Every finding on record at Parker Nursing & Rehab Center

Based on interview and record review the facility failed to investigate an allegation of misappropriation of resident's funds for 1 of 3 residents (R1) reviewed for misappropriation of property in the sample of 7.The findings include:R1's electronic face sheet shows R1's original admission date was 3/26/21. The same face sheet show, R1 was discharged from the facility last 12/23/23.R1's facility assessment dated [DATE] show R1 has no cognitive impairment with BIMS of 15.On 6/5/25 at 10:23 AM, R1 said in 2023, she had gotten an inheritance after her dad passed away. The staff member (V7) Certified Nursing Assistant-(CNA) that transport residents for doctor's appointments became her friend while she was at the facility. R1 said they would text each other if V7 (CNA) was off. R1 said she had shared with V7 about her inheritance. Shortly after that, V7 asked R1 if she could borrow money from her for a car down payment. R1 said since she considered V7 as her friend, and she trusted V7, R1 agreed. The verbal arrangements were for V7 to make payments monthly between 50-100$. R1 said she loaned the money to V7 before she was discharged . R1 said she gave the money, $ 2000.00 cash in her room at the facility. R1 discharged at the end of December 2023. R1 said V7 made payments starting February 2024. In August 2025, V7 stopped paying, V7 did not respond to her calls or her text messages. R1 said she got tired waiting, so she decided to call the Nursing home last April 2026 and spoke to V3 (MDS Nurse) and reported V7, that while R1 was still a resident at the facility, V7 borrowed money from her in the amount of $2000.00. V7 still has a balance of $735.00. R1 said the MDS Nurse said she will report this to the Administrator. R1 said last month (May) she again called the Nursing Home and spoke to Social Services (V5). V5 (SS) told her that it will be your words against hers (V7). R1 said all she wanted was for the Nursing home to investigate her complaint, to talk to other residents because if V7 borrowed money from her, it was possible V7 was also borrowing money from other residents who still leaves there. R1 said she then decided to call the state agency to call in a complaint.On 5/5/26 at 9:27 AM, V3 (MDS Nurse) said last April 15, 2026, she received a text from R1, she wanted to know if V7 was still working at the facility. R1 said V7 owes R1 money. V3 said she asked when did this happened, R1 said she had loaned the money to V7 when she was still a resident in the Nursing home. V3 said she reported exactly what R1 told her to V4 (Regional Director.) that according to R1, V7 borrowed money from R1 while R1 was still a resident at the facility in 2023.On 5/5/26 at 9:40 AM, V4 (former Regional Director of Operations) said last April 2026 she was at the facility covering for V1 (Administrator). V4 said V3 (MDS Nurse) informed her that R1 who had been discharged from the facility reported that V7 borrowed money from R1. V4 said she assumed this happened in the community since R1 had been discharged . V4 said she did not initiate an investigation; she did not talk to the accused staff (V7) who still works at the facility and did not ask other residents if this was happening to them.On 6/5/26 at 12:10 PM, V5 (Social Services) said R1 called her around May 2026. R1 was letting her know that a staff member (V7) borrowed money from her. V5 said she told R1 that it will be her words against V7. V5 said staff should not borrow money from residents. That was financial abuse. V5 said she reported this to V1 (Administrator). On 6/5/26 at 1:21 PM, V7 (CNA) said she was confirming she borrowed money from R1. V7 said she still owes money around $700.00. V7 said she will pay back R1 once she has the money. V7 said it was an agreement made with R1 who now lives in the community.On 6/5/26 at 2PM, V1 (Administrator) said R1 had been discharged at the facility. V7 (CNA) still works at the facility. There has been no investigation initiated regarding R1's allegations against V7 since R1 first called last April 2026. Any allegation of misappropriation of property should be investigated immediately. V1 said investigation started today, and police had been called.The facility policy on Abuse Prevention dated 9/21 under Investigation shows, all incident or allegation involving abuse, neglect, exploitation, misappropriation of property, or crime against a resident will result in an abuse investigation.

Based on observation, interview and record review the facility failed to ensure that a resident received a diet as ordered, including failure to implement and communicate an ordered diet alternative. This resulted in a significant, unplanned weight loss of 11.1% for 1 of 4 residents (R13) reviewed for significant weight loss in the sample of 17.The findings include:R13's Face Sheet printed on 3/31/26 shows R13 was initially admitted to the facility on [DATE] with diagnoses that include polyneuropathy (damage to nerves in body), major depressive disorder, bipolar disorder, and personal history of transient ischemic attack and cerebral infarction (type of stroke) without residual deficits. The Face Sheet also shows that R13 was readmitted to the facility, following a hospitalization, on 3/11/26 with diagnosis of cerebral infarction. The Face Sheet does not show a diagnosis related to difficulty swallowing.R13's Order Summary Report dated 3/31/26 shows that R13's Dietary order as general diet, pureed texture, thin liquids with allowance for mechanical soft texture upon request.On 3/30/26 at 11:37 AM, during plating of lunch meals, R13's ticket showed double portion/protein, but double portion of protein was not provided.On 3/30/26 at 12:24 PM, R13 was in the dining area and was provided a plate with pureed turkey tetrazzini, dinner roll, blended veggies, cinnamon roll cake, and instant mashed potatoes. R13 only ate the mashed potatoes and stated her dislike of pureed foods and therefore did not eat most meals. R13 stated multiple requests to staff for different foods due to not eating pureed, and that mashed potatoes are provided.On 4/1/26 at 9:26 AM, R13 stated that she was unaware her dietary order showed she can receive a mechanical soft for meals upon request. R13 stated that she has requested an alternate diet to pureed multiple times but is still served pureed.4/1/26 9:29 AM, V19 (Certified Nursing Assistant-CNA) stated that R13 has a diet order of pureed foods and was aware that R13 was not eating pureed foods but was not aware that R13 could request mechanical soft foods. V19 stated R13 typically consumes only 25% of all meals.On 4/1/26 at 10:06 AM PM, V4 (Dietary Manager) stated that R13's diet order was pureed with no other alternatives. V4 then reviewed R13's medical record and confirmed that R13's diet order was pureed with an allowance for a mechanical soft diet upon request. V4 stated she was aware that R13 does not like pureed and does request different food.On 4/1/26 at 12:37 PM, V20 (Dietician) stated that R13's current diet order was for pureed with the stipulation for allowance of mechanical soft upon request. V20 stated she did not agree with the order due to safety concerns, however, confirmed that she documented R13's diet order for pureed with allowance of mechanical soft in her Dietary Progress Note. V20 confirmed that R13 has weight loss, has a upcoming video swallow evaluation, and has interventions in place that include: 'med pass' supplement (high calorie/high protein) supplement, pureed textured food that R13 will eat can be provided such as the mashed potatoes and double portions, although the double portions are not effective as the resident is not eating pureed food. On 4/1/26 at 12:31 PM, R13 was sitting up in wheelchair outside of dining room. R13 stated she was so happy due to being served real food today; a taco and it was so good, I ate all of it!On 4/1/26 at 1:08 PM, V4 (Dietary Manager) stated that R13 was served a mechanical soft diet for lunch today due to the social worker's request. V4 was informed that R13 consumed 100% of the meal.R13's Weights and Vitals Summary dated 4/1/26 shows the following weights which represent a 15.8lb (pound), 11.1% unplanned weight loss over approximately six weeks, meeting criteria for significant weight loss:-2/13/26: