, 11/13/2015, and 11/23/2015. - [MEDICATION NAME] 40mg/mL was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, 11/13/2015, and 11/23/2015. - Quetiapine [MEDICATION NAME] 25mg was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, 11/13/2015, and 11/23/2015. - Renal Tablet was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, and 11/13/2015. - [MEDICATION NAME] Suspension 1gm/mL was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, 11/13/2015, and 11/23/2015. - [MEDICATION NAME] 50mg was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, 11/13/2015, and 11/23/2015 at the 9:00am scheduled time, and 11/16/2015 at the 4:00pm scheduled time. - Nepro Liquid was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, and 11/13/2015 at the 8:00am scheduled time, and 11/16/2015 at the 4:00pm scheduled time. - Pregabalin 25mg was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/14/2015, and 10/16/2015 at the 8:00am scheduled time, and 11/16/2015 at the 4:00pm scheduled time. - [MEDICATION NAME] 150mg was marked as not given due to away from facility without meds on 10/5/2015, 10/7/2015, 10/9/2015, 10/14/2015, 10/16/2015, 10/21/2015, 10/23/2015, 10/26/2015, 10/28/2015, 11/2/2015, 11/4/2015, 11/6/2015, 11/9/2015, 11/11/2015, 11/13/2015, and 11/23/2015 at the 9:00am scheduled time, and 11/16/2015 at the 4:00pm scheduled time. In an interview on 12/8/2015 at 2:30pm, LVN C said she cared for Resident #67. She said they held Resident #67 ' s blood pressure medications on the days she goes to [MEDICAL TREATMENT] because her blood pressure usually decreases during the procedure. She said they are supposed to get orders from the physician to hold medications on [MEDICAL TREATMENT] days. She said she could not find the order to hold medications for Resident #67. When asked what could happen if missing medications on those days, she said a lot could happen. In an interview on 12/8/2015 at 3:30pm, ADON A said if residents are missing medications on [MEDICAL TREATMENT] days, there should be an order from the physician. In an interview on 12/9/2015 at 8:20am, Resident #67 said she was about to leave for [MEDICAL TREATMENT]. She said on the days she goes to [MEDICAL TREATMENT], she m

Based on observation, interview, and record review the facility failed to provide and ensure 1 of 25 residents (Resident #76) reviewed for receiving physician ordered [MEDICATION NAME] received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. -The facility failed to administer Resident #76 his [MEDICATION NAME] 125 mcg for [MEDICAL CONDITION] for 39 days. -Resident #76 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. This deficient practice affected one resident and could place a facility census of 38 residents receiving [MEDICATION NAME] for [MEDICAL CONDITION] at risk for adverse side effects, long [MEDICATION NAME] medical complications, unnecessary hospitalization s and death. Findings include: Record review of the facility face sheet revealed Resident #76 was a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with the following [DIAGNOSES REDACTED]. Record review of the quarterly MDS dated [DATE] revealed Resident #76 was moderate cognitive impaired and was able to make self understood and was able to understand others. Record review of Resident #76's physician orders [REDACTED]. [MEDICATION NAME] 125 mcg tablet, give one tablet orally one time a day related to unspecified [MEDICAL CONDITION]. Record review of the pharmacy Shipment summary dated 10/09/2015 at 2:43 a.m. revealed a delivery of 15 tablets of [MEDICATION NAME] 125 mcg for Resident #76. Record review of Resident #76's eMAR (Electronic Medication Administration Record) dated 10/01/2015 to 10/31/2015 revealed the following: -[MEDICATION NAME] 125 mcg tablet, give 1 tablet orally one time a day related to unspecified [MEDICAL CONDITION]. Further record review revealed that [MEDICATION NAME] 125 mcg tablet was administered only on October 4, 5, 7, 8, 11, 12 and 15. Continued record review revealed that eMAR did not have a reason why doses were missed. Record review of facility's pharmacy consultation report dated October 1, 2015 through October 14, 2015 revealed in part: .(Resident #76) To: DON. (Resident #76) has missed doses of several medications according to the medication administration record (MAR), but the reason why doses were missed was not documented. -Recommendation: Please ensure that the prescriber has been made aware of these missed doses, and remind nursing staff to record appropriate documentation describing why doses were missed Record review of Resident #76's eMAR (Electronic Medication Administration Record) dated 11/01/2015 to 11/30/2015 revealed the following: -[MEDICATION NAME] 125 mcg tablet, give 1 tablet orally one time a day related to unspecified [MEDICAL CONDITION]. Further record review revealed that [MEDICATION NAME] 125 mcg tablet was not administered from November 1 to November 23rd 2015 and the eMAR did not have a reason why doses were missed. Record review of the Resident #76's Progress notes dated 11/23/2015 at 8:42 p.m. revealed in part Resident #76's family member was called around 6:00p.m. and informed that Resident #76 was admitted at the Hospital and will not be back tonight. Record review of Resident #76's hospital's history and physical dated 11/23/2015 at 8:51 p.m. revealed in part .Resident #76 presents from the clinic after being found to be bradycardic (slow heart rate under 60 beats per minute) to 36 and hypotensive (low blood pressure) to 77/56. [MEDICAL CONDITION]: Likely secondary to [MEDICAL CONDITION] (TSH 14.8).(Expected range 0.270 - 4.20 uIU/mL). Restart [MEDICATION NAME]. [MEDICAL CONDITION]: TSH 14.8. Possibly due to not getting appropriate dosage at the nursing home. Further record review of Resident #76's hospital discharge note and final assessment and plan dated 11/25/2015 revealed in part: [AGE] year old male with history of [MEDICAL CONDITION]. Found to have a TSH ([MEDICAL CONDITION]-Stimulating Hormone) level of 14.8 on admission, which was the likely cause of his [MEDICAL CONDITION]. He was started on [MEDICATION NAME] dose (.125 mg daily) with improvement in heart rate (30s - 50s with low of 29 overnight on day of admission and 50s to 70s with low of 39 on day of discharge). Given acute improvement, there is concern that Resident #76 was not getting his appropriate dose of [MEDICATION NAME] in the nursing home. In an interview on 12/7/2015 at 12:29 p.m. with ADON A, she stated that she was responsible for the reconciliation of medications at the end of each month and that she would usually compare the old orders with the new orders and would check the orders against the Medication Administration Record. When asked if she was aware that Resident #76 received his [MEDICATION NAME] 125 mcg only 7 times in the month of October 2015 and did not receive his [MEDICATION NAME] 125 mcg from November 1st to November 23rd when he was admitted to the hospital, she responded yes, we knew from Resident #76 and his family member when he came back from the hospital, everybody knew that his medications were not given. When asked if she had checked the eMAR in October 2015 while doing the reconciliation of orders, she responded I don't remember. In an interview on 12/7/2015 at 2:50 p.m. with the DON, he stated that they had found a problem on the computer system and that it was the reason why they had moved from electronic MAR to paper MAR on 12/2/2015. DON continued saying that it was a configuration system problem that before he was a DON (approx 5 months ago), there were missing room assignments on the computer system and further said it goes by room numbers and the mechanism would be triggered by the room numbers, so if the number of the room was not there, the medication would not come on the screen. Surveyor requested the room numbers that were affected by the configuration system problem. DON continued saying that the facility was made aware on November 25th that Resident #76 did not received his [MEDICATION NAME] medication as ordered and that it was the reason that his TSH levels were high and the heart rate low at 36 because the medication was not given. The requested room numbers were not provided by the time of exit from the facility. Further interview at that time, surveyor asked DON if incident involving Resident #76's [MEDICATION NAME] medication not given as ordered and Resident #76 ending in the hospital was reported to the State office and the DON stated No, because the (family member) said she had already reported it to the State office and also the VA nurse. They told me it was going to be reported. Continued interview with the DON, he stated that the facility started charting on August 1st on the eMAR system and that it was around September 2015 that staff started complaining of orders not appearing on the screen of the eMAR and that the facility provided training on using the eMAR system and entering orders. DON continued saying that he believed that the configuration problem had been resolved until he heard the problem of the medication with Resident #76. DON further said that he spoke with LVN D about Resident #76's medication [MEDICATION NAME] not given and that he questioned her why the medication [MEDICATION NAME] was last ordered on [DATE] where 15 doses were sent only and that LVN D said that the medication would not appear on the screen sometimes. In an interview on 12/8/2015 at 9:15 a.m. with ADON B, he stated that he was also responsible of consolidating physician orders [REDACTED]. He said that he would only compare the previous physician orders [REDACTED]. In an interview on 12/08/2015 at 9:25 a.m. with LVN Q, she stated that she would occasionally see problems with the eMAR system in which orders would not appear on the screen and heard that some nurses would write orders in the computer Point Click Care (electronic clinical records) and then the order would not show on the eMAR. She further said that ADON's and DON had been made aware of the problems since the problems were happening back in October and November. In a phone interview on 12/08/2015 at 10:21 a.m. with RN C, he stated that he worked on the afternoon and the night shift and would give the [MEDICAL CONDITION] medications to residents at around 6:00 a.m. whenever he would work on the night shift. He further stated that sometimes the medications would not come on the eMAR computer screen and that he had been reporting problem since a couple of months ago. RN C continued saying that he did remember Resident #76's medication [MEDICATION NAME] was not available at one point and that he was not able to order the medication on the computer and that he reported the information to the incoming nurse to let the ADON know about it. RN C did not remember the date when the medication was not available or who did he spoke to about it. In an interview on 12/08/2015 at 12:35 p.m. with Resident #76, he said They failed to give me one of my pills. I asked them about it and they told me that they did not have it, then I went to the VA hospital. The facility did not have it on the computer. Resident #76 further said I do not receive medications from the VA hospital, the VA hospital only pays for my medications here at the facility. Further interview on 12/08/2015 at 12:44 p.m. with the DON, he stated that on December 2nd, 2015 the facility went on paper MAR because the facility did not know what was happening on the computer system and further said last 3 months, there were so many residents with holes in the MARs well a couple. DON continued saying the holes in the eMAR means that the medications were not given at that time. We are checking all residents, we are in the process. It was a computer error. When asked who was supposed to checked the eMARs to make sure residents were getting their medications, the DON said we just started having the nurses and CMA's checking the MARs for holes. The ADONs were supposed to check the eMARs before. DON further said that he trained the staff on October 2015 because he looked at few eMARs and noticed some holes and that he thought it was a training issue. DON continued saying that he called the VA pharmacy on December 2, 2015 and that he was told that the facility was supposed to provide medications for the residents and that they would only provide the high value medications. In an interview on 12/08/2015 at 2:20 p.m. with LVN C, she stated that she has reported to ADON A that some medications would not appear on the computer screen. LVN C continued saying that it has been a problems since the facility started using the computer system and that the DON was made aware already and that people from the Corporation were in the facility approx 2 weeks ago and that it was reported to them that some medications would not show up on the computer screen. In a phone interview on 12/08/2015 at 3:10 p.m. with Pharmacist at VA hospital, she stated that the last time they sent [MEDICATION NAME] for Resident #1 was on 2012. She said they had just recently provided 30 tablets on November 25, 2015. In an interview on 12/09/2015 at 8:15 a.m. with LVN D, she stated that she worked the night shift with Resident #76 and that she had been having problems with medications at 6:00 a.m. not showing up on the screen and further said staff would give medications to the residents that would come on the screen, the system would highlight the medications that were due to give at certain time and that was one of the problems. LVN D continued saying that the problem had been since August 2015 and that she was told recently that it was a glitch problem and that that was the reason the facility had moved to paper MARs. LVN D further said that the [MEDICATION NAME] for Resident #76 was not coming up on the system and that she thought that the medication had been discontinued because it would not come up on the system at 6:00 a.m. LVN D said that she talked to ADON A about Resident #76's medication not showing on the screen and that ADON A said OK and that she believed that she was looking into it and further said I told her several times. When the medication was coming up on the screen, Resident #76 was getting his medication but once it didn't come on the system, he did not get it and we did not have it. If a medication was not signed, was not given. No medications were coming up on the screen for Resident #76 at 6:00 a.m. and [MEDICATION NAME] was a medication due to be given at 6:00 a.m. In continued interview with LVN D, she continued saying that she gave a letter to ADON A with the name of 4 other residents that medications were not showing on the screen but she did not remember the names of those residents or when did she give her the list. LVN D further said that she tried to re-order [MEDICATION NAME] but couldn't do it so she reported the information to the LVN C. When asked if she checked the physician orders [REDACTED]. In an interview on 12/09/2015 at 9:00 a.m. with RN K, she stated that she only works PRN night shift in the facility and that she did noticed an issued with the [MEDICATION NAME] medication of Resident #76 and further said Resident #76 told me that he was supposed to get his morning pill and I went to look at his MAR on the computer and there was nothing scheduled for him so he did not get the [MEDICATION NAME] medication because nothing was showing up on the computer screen. In an interview on 12/09/2015 at 10:15 a.m. with the DON and the DDO, the DDO stated that the Administrator was on vacation since the day after thanksgiving and that he came to the facility on November the 28th. The DDO further said that during a previous state investigation on 12/2/2015, he was told about the incident with Resident #76's medication, and that facility had an ad hoc meeting on 12/02/2015 and that eMAR was changed to paper MAR. DON continued saying that he noticed there were some omissions on the eMARs and that he thought it was a training issue and that he trained the staff. DON further said that LVN D had told him that she had administered the [MEDICATION NAME] medication to Resident #76 even thought it was not documented. DON continued saying LVN D told me that the medication was here from VA pharmacy in a bottle. DON further said that the MARs are supposed to be checked periodically by the unit managers who are the ADONs and said If we see there is something going on, we need to implement something. When asked how many residents could potentially be affected, the DON responded Do not know, but everybody with an omission could be potential. In an interview on 12/10/2015 at 10:25 a.m. with ADON A, she stated that LVN D told her at around the beginning of October that some medicines would not come on the screen and that she told her to check the nurse's MAR and then the MA's MAR and that LVN D did not report further problems and that she assumed everything was OK. ADON A further said LVN D said that she has always given the medicine [MEDICATION NAME] to Resident #76 from the blister packet, the one we received from our pharmacy and not from the VA bottle. ADON A further said that she never received any list of residents with problems during the night shift from anybody in the facility and that no nurses or MA's had reported to her any problems with medications not available or not showing on the computer screen. Record review of a facility policy revised June 2008 titled, Medication Administration revealed in part: Resident Medications are administered in an accurate, safe, timely and sanitary manner. Documentation: Record the name, dose, route, and time of medication the Medication Administration Record Record review of a facility policy revised September 2011 titled, Physician orders [REDACTED].Physician orders [REDACTED]. Record review of a facility policy revised January 2012 titled, Receiving Physician orders [REDACTED].The entire process of medication administration must be handled with the utmost degree of care. From the time that we receive an order from a physician until the time the medication is delivered to the patient, accuracy is very important . The DON identified 39 residents receiving [MEDICATION NAME] in the facility.

Based on observation, interview and record review, the facility failed to provide necessary care and services to 1 of 25 residents (Resident #18) who were unable to carry out activities of daily living reviewed for ADL care, as evidenced by: -The facility staff failed to provide timely incontinent care to Resident #18 and he was found with brief heavily saturated with urine and open areas to left ischium (lower buttocks) and right buttocks that were not identified by the staff. This failure affected 1 resident and could place an additional 91 residents who were occasionally or frequently incontinent of bladder at risk for not receiving care and assistance when needed. Findings included: Record review of the medical record face sheet revealed Resident # 18 was admitted on [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years old. Record review of Resident #18's Plan of Care initiated 9/10/2015 revealed in part: Focus: Resident #18 requires assistance with ADL's related to Dementia. -Goal: Resident #18 will have grooming and [MEDICATION NAME] needs met with staff assistance of extensive assistance of 2 staff. -Intervention: Provide assistance as required for completion of ADL tasks. Further record review -Pressure ulcer Actual problem related to sensory perception, moisture/incontinence, decreased activity, impaired mobility, friction and shear. Has stage three pressure ulcers to bilateral heels. -Goal: Free of further breakdown through next review. Target date 3/6/2016. -Interventions: Provide incontinence care after each incontinent episode, reposition in chair/bed frequently for comfort and pressure reduction. Turn and reposition frequently to decrease pressure. Braden scare 16 - At risk. Record review of Resident #18's Braden Scale - Predicting Pressure Score Risk revealed on 11/25/2015 his score was an 13 (moderate risk). Record review of Resident # 18's quarterly MDS assessment with 12/04/2015 ARD date revealed his Cognitive Skills for Daily Decision Making was assessed as severely impaired. He required extensive assistance of two staff support with bed mobility, transfers, dressing and extensive assistance of one staff support for locomotion, eating, toilet use and personal hygiene and was total dependent on staff for bathing. He was assessed as having a range of motion impairment on both sides of his upper and lower extremities. He was always incontinent of bowel and bladder. The skin condition section of the assessment revealed he had two stage three pressure ulcers that were present upon admission/entry or reentry. Further record review revealed that he was at risk of developing pressure ulcers, had a pressure reducing device for chair and for bed and was not on a turning/repositioning program. Record review of Resident # 18's SBAR Communication Form and Progress Note dated 12/08/2015 read in part: -Situation: New abrasion area noted on left buttock (1cm x 4cm) small open skin on right buttock (1x1 cm) -Things that make condition or symptom worse are: Limited bed and chair mobility. -Things that make the condition or symptom better are: turning and repositioning, keep clean, dry. -Nursing notes: New skin abrasion/breakdown on left buttock and right buttock. Additional Nursing notes as applicable: New skin abrasion/breakdown on left buttock (4x1 c.m.) and right buttock (1x1c.m.). Wound base is pink with dark spot in center. New order to apply triple antibiotic ointment and dry dressing until wound consult. Record review of Resident #18's physician's orders [REDACTED]. -Wound consult for left and right buttock skin breakdown -Clean left and right buttock wound with NS, pat dry, apply triple antibiotic ointment and cover with dry dressing daily until wound consult. An observation on 12/08/2015 at 3:20 pm revealed that Resident # 18's room had strong urine odor to the outside of his room. Further observation revealed as surveyor entered Resident #18's room that the curtain was half way closed and Resident #18 was slouched in his chair with the buttocks at the edge of the chair behind the closed curtain. Resident #18 tried to reached surveyor with his right hand and softly said help me with a soft voice while grimacing his face. Continued observation at that time revealed that Resident #18's pants were wet from his waist down to his buttocks area, his right heel protector had come off form his right foot and there was a strong odor of urine in his room. At that moment surveyor exited the room and brought LVN Q immediately to the room as she was at the nursing station. Record review of Resident #18's wound assessment report dated 12/09/2015 revealed in part: Left Ischium: 0.9 x 0.7 x 0.2 c.m. ( LxWxD) Wound type: Pressure. Stage: Three. In house, new Right buttock: 3.7 x 1.6 x 0.1 c.m. ( LxWxD) Wound type: Pressure. Stage: Three. In house, new Further observation and interview at that time while LVN Q entered Resident #18's room, she stated as she pulled Resident #18's shirt up his gastrostomy tube is closed, but he is wet, he usually goes to bed after lunch, let me go out and get somebody. Continued observation at that time as LVN Q exited the room, Resident #18 grimaced his face and tried to move himself up in the chair with his right hand unsuccessfully and tried to reached surveyor with his right hand and softly moaned again help me. Observation on 12/08/2015 at 3:34 p.m. revealed that LVN Q, RN G, CNA UU and CNA U entered the room as Resident #18 was still trying to reach surveyor for help and his face was grimaced. Further observation and interview, LVN Q stated as she got closer to Resident #18 he is uncomfortable, he is going to bed, he is being up since 9:00 a.m. At that time, LVN Q and RN G repositioned Resident #18 back to his chair while Resident #18's face continued to grimaced. Continued observation at that time revealed that as CNA U removed Resident #18's shirt, LVN Q stated is wet, is gross. Further observation while CNA U and CNA UU removed Resident #18's brief, the brief was noted heavily saturated with urine, brownish in color and had several spots of blood on the brief on the buttocks area. Resident #18's wheelchair cushion appeared to be totally indented and wet. Surveyor asked LVN Q if the cushion from Resident #18's wheelchair was wet and she responded Yes, is very wet. Further observation at that time revealed Resident #18's scrotum area was very reddened and as Resident #18 was turned to his side, his buttocks areas appeared very reddened with open areas on each of his buttocks. Continued observation and interview, LVN Q stated as she looked at the buttocks of Resident #18 This is skin breakdown, he didn't have it before. I see some black tissue with redness around, necrotic tissue to his right buttocks. LVN Q further said that she told CNA EE to take care of Resident #18 before the end of the shift and that she thought Resident #18 was OK. Continued observation and interview at that time, RN G said I will assess the wounds now and stated as he measured Resident #18's right buttock's wound the lower right buttock, is 1.0 x 1.0 c.m. is thickness loss of the skin, wound base is pink and surrounding site is blackish, necrotic tissue. Left inner buttocks, has a width of 4.0 c.m. and length of 1.5 c.m. with wound base skin peeled off and red and has an area of 1.0 x 1.0 c.m. of darker color in the middle, like brownish, blackish in color. It happened today, is fresh. I worked yesterday and nothing was reported, need to get wound consult, that's a new area. In an interview on 12/08/2015 at 5:05 p.m. with CNA U, she stated that she was the afternoon shift aide and that she started her shift at 3 p.m. and that nobody gave her report about Resident #18 and that she did not know how long he was up in his chair or if he needed to go to bed until LVN Q called her. In a phone interview on 12/9/2015 at 1:00 p.m. with CNA EE, she stated that she worked with Resident #18 on 12/08/2015 during the 7 - 3 p.m. shift and that the only skin problems were the pressure sores to his heels. CNA EE further said that the last time she checked on Resident #18 was at 2:40 p.m. because LVN Q told her to changed his clothing and that she changed his shirt only because his brief was dry. CNA EE continued saying that she did incontinent care to Resident #18 at around 10:00 a.m. and that she did not see any open areas to his buttocks and that at that time, she got Resident #18 up in his chair and that Resident #18 remained on his chair until she left at 3:00 p.m. and that he did not get further incontinent care because when she checked him at 2:40 p.m. Resident #18 was dry. When asked how did she checked Resident #18's brief for wetness, she replied I looked at the front of his pants and the brief looked dry. When asked if Resident #18 was on a repositioning program, CNA EE responded Not that I know. When patients are in bed, they get turn every 2 hours but when Resident #18 was on his chair, I was not aware that he needed to be repositioned in his chair. Further interview at that time, surveyor asked her how often do residents get checked for incontinent care and CNA EE responded every 2 hours. When asked why Resident #18 was not checked for incontinent care between 10 a.m. and 2:40 pm., CNA EE responded I had to complete showers, got everybody up, then by that time was lunch time and then I was in the dining room assignment, I did not leave the dining room until around 1:15 p.m. I had 13 residents. I usually do only 2 rounds, but depends because sometimes we have only 4 C.N.A's and we are supposed to have 5 CNA's. When asked if she got report about which residents needed to be turn and repositioned, CNA EE responded No, staff figure it out on their own. Continued interview at that time, CNA EE stated that whenever they see any new skin problem on the residents, they report it to the nurses verbally and further said everything you want to report about the skin has to be done verbally because you can not even put the information on point of click (computer) because there is no way of doing it. When asked if she reported any new skin problem about Resident #18 on 12/08/2015 during the 7 - 3 shift, she responded no because he did not have any new skin problem and the last time I did incontinent care at 10:00 a.m. he did not have signs of skin breakdown. In an interview on 12/11/2015 at 9:30 a.m. with the DON, he stated that Aides were supposed to report to nurses immediately any changes in the skin and that CNA's did not have any papers to document skin condition but that they could in put the information on the computer when doing their ADL's. DON further said that staff were supposed to report skin conditions on the beginning of the problem like stage one pressure sores and not wait until residents have stage three or deep tissue injuries and said If residents are at risk to develop pressure sores, the charge nurses are supposed to communicate with the CNA's the information and residents are supposed to be turned and repositioned every 2 hours even when they are on their chairs . The DON stated that incontinent care is supposed to be done every 2 hours and that nurses on the floor were in charge of monitoring the CNA's to make sure the residents were being checked for incontinent care every 2 hours and said I don't expect that residents are found soaking wet with wound on the skin . The DON stated that charge nurses were in charge of performing the weekly skin assessments of the residents and that they were supposed to include the perineal areas when doing the body assessments. Record review of a facility's undated document with title Incontinent care revealed in part: .Perineal care: If an incontinent resident's perineal area is exposed to urine and stool, this can cause skin irritation and infections. Lack of mobility as well as prolonged exposure to incontinent waste makes the skin much more susceptible to breakdown or the development of pressure ulcers. Based on the facility CMS form 672 there were 92 residents occasionally or frequently incontinent of bladder.

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 11 residents (CR # 1) reviewed for quality of care, as evidenced by: The facility failed to assess CR #1 who had a change in condition and was sent to the hospital by family request. The resident was found at the hospital to have severe dehydration. This failure affected 1 resident and placed the remaining 13 residents dependent on staff for assistance eating in the facility residents at risk of not being provided adequate care and a decline in health status. Findings include: Complaint # 9 CR # 1 Record review of CR # 1's facility medical record revealed she had been admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of CR #1's last Braden Scale assessment dated [DATE] revealed she was at high risk to develop pressure ulcers. Record review of CR #1's quarterly MDS assessment dated [DATE] revealed that she did not have a pressure ulcer and did not have a weight loss. She had a mechanically altered diet. Record review of CR #1's closed facility medical record revealed that there were no treatment administration records, indicating she had not received any treatments. Continued record review of CR #1's facility medical record revealed that a notification to the physician was dated 9/23/2015 documenting increased drowsiness. The physician orders [REDACTED]. Record review of a report sent to the physician written 9/30/2015 at 7:42 PM which reflected that CR #1 had Altered Mental Status, lethargy, [MEDICAL CONDITION](pulse greater than 120 bpm), [DIAGNOSES REDACTED], and was not able to drink or eat. Family at bedside trying to feed resident. Symptoms not occurred before. Diagnoses: [REDACTED]. Difficult to arouse. Full Code. RN Note: AMS, increased hr, low grade temp, [MEDICAL CONDITION]. NP orders to transfer to nearest hospital. Record review of CR #1's weekly skin sheets revealed they were not completed on a weekly basis and did not document a pressure ulcers, but did document that CR #1 had a rash under her breast that was being treated. The last weekly skin check documented on her chart was dated 8/20/2015 which indicated she had an existing rash under left breast. Treatment in progress. There was no Treatment Administration Record on her chart. Record review of the monthly nurses' summary notes for CR #1 had not been completed every month. During an interview on 10/14/2015 at 11:25 AM with the DON he said they had a resident (CR #1) who had been transferred to a hospital by the family who had not been happy with the way the resident was treated in the facility. He said that he knew that the family and the administrative staff of the facility had met several times to try to work out the problems. He said that the family had called State several times on the facility. He said he was told that one time the daughter came in to see the resident (CR #1) and found her in the dining room with staff feeding her. He said, apparently the daughter thought her mother was asleep, because she had her eyes closed and that the staff person feeding her was just pushing food into her mouth. He said the nurse (LVN B) said that the daughter told him that she thought the facility was over-medicating her mother because she was so sedated. He said, apparently the nurse didn't do anything about it. He said he was out of state for training and said he found out about it when he got back. he said that nurse was suspended pending the outcome of the investigation and he never came back. He said, according to other staff there had been a change in condition noticed with (CR #1) and that nurse failed to do a physician report, failed to call the doctor and failed to document anything about it. During an interview on 10/14/2015 at 1:20 PM with CNA A, she said when she went to the dining room she saw one of the nurses feeding (CR#1). She said the other aide had to leave to help out on the hall. She said she went over to CR #1. She was not her usual self. Then her sister walked in. She said she was familiar with the resident. She used to look all around but couldn't really communicate. Her sister wanted to know why we were feeding her with her eyes closed. She said she asked the charge nurse about (CR #1)'s change and he didn't say anything about it. So she said she asked some of the aides in the dining room why she was so lethargic. She said they didn't know. On 10/14/2015 at 3:00 PM an attempt to contact and interview LVN B by phone resulted in a recorded message that the phone number was no longer in service. Record review of CR #1's hospital records from her admission to the emergency roiagnom on the night of 9/30/2015 through her discharge to another facility on 10/05/2015 revealed that CR #1 arrived at the hospital with a pressure ulcer stage 2, AMS, urinary tract infection, dehydration, [MEDICAL CONDITION], metabolic [MEDICAL CONDITION], kidney failure, high sodium and bacteremia. Further record review of the hospital records revealed the following: Inpatient [DIAGNOSES REDACTED]. Record review of a hospital history and physical dated 10/01/2015 read in part Chief Complaint: Acute change in mentation and urinary tract infection .History of Present Illness: . Apparently over the last several days, she has not been eating and has not been talking, she has been less responsive so the family members have brought her to the emergency room where she was found to have a severe urinary tract infection and have [MEDICAL CONDITION] secondary to dehydration. It appears as if they had not been giving her oral water nor she had any recent food because she was very somnolent. Initially the family had to stop her [MEDICATION NAME] and any medications they felt that was causing her to be lethargic, but that was of no consequence. In the emergency room she was found to have sodium of 160 (normal level between 135-145), potassium of 4.4, chloride of 122 (normal level between 96-106), BUN of 26 (normal level between 7-20), and creatinine of 1.4 (normal level between 0.5-1.1). She had an elevated white count of 12,200. She did have a urinary tract infection with too numerous to count white blood cells and bacteria. Therefore, she is being admitted to the hospital to treat her [MEDICAL CONDITION], her urinary tract infection and her dehydration Past Medical History: .She also has had a history of [REDACTED]. I am concerned that her dehydration was secondary to her not receiving enough oral water as well as food in the nursing home. I will replenish her fluids and hopefully her natremia should resolve. Her urinary tract infection will be treated with antibiotics .Impression: Her altered mental status is probably secondary to her dehydration and urinary tract infection . Record review of a hospital consultation progress note dated 10/02/2015 read in part .Patient has noted to be having altered mental status, low-grade fever, low-grade leukocytosis noted. Electrolyte imbalance noted. Patient has been swallowing OK, but appears to be dehydrated with elevated creatinine. Urinalysis was abnormal with [MEDICATION NAME] started.Physical Examination: Dry mucous membranes Patient does appear to have a sacral decubitus wound foley catheter noted .Laboratory Data: Staphylococcus bacteremia .Assessment: 1) Patient [MEDICAL CONDITION], altered mental status, and urosepsis remained likely with [MEDICAL CONDITION]ly [DIAGNOSES REDACTED]. 2) Altered mental status could have been secondary to electrolyte imbalance causing the toxic metabolic [MEDICAL CONDITION] versus other [MEDICAL CONDITION] related possibility remained 3) [MEDICAL CONDITION], likely secondary to dehydration 8) Coagulase-negative Staphylococcus bacteremia likely to be contaminated . Plan: 3)Continue IV hydration .4) Local wound care to continue for sacral decubitus, avoid pressure. A hospital Final Report related to discharge date d 10/02/2015 read in part Contacted patient's sister to discuss transition planning, she is requesting .she states she does not want her sister to go back to the (nursing facility), referral sent. According to the CMS Form 672 there were 126 residents in the facility.

Based on observation, interview and record review, the facility failed to consult with the physician when there was a need to alter the medical treatment of [REDACTED].#1) reviewed for physician consultations occuring when an alteration in the resident's medical care was required . Resident #1 did not receive the antibiotic treatment ordered by her physician. The antibiotic ordered by the physician was contradictive with other medications of the resident so the antibiotic was not filled by the pharmacy. The physician was not consulted with so the resident went without any antibiotic treatment for [REDACTED].#1 required surgery to drain the infected surgical wound and an extended course of antibiotics IV (intravenously) due to infection in the wound. This failure affected one resident who required an additional hospitalization stay and surgery for [REDACTED]. Findings include: Intake # 3 Resident #1 Record review of Resident #1's face sheet revealed she was admitted to the facility on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Observation and interview on 12/10/2014 at 11:00 A.M. revealed Resident #1 in her room. Resident #1 had a site on her arm for IV medication administration. Resident #1 stated when she first fell on [DATE] she knew she had hurt herself. She stated she consistently told the nursing staff that her arm was hurting but the nurse ' s thought she just wanted more pain medication. Resident #1 stated even though the x-rays did not show anything was broken she knew something was wrong with her arm because of the pain. She said after the Orthopedic doctor found the break the surgery was scheduled. Resident #1 stated the nursing staff told her when the antibiotic order was changed and why they could not give her the new antibiotic. She stated the nurses kept trying to contact the doctor for days but could not get a hold of him so she did not get any antibiotics for several days. Resident #1 said she was very angry she had to go without even the discontinued antibiotics and the wound just kept getting worse. Interview on 12/10/14 at 11:46 A.M. RN #1 stated she had taken care of Resident #1 on several occasions prior to her surgery. She stated the resident asked for pain and nausea medication frequently. She said the resident was uncooperative and just wanted her pain medication when she asked for it. She further stated the resident was often sleepy and unsteady but would still ask for her pain medication. She said the resident always complained of pain to her shoulder, not her arm. Record review of Resident #1 ' s MDS dated [DATE] revealed a BIMS score of 15 which indicated the resident was cognitively intact for daily decision making skills. Record review of Resident #1 ' s medical record revealed the resident fell on [DATE] while away from the facility. Record review of Resident #1 ' s medical record revealed an order from the PCP (primary care physician) dated 10/22/14 for an Orthopedic physician to exam Resident #1. Continued review of the medical record revealed no indication as to why the appointment was ordered. Record review of Resident #1 ' s nurse ' s notes dated 11/5/14 revealed documentation the resident returned to the facility from a medical appointment and told the nurse she had a broken arm. Record review of Resident #1 ' s medical record revealed in the back of the chart were pre-op orders from the hospital for a surgery scheduled for 11/7/14. Continued review of Resident #1' s chart revealed an x-ray of the resident ' s elbow dated 11/5/14 at 1:34 P.M. with an area of the elbow circled. There were no written results on the x-ray results. Record review of the Nurse ' s Notes dated 11/7/14 at 3:00 P.M. revealed documentation that Resident #1 had returned from surgery with physician's orders [REDACTED]. (11/14/14 or 11/17/14). Record review of Resident #1 ' s medical record revealed a prescription dated 11/21/14 from the orthopedic surgeon for two antibiotics ([MEDICATION NAME] and [MEDICATION NAME]) each ordered for 10 days. Record review of Resident #1 ' s medical record revealed she had an appointment with the orthopedic surgeon on 11/25/14. She returned with a prescription for a new antibiotic ([MEDICATION NAME]) to be given twice a day for 2 weeks. Review of Resident #1 ' s physician's order [REDACTED]. Review of the Nurse ' s Notes revealed documentation the nurse faxed the order for the [MEDICATION NAME] to the pharmacy on 11/26/14. The nurse further documented the antibiotic was not available in the emergency box and the medication would be started when the medication arrived from pharmacy. Continued review of Resident #1 ' s Nurse ' s Notes revealed no further documented communication with the physician or pharmacy until 11/28/14 by LVN #1. LVN #1 called and talked to the pharmacy regarding the [MEDICATION NAME]. While LVN #1 was checking to make sure the order had been faxed the charge nurse called the pharmacy and spoke with the pharmacist who said the medication would be delivered. This communication was documented at 11:00 A.M. Record review of Resident #1's nurse's note documentation on 11/28/14 at 3:30 P.M. revealed the nurse called the pharmacy because the medication had not been received at the facility and was told the [MEDICATION NAME] would have interactions with three of the medications Resident #1 was taking and the physician should be called to clarify the order and medications. Review of Resident #1 ' s nurse ' s notes on 11/28/14 revealed there were several calls placed to the nurse practitioner with no response. The nurse documented at 5:30 P.M. Resident #1 ' s family member called the nurse to let her know the resident had called her and was complaining of her left arm swelling and the resident ' s family member wanted to know what was going on with the antibiotics. Review of Resident #1 ' s Nurse ' s notes revealed on 11/28/14 the nurse practitioner was called again later at 8:00 P.M. with no return call back to the facility. The nurse documented at 8:00 P.M. she called the ADON and was told to call the medical director. The nurse wrote she called the medical director and left a voice mail because there was no answer at 9:00 P.M. She further documented she notified the DON of her inability to reach the medical director at 9:00 P.M. The nurse documented she then assessed Resident #1 ' s left arm surgical site and there was a mild amount of serous fluid and the left arm looked swollen. Record review of Resident #1 ' s Nurse ' s note at 10:00 P.M. on 11/28/2014 revealed Resident #1 was concerned the new antibiotic was not started and requested the antibiotics previously ordered. It was documented the resident was told the previous antibiotics had been discontinued and could not be given. The nurse then documented at 10:25 P.M. the resident complained of pain and muscle spasms. The nurse practitioner was called again at 10:50 P.M. before the nurse ended her shift and it was documented there was no response from the nurse practitioner. Record review of Resident #1 ' s Nurse ' s Notes dated 11/29/14 at 10:00 P.M. Resident #1 again asked for her antibiotic and was told it was not available. The nurse attempted to call the resident's PCP three times with no return call and a voice mail was left. Record review of Resident #1 ' s Nurse ' s Note dated 11/30/14 at 8:00 A.M. revealed Resident #1 complained of drainage to her left elbow and redness was noted to the wound edges. A small amount of drainage was noted on the dressing. Resident was medicated for pain. The same note revealed at 10:20 A.M. Resident #1 again inquired about her new antibiotic and the nurse was still awaiting a call back from her PCP with new orders. Record review of Resident #1 ' s Nurse ' s Note dated 11/30/14 at 10:30 A.M. revealed the nurse called the PCP again twice and then called the NP twice with no answer. A voicemail was left and the nurse was awaiting a call back. Record review of Resident #1 ' s Nurse ' s Note dated 11/30/14 at 2:45 P.M. revealed the medical director was called with no response. The NP was contacted who told the nurse the Medical Director would have to be notified directly. At 3:40 P.M. the note revealed there was still no reply from the physician and Resident #1 was sent to the hospital per family and resident request. Resident returned to the facility later the same day. Record review of Resident #1 ' s hospital discharge instructions dated 11/30/14 revealed the following Diagnosis: [REDACTED]. Prescription given for Bactrim DS 160-800 mg every 12 hours for seven days. Interview on 12/10/14 at 1:45 P.M. LVN #1 LVN #1 said the nurses who had taken care of Resident #1 the most during the month of November no longer worked at the facility. She said she called the resident's physician on 11/28/14 but she did not realize there had been no calls made to him since 11/26/14. She further stated there was no facility procedure for getting information from the doctor ' s offices when a resident had an appointment. Review of the physician's order [REDACTED].#1 was transferred to the hospital for I&D (incision and drainage) surgery. Record review of Resident #1 ' s consultation report from the hospital dated 12/4/14 revealed in part the following: History of present illness:.. s/p fall with a left radial neck fracture. Had a chronic nonunion. Underwent a left radial head arthroplasty on the 7th of last month. Postoperatively, she had issues with nonhealing and was taken back to the OR and underwent an I&D. " Assessment and plan: " ...Nonunion surgical wound, concerned about possible hardware infection, status [REDACTED]. " Record review of Resident #1 ' s operative report dated 12/4/14 revealed a pre and post-operative [DIAGNOSES REDACTED]. Record review Resident #1 readmission orders [REDACTED]. The resident had an order to follow-up with the surgeon on 12/16/14. Interview on 12/10/14 at 4:00 P.M. the DON stated the staff had a lot of problems with contacting any physician regarding Resident #1. She stated she was not made aware of the situation until 11/29/14, the nurse ' s documented they contacted the DON on 11/28/14. When a policy was requested the DON said there was no plan or policy to address physicians not responding to phone calls. She also said staff should have called her or the administrator sooner to intervene. The facility reported a census of 125.

Based on observation, record review and interview the facility failed to provide the necessary cordination of services and care to attain or maintain the highest practicable physical, mental and psychosocial well-being for one of eight residents (Resident #1) reviewed for receiving the necessary medical care and services to maintain their highest medical well-being. The facility staff failed to provide alternate medical interventions when Resident #1's physician ordered antibiotics could not be given to the resident and the physician could not be reached. After missing five days of antibiotic treatments, Resident #1 required another surgery and will require several weeks of antibiotics IV (intravenously) due to surgical wound complications. This failure affected one resident who required an additional hospitalization stay and surgery for [REDACTED]. Findings include: Intake # 3 Resident #1 Record review of Resident #1's face sheet revealed she was admitted to the facility on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Observation and interview on 12/10/2014 at 11:00 A.M. revealed Resident #1 in her room. Resident #1 had a site on her arm for IV medication administration. Resident #1 stated when she first fell on [DATE] she knew she had hurt herself. She stated she consistently told the nursing staff that her arm was hurting but the nurse ' s thought she just wanted more pain medication. Resident #1 stated even though the x-rays did not show anything was broken she knew something was wrong with her arm because of the pain. She said after the Orthopedic doctor found the break the surgery was scheduled. Resident #1 stated the nursing staff told her when the antibiotic order was changed and why they could not give her the new antibiotic. She stated the nurses kept trying to contact the doctor for days but could not get a hold of him so she did not get any antibiotics for several days. Resident #1 said she was very angry she had to go without even the discontinued antibiotics and the wound just kept getting worse. Interview on 12/10/14 at 11:46 A.M. RN #1 stated she had taken care of Resident #1 on several occasions prior to her surgery. She stated the resident asked for pain and nausea medication frequently. She said the resident was uncooperative and just wanted her pain medication when she asked for it. She further stated the resident was often sleepy and unsteady but would still ask for her pain medication. She said the resident always complained of pain to her shoulder, not her arm. Record review of Resident #1 ' s MDS dated [DATE] revealed a BIMS score of 15 which indicated the resident was cognitively intact for daily decision making skills. Record review of Resident #1 ' s medical record revealed the resident fell on [DATE] while away from the facility. Record review of Resident #1 ' s medical record revealed an order from the PCP (primary care physician) dated 10/22/14 for an Orthopedic physician to exam Resident #1. Continued review of the medical record revealed no indication as to why the appointment was ordered. Record review of Resident #1 ' s nurse ' s notes dated 11/5/14 revealed documentation the resident returned to the facility from a medical appointment and told the nurse she had a broken arm. Record review of Resident #1 ' s medical record revealed in the back of the chart were pre-op orders from the hospital for a surgery scheduled for 11/7/14. Continued review of Resident #1' s chart revealed an x-ray of the resident ' s elbow dated 11/5/14 at 1:34 P.M. with an area of the elbow circled. There were no written results on the x-ray results. Record review of the Nurse ' s Notes dated 11/7/14 at 3:00 P.M. revealed documentation that Resident #1 had returned from surgery with physician's orders [REDACTED]. (11/14/14 or 11/17/14). Record review of Resident #1 ' s medical record revealed a prescription dated 11/21/14 from the orthopedic surgeon for two antibiotics ([MEDICATION NAME] and [MEDICATION NAME]) each ordered for 10 days. Record review of Resident #1 ' s medical record revealed she had an appointment with the orthopedic surgeon on 11/25/14. She returned with a prescription for a new antibiotic ([MEDICATION NAME]) to be given twice a day for 2 weeks. Review of Resident #1 ' s physician's order [REDACTED]. Review of the Nurse ' s Notes revealed documentation the nurse faxed the order for the [MEDICATION NAME] to the pharmacy on 11/26/14. The nurse further documented the antibiotic was not available in the emergency box and the medication would be started when the medication arrived from pharmacy. Continued review of Resident #1 ' s Nurse ' s Notes revealed no further documented communication with the physician or pharmacy until 11/28/14 by LVN #1. LVN #1 called and talked to the pharmacy regarding the [MEDICATION NAME]. While LVN #1 was checking to make sure the order had been faxed the charge nurse called the pharmacy and spoke with the pharmacist who said the medication would be delivered. This communication was documented at 11:00 A.M. Record review of Resident #1's nurse's note documentation on 11/28/14 at 3:30 P.M. revealed the nurse called the pharmacy because the medication had not been received at the facility and was told the [MEDICATION NAME] would have interactions with three of the medications Resident #1 was taking and the physician should be called to clarify the order and medications. Review of Resident #1 ' s nurse ' s notes on 11/28/14 revealed there were several calls placed to the nurse practitioner with no response. The nurse documented at 5:30 P.M. Resident #1 ' s family member called the nurse to let her know the resident had called her and was complaining of her left arm swelling and the resident ' s family member wanted to know what was going on with the antibiotics. Review of Resident #1 ' s Nurse ' s notes revealed on 11/28/14 the nurse practitioner was called again later at 8:00 P.M. with no return call back to the facility. The nurse documented at 8:00 P.M. she called the ADON and was told to call the medical director. The nurse wrote she called the medical director and left a voice mail because there was no answer at 9:00 P.M. She further documented she notified the DON of her inability to reach the medical director at 9:00 P.M. The nurse documented she then assessed Resident #1 ' s left arm surgical site and there was a mild amount of serous fluid and the left arm looked swollen. Record review of Resident #1 ' s Nurse ' s note at 10:00 P.M. on 11/28/2014 revealed Resident #1 was concerned the new antibiotic was not started and requested the antibiotics previously ordered. It was documented the resident was told the previous antibiotics had been discontinued and could not be given. The nurse then documented at 10:25 P.M. the resident complained of pain and muscle spasms. The nurse practitioner was called again at 10:50 P.M. before the nurse ended her shift and it was documented there was no response from the nurse practitioner. Record review of Resident #1 ' s Nurse ' s Notes dated 11/29/14 at 10:00 P.M. Resident #1 again asked for her antibiotic and was told it was not available. The nurse attempted to call the resident's PCP three times with no return call and a voice mail was left. Record review of Resident #1 ' s Nurse ' s Note dated 11/30/14 at 8:00 A.M. revealed Resident #1 complained of drainage to her left elbow and redness was noted to the wound edges. A small amount of drainage was noted on the dressing. Resident was medicated for pain. The same note revealed at 10:20 A.M. Resident #1 again inquired about her new antibiotic and the nurse was still awaiting a call back from her PCP with new orders. Record review of Resident #1 ' s Nurse ' s Note dated 11/30/14 at 10:30 A.M. revealed the nurse called the PCP again twice and then called the NP twice with no answer. A voicemail was left and the nurse was awaiting a call back. Record review of Resident #1 ' s Nurse ' s Note dated 11/30/14 at 2:45 P.M. revealed the medical director was called with no response. The NP was contacted who told the nurse the Medical Director would have to be notified directly. At 3:40 P.M. the note revealed there was still no reply from the physician and Resident #1 was sent to the hospital per family and resident request. Resident returned to the facility later the same day. Record review of Resident #1 ' s hospital discharge instructions dated 11/30/14 revealed the following Diagnosis: [REDACTED]. Prescription given for Bactrim DS 160-800 mg every 12 hours for seven days. Interview on 12/10/14 at 1:45 P.M. LVN #1 LVN #1 said the nurses who had taken care of Resident #1 the most during the month of November no longer worked at the facility. She said she called the resident's physician on 11/28/14 but she did not realize there had been no calls made to him since 11/26/14. She further stated there was no facility procedure for getting information from the doctor ' s offices when a resident had an appointment. Review of the physician's order [REDACTED].#1 was transferred to the hospital for I&D (incision and drainage) surgery. Record review of Resident #1 ' s consultation report from the hospital dated 12/4/14 revealed in part the following: History of present illness:.. s/p fall with a left radial neck fracture. Had a chronic nonunion. Underwent a left radial head arthroplasty on the 7th of last month. Postoperatively, she had issues with nonhealing and was taken back to the OR and underwent an I&D. " Assessment and plan: " ...Nonunion surgical wound, concerned about possible hardware infection, status [REDACTED]. " Record review of Resident #1 ' s operative report dated 12/4/14 revealed a pre and post-operative [DIAGNOSES REDACTED]. Record review Resident #1 readmission orders [REDACTED]. The resident had an order to follow-up with the surgeon on 12/16/14. Interview on 12/10/14 at 4:00 P.M. the DON stated the staff had a lot of problems with contacting any physician regarding Resident #1. She stated she was not made aware of the situation until 11/29/14, the nurse ' s documented they contacted the DON on 11/28/14. When a policy was requested the DON said there was no plan or policy to address physicians not responding to phone calls. She also said staff should have called her or the administrator sooner to intervene. The facility reported a census of 125.

Based on observation, interview, and record review, the facility failed to identify and treat two facility acquired pressure sores for 1 of 6 sampled residents (Resident # 84) with pressure sores. Resident # 84 had two Stage II pressure sores on her bilateral heels that were facility acquired. This failure caused one resident to develop pressure sores and placed 11 residents at risk for pain, pressure ulcers, and a decline in ROM. Findings include: Resident # 84 Review of Resident # 84 ' s face sheet revealed she was [AGE] years old and was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Quarterly MDS dated [DATE] revealed Skin Conditions revealed Resident # 84 was not at risk for developing pressure ulcers and did not have any unhealed pressure ulcers. Further review revealed she required extensive assistance and 2 person assistance with bed mobility, transfers, dressing, and eating. She required total assistance with locomotion, toilet use and personal hygiene. Further review revealed she had lower extremity impairment on both sides. Review of Comprehensive Care Plan dated 3/11/11 revealed Resident #84 had the potential for pressure ulcers. Further review revealed Care plan dated 4/14/11 identified Resident #84 having stage II wounds on her heels and identified heel protectors as an approach. Review of Nursing Admission assessment dated [DATE] revealed Resident #84: 1. Braden Scale of 13 which indicated her to be at Moderate Risk. 2. She was bedfast and had very limited mobility. 3. Great Toe opened area was identified on right foot. Left foot had healed area. 4. Provide wound care/preventative skin care per order. 5. Observe wound healing weekly Review of Braden Scale dated 4/14/11 and 4/21/11 revealed a score of 11 which identified Resident # 84 as high risk for pressure sores. Review of Non-Pressure Skin Condition Record dated 4/6/11 revealed under the site location read " Right great toe open area " . Under the progress notes section revealed " upon admission noted left great toe open area " . Review of Change of Condition dated 4/14/11 revealed Resident #84 was noted with open wound (blister) Stage 2 on right and left heel. Review of Weekly Pressure Ulcer Record dated 4/14/11 revealed: Right Foot: Stage II; was 8x9 cm and .1 depth. Specialty interventions identified heel protectors. Left foot: Stage II, was 3x5 cm and .1 depth. Specialty interventions identified heel protectors. Review of Physician order [REDACTED]. Review of Medication Chart Record dated 4/6/11 to 4/29/11 revealed weekly skin assessments were conducted on 4/8/11, no pressure sores identified and 4/15/11, 4/22/11 and 4/29/11, pressure sores on heels idendified. Review of Daily Monitoring Pressure Ulcer Record dated 4/14/11 through 4/27/11 revealed the left and right heels were being monitored. Observation on 4/26/11 at 10:45 A.M. revealed Resident # 84 was alert, awake, and in bed. She was groomed and had just received a shower. Her feeding tube was not connected to any feeding at this time. She had two Stage II wounds to her bilateral heels, heel protectors were in place. She was not able to answer any questions. Interview at this same time, RN #2, stated Resident # 84 required total assistance from staff with transfers and her activities of daily living (ADL). Interview on 4/27/11 at 10:00 A.M. the Treatment Nurse stated a resident with a Braden Scale score that identified them at risk for pressure sores would have preventative measures of heel protectors, a nutritional assessment, an air-flow mattress, a repositioning schedule, and weekly monitors. Interview on 4/28/11 at 10:30 A.M. the Treatment Nurse stated Resident #84 had two stage II pressure ulcers, one on each heel, that were water filled blisters. She stated that the pressure ulcers were facility acquired. She further stated the right heel was opened, red, and draining. She stated she became aware of the skin issues on both heels on 4/14/11. She stated at the time of the assessment on 4/14/11, the heel protectors were placed on her feet and the resident was placed on a repositioning schedule. Interview on 4/29/11 at 2:30 P.M. the DON stated Resident # 84 should have had preventative measures in place when she returned from the hospital on [DATE]. She stated that since Resident #84 came into the facility with a wound to her great toe, the wounds to her heels could have been identified sooner than 4/14/11. Record review of Skin Management Program dated 2010 revealed that appropriate measures such as protective skin surfaces on beds, wheelchairs, etc would be implemented on all residents identified at risk and these interventions would be documented on the Care Plan. CMS form 672 listed 12 Residents with Pressure Ulcers.

Based on observation, interview, and record review, the facility failed to identify and treat a newly developed hand contracture and provide hand rolls, spints and repositioning to prevent further Range Of Motion (ROM) decline for 2 of 3 sampled residents ( #s 86 and 108). The facility failed to: Assess or treat Resident #86's left hand which developed into a contracture. Treat Resident # 108's contractures with heel protectors, splints, hand rolls, or repositioning. This failure caused one resident to develop a contracture. This failure placed Resident 108 and 9 other residents at risk for futher declin in RO<, pain and loss of indepencence. Finidings include: Resident # 86 Record review of Resident # 86 ' s face sheet revealed Resident # 86 was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. Record review of the annual MDS assessment dated [DATE] revealed Resident # 86 had no limitations in the range of motion of all her extremities. Record review of the quarterly MDS assessment dated [DATE] revealed Resident # 86 had no limitations in any range of motion of all her extremities. Review of the Resident # 86 ' s Care Plan dated 1/31/11 revealed Resident # 87 was receiving restorative care : range of motion - passive, range of motion - active, splint /brace for assistance to left knee, and cervical collar when up in a wheel chair. The approaches identified included apply left knee braces for 4- 6 hour, active range of motion to right lower extremities and passive range of motion to left lower extremities 10 times . There was no planned care for her left hand. Record review of the quarterly MDS assessment dated [DATE] revealed Resident # 86 had impairments on one side of upper extremities and also had impairment on both side of her lower extremities. Resident # 86 required extensive assistance and was dependent on the staff for all activities of daily living (ADL). Record Review of Resident #86's medical record, treatment sheets and medication administration sheets revealed no documentation of the knee brace being applied for 4 to 6 hours each day. There was no documentation any assessments of the left hand contracture or of hand rolls for the left hand. Observation on 4/26/11 at 9:14 A.M., during initial tour, revealed Resident # 86 was lying on her back in her room. Her lower extremities were in a flexed position that swept to the left side of the bed. A leg brace was noted on the night stand on the resident ' s right side of bed. Resident had on heel protectors on both feet. Resident # 86 had a stage II pressure sore on the left lateral ankle. Resident # 86's left hand was clinched with the thumb running across and in between the pointer finger and the ring finger. Resident was not able to open her left hand when asked . Observation on 4/26/11 at 4:00 P.M. revealed the resident in bed, with the left knee brace on the night stand by the resident. Her left hand was clinched with no rolls in the hand. Observation on 4/27/11 at 7: 40 A.M. Resident # 86 was observed lying on her back in her room. There was no brace on her left knee. Her left hand was clinched. Knee brace was on the night stand in the resident's room. Observation on 4/28/11 at 8:00 A.M. Resident # 86 was observed lying in bed. No knee brace noted on her left knee. No hand rolls in her left hand. Observation on 4/28/2011 at 12 noon revealed the resident in a wheel chair and was being transported to the dinning room for lunch. She had no knee brace on and had no hand roll in place. Interview at this same time the resident stated she could not open her left hand and could not keep it open. Interview on 4/29/11 at 12 noon RN # 2 said Resident# 86 recently had a stroke and had left sided weakness. She said the resident could not use her left hand but used the right hand. When asked if she knew that the fingers were folded inward, she said the resident did not use that hand since she had the stroke. Interview on 4/29/11 at 2:25 P.M. the DON said she recalled that Resident # 86 had a recent stroke and had left sided weakness. She said she would follow up with the therapy department to see what was being done for her left hand. During this interview the DON talked to the Therapy Director who observed Resident # 86 ' s hand and agreed that the resident had developed a contracture to her left hand and needed some attention to it to prevent more contractures. In the same interview the DON said the resident should have the knee brace on but would find out when the staff put it on the resident. She said she thought the resident wore the brace at night. She said the nurse and the aides could put it on. When asked she could not say how the staff knew when and for how long to have the brace on the resident. Resident # 108 Record review of Resident #108 ' s face sheet revealed he was [AGE] years old and was admitted to the facility on [DATE]. He was diagnosed with [REDACTED]. Observation on 4/26/11 at 9:15 A.M. revealed Resident # 108 was awake and laying in his bed flat on his back. His hands were both contracted and fingernails were approximately ? inch long and had brown and black substance under his nails. Further observation revealed his feet were bare and were both contracted. He had no hand rolls in his hands and had no heel protectors on his feet. During an interview at the same time, RN #5 stated Resident #108 used a wheelchair for ambulation and required two-person physical assistance with transfers. She further stated he required total assistance with his Activity of Daily Living (ADL) and stated he had contractures to both hands and both feet. She stated he used hand rolls as a splint to help with the contractures. Observation on 4/27/11 at 4:30 P.M. revealed Resident # 108 was awake in bed laying flat on his back with his head elevated. He had no heel protectors on his feet and no hand rolls in his hands. His fingernails were ? inch long and the fingers were extremely contracted on both hands. Observation on 4/28/11 at 10:00 A.M. revealed Resident # 108 was awake in bed covered with a blanket laying flat on his back. He had no heel protectors on his feet or hand rolls in his hands. Both hands and feet were contracted. Record review of Annual Minimum Data Set ((MDS) dated [DATE] revealed his legs had limitated ROM on both sides and had partial use loss. Record review of Quarterly MDS dated [DATE] revealed no impairment noted for upper extremity (shoulder, elbow, wrist, hand) and impairment to both sides of his lower extremity (hip, knee, ankle, foot). Review of the Braden Scale dated 2/8/11 revealed Resident # 108 had moderate risk for pressure sores. Record review of the Comprehensive Plan of Care dated 2/8/11 revealed Resident # 108 was at risk for Skin Breakdown. Under the Approach section revealed " ... Turn and reposition Q2H {every 2 hours) " . The problem revealed " Inability to participate in any independent ADL activities resident not able to perform ADLs on own " .. The Approach section read " ... Turn q2 when in bed ... " Record review of Medication Administration Review dated 3/2011 revealed no documentation that the hand rolls or heel protectors were applied during the month of March 2011. Record review of Medication Administration Review dated 1/2011 revealed no documentation of heel protectors being applied while Resident # 108 was in bed. Further review revealed hand rolls were applied every shift during the month of January 2011. Observation on 4/29/11 at 11:50 A.M. revealed Resident # 108 was alert, awake, and was in his wheelchair in the Activity/TV Room. He had hand rolls in both hands and socks on his feet. Review of the Monthly Physician order [REDACTED]. 1. Out of bed every day 2. Apply hand roll in both hands at all times due to contractures 3. Heel protectors while in bed. Facility's 802 form identified 11 residents with limited ROM/ contractures.

Based on observation, record review and interview the facility failed to provide services to 1 of 4 sampled residents (Resident #1) according to the written plan of care in that Resident #1 required two staff assistance for bathing due to her rocking back and forth behavior. CNA #1 bathed resident without assistance which resulted in Resident #1 falling and fracturing her hip. This failure resulted in one resident sustaining a fracture to the hip, hospitalization , and surgery. This placed 60 residents ' health and safety at risk by staff not following their plans of care. Findings include: # 0 Review of Resident # 1 ' s facility Face Sheet revealed she was [AGE] years old and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Observation on 12 /29/10 at 11:40 A.M. revealed Resident #1 in a specialty hospital, lying in bed asleep. Resident had a catheter for urine and was being fed Glucerna formula through a [MEDICAL CONDITION] tube (tube going into the nose to the stomach). Both hands were contracted. Resident #1 did not communicate with surveyor when interview was attempted. Review of the facility Incident/Accident report dated 12/9/10 revealed Resident #1 had fallen off the shower chair after being bathed by Certified Nurse Aide (CNA) #1. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident required total assistance from 2 staff members for bathing. It further revealed Resident #1 required assistance of two staff with all transfers and was unable to ambulate. Review of Resident #1 ' s care plan, date unreadable, revealed problem of behavioral symptom of resident "rocks back & forth" with intervention "be alert for triggers of undesired behavior. " Review of care plan dated 10/20/2010 revealed problem " at risk for falls " and listed resident as having spastic movements. The same care plan revealed resident required assistance with ADLs (activities of daily living). Bathing was checked and below it stated Hoyer lift transfers, extensive transfers with two people assist. Review of Resident #1's Nurse's Note dated 12/09/2010 revealed an entry at 3:00 P.M. which read that the resident was lying in bed on assessment complaining of pain to Right Hip. Tylenol was administered at that time and resident was kept in bed until x-ray results were obtained. Review of X-ray report dated 12/09/10 revealed that Resident #1 had a fracture to the left hip. Review of the facility ' s internal investigation report revealed a witness statement dated 12/09/10 from RN#1. The statement revealed she assigned CNA #1 to bathe Resident #1 on 12/09/10 due to the resident being soiled. The statement read " Asked (RN #1) if she had informed (CNA #1) about the resident safety risk since it was her first time caring for the resident. Stated, " Honestly, I did not; it was just too much going on at the time. " The statement was signed and dated 12/14/10 by the DON as being the one conducting the interview. Interview on 12/22/10 at 10:30 A.M. RN #1 stated that Resident #1 had an incontinent episode in the activity room on 12/09/10. She said she took the resident back to her room and asked CNA#1 to provide incontinent care to the resident. RN #1 stated she instructed CNA #1 to shower the resident. CNA #1 took Resident #1 to the shower and proceeded to clean the resident without assistance. After the shower was completed CNA#1 turned her back to Resident #1 to obtain a towel and Resident #1 fell to the shower floor. RN #1 stated that Resident #1 had a tendency to rock back and forth when seated. She stated CNAs were instructed to review the resident ' s Cardex prior to providing care to see if there were any special precautions required. Interview on 12/22/10 at 12:00 noon LVN #1 stated that on 12/09/10 Resident #1 had a large bowel movement while sitting in her chair. She and CNA#1 were trying to clean Resident #1 in her room. She said they had difficulty cleaning the resident. CNA #1 got the shower chair and LVN #1 assisted CNA #1 in transferring the resident to the shower chair. She stated she instructed CNA #1 that if she had any problems to call for help by using the call light in the shower. She stated she then proceeded to perform a nursing procedure for another resident when another CNA asked her to come to the shower room. She stated when she went in the shower area Resident #1 was lying on the floor. Phone interview on 12/22/10 at 2:45 P.M. CNA#1 stated that Resident #1 was in a wheelchair. She and LVN #1 transported the resident to her room. CNA #1 stated that LVN #1 assisted when she transferred Resident #1 to the shower chair. She had completed giving Resident #1 a shower and had turned around to get a towel and that was when the resident fell . She stated she did not know how she fell . She stated that she was the only staff in the shower room with the resident. Interview on 12/22/10 at 10:00 A.M. the DON stated that all CNAs were to follow the care plan in the Cardex. She stated Resident # 1 required total assistance with all care and had a history of [REDACTED]. Interview on 12/22/10 at 2:05 p.m. CNA #2 stated that she would look in the blue Cardex book every morning to check the assistance needed on the residents she had been assigned. Review of CNA #2's employee folder revealed her date of hire at the facility was 2/12/09. Interview on 12/22/10 at 2:20 P.M. CNA #3 stated that she checked the blue Cardex book every morning to see if the residents she had been assigned had any changes in their care. Review of CNA #3's employee folder revealed her date of hire was 5/29/07 Interview on 12/22/10 at 2:25 P.M. the Staff Development Nurse, LVN #2, when asked how report was obtained from shift to shift, stated the staff got report from the blue book. The blue book had the Cardex and had everything needed to take care of the resident. She stated with new staff she completed an orientation with them and then observed them working with the residents and other staff. Interview on 12/22/10 at 2:50 P.M. CNA #4 stated that she had been a CNA at the facility since 2009. She stated that she would ask the off going nurse about her residents for the day. She stated she would always read the Cardex and if it showed that a resident required two person assist she would get a co-worker to assist her. She then stated before taking a resident to the shower she gathered all the supplies she would need and then she had them ready when she showered the resident. Review of Resident #1's CNA Care Cardex Worksheet, not dated, revealed she required total assistance from staff for care. The Cardex revealed that shower was checked under personal hygiene and that total care was written in. It revealed Resident #1 required two person assistance. The Care Cardex revealed no documentation of the behavior of rocking back and forth. Review of the hospital History and Physical form dated 12/09/2010 revealed "The patient will need a cardiac creatinine clearance before the surgery as patient will be high risk for any extensive surgery". Review of the hospital records dated 12/15/10 revealed resident was transferred to a specialty hospital. The specialty hospital Admission Database form dated 12/15/10 revealed the resident had Left Hip surgery on 12/12/10. Review of specialty hospital Progress Note dated 12/24/2010 revealed [DIAGNOSES REDACTED]. Review of the specialty hospitals Speech Pathology Note dated 12/28/2010 revealed that Resident #1 would not open her mouth when presented with food. The resident was considered inappropriate for a swallowing test or any intake by mouth. The same note revealed the Speech Pathologist recommended that Resident #1 have nothing by mouth and long-term non-oral nutrition. Interview on 12/29/10 at 11:40 A.M. with hospital staff RN #2 stated that Resident #1 did not communicate. She stated that the resident had not been eating since the surgery (12/12/10) and a [MEDICAL CONDITION] tube was ordered to provide nourishment. Interview on 12/29/10 at 4:00 P.M. the DON stated that Resident #1 was eating a pureed diet at the facility with the assistance of staff. She stated the resident ' s appetite was good prior to the fall. The facility listed the census on the 100 hall as 60.

Based on observation, record review, and interview the facility failed to provide adequate supervision and assistance to prevent an accident for 1of 4 sampled residents (Resident #1) in that Resident #1 was assessed to need two staff member assistance when bathed. CNA #1 bathed Resident #1 without assistance which resulted in Resident #1 falling and fracturing a hip. This failure resulted in one resident sustaining a fracture to the hip, hospitalization and surgery. This failure placed 60 residents at risk of injuries due to lack of assistance or supervision. Findings include: # 0 Review of Resident # 1 ' s facility Face Sheet revealed she was [AGE] years old and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Observation on 12/29/10 at 11:40 A.M. revealed Resident #1 in a specialty hospital, lying in bed asleep. Resident had a catheter for urine and was being fed Glucerna formula through a NasoGastric tube (tube going into the nose to the stomach). Both hands were contracted. Resident #1 did not communicate with surveyor when interview was attempted. Review of the Incident/Accident report dated 12/9/10 revealed that Resident #1 had fallen off the shower chair after being bathed by a CNA. Review of Resident #1's Nurse's Note dated 12/09/2010 revealed an entry at 3:00 P.M. which read that the resident was lying in bed on assessment complaining of pain to Right Hip. Tylenol was administered at that time and resident was kept in bed until x-ray results were obtained. Review of X-ray report dated 12/09/10 revealed that Resident #1 had a fracture to the left hip. Record review of the Annual Minimum Data Assessment Set ((MDS) dated [DATE] revealed the resident required total assistance from 2 staff members for bathing. The same form revealed that the resident could make concrete requests verbally and sometimes understood direct communication. She had very limited use of her upper extremities and had disorganized thinking. She was unable to transfer or ambulate. Review of the pain section of this MDS revealed that the resident had no pain and received no routine or as needed pain medication. Review of Resident #1 ' s care plan, date unreadable, revealed problem of behavioral symptom of resident "rocks back & forth" with intervention "be alert for triggers of undesired behavior. " Review of care plan dated 10/20/2010 revealed problem " at risk for falls " and listed resident as having " impulsive spastic movements. " The same care plan revealed resident required total assistance with bathing and that a Hoyer lift was to be used for transfers with two person assist. Record review of Certified Nurse ' s Aide Care Cardex Worksheet revealed Resident # 1 required total assistance from staff for care. It revealed that two staff were to assist with the resident's showers. Further review revealed that the CNA Care Cardex had no documentation that reflected that Resident #1 had behavior of rocking back and forth or that she had impulsive spastic movements. Interview on 12/22/10 at 10:00 A.M. the DON stated that CNAs were to follow the care plan in the Cardex. She stated that Resident # 1 required total assistance with all care and had a history of [REDACTED]. Interview on 12/22/10 at 2:25 P.M. the Staff Development Nurse, LVN #2, when asked how report was obtained from shift to shift, stated the staff got report from the blue book. The blue book had the Cardex which documented everything needed to take care of the resident. She stated with new staff she completed an orientation with them and then observed them working with the residents and other staff. Review of the internal investigation report revealed a witness statement dated 12/09/10 from RN#1. The statement revealed she assigned CNA #1 to bathe Resident #1 on 12/09/10 due to the resident being soiled. The statement read " Asked (RN #1) if she had informed (CNA #1) about the resident safety risk since it was her first time caring for the resident. Stated, " honestly, I did not; it was just too much going on at the time. " The statement was signed and dated 12/14/10 by the DON as being the one conducting the interview. Interview on 12/22/10 at 10:30 A.M. RN #1 stated that Resident #1 had an incontinent episode in the activity room on 12/09/10. She said she took the resident back to her room and asked CNA#1 to provide incontinent care for the resident. RN #1 stated she instructed CNA #1 to shower the resident.CNA#1 took Resident #1 to the shower and proceeded to clean the resident without assistance. After the shower was completed CNA#1 turned her back to Resident #1 to obtain a towel and that was when Resident #1 fell to the shower floor. RN #1 stated that Resident #1 had a tendency to rock back and forth when seated. She stated that CNAs were instructed to review the resident ' s Cardex prior to providing care to see if there were any special precautions required. Interview on 12/22/10 at 12:00 noon LVN #1 stated that on 12/09/10 Resident #1 had a large bowel movement. She and CNA#1 were trying to clean Resident #1 in her room. She said they had difficulty cleaning all the feces off the resident and since it was the resident ' s shower day, CNA #1 got the shower chair and LVN #1 assisted CNA #1 in transferring the resident to the shower chair. She stated she instructed CNA #1 that if she had any problems to call for help by using the call light in the shower. She stated she then proceeded to perform a nursing procedure for another resident when another CNA asked her to come to the shower room. She stated when she went in the shower area Resident #1 was lying on the floor. Phone interview on 12/22/10 at 2:45 P.M. CNA #1 stated that Resident #1 was in a wheelchair and she and LVN #1 transported the resident to her room. CNA #1 stated that LVN #1 assisted when she transferred Resident #1 to the shower chair. She had completed giving Resident #1 a shower and had turned around to get a towel and that was when the resident fell . She stated she did not know how she fell . She stated that she was the only staff in the shower room with the resident. Review of the hospital History and Physical form dated 12/09/2010 revealed under Plan section " .The patient will need a cardiac creatinine clearance before the surgery as patient will be high risk for any extensive surgery ... " Review of the hospital MAR dated 12/09/2010 revealed that the resident received Morphine Sulfate for pain at 6:35 P.M. and 11:52 P.M. Review of the hospital records dated 12/15/10 revealed resident was transferred to a specialty hospital. The specialty hospital Admission Database form dated 12/15/10 revealed the resident had Left Hip surgery on 12/12/10. Review of the specialty hospitals Speech Pathology Note dated 12/28/2010 revealed that Resident #1 would not open her mouth when presented with food. The resident was considered inappropriate for a swallowing test or any intake by mouth. The same note revealed the Speech Pathologist recommended that Resident #1 have nothing by mouth and long-term non-oral nutrition. Interview on 12/29/10 at 11:40 A.M. with hospital staff RN #2 stated that Resident #1 did not communicate. She stated that the resident had not been eating since the surgery 12/12/10 so was being fed through a NasoGastric tube. Interview on 12/29/10 at 4:00 P.M. the facility's DON stated that Resident #1 was eating a pureed diet at the facility with the assistance of staff. She stated the resident ' s appetite was good prior to the fall. Review of the Abuse and Neglect Prohibition policy dated March 2009 revealed the definition of neglect as " ...failure to provide goods and services necessary to avoid physical harm, mental abuse, or mental illness ... " The facility listed the census on the 100 hall as 60.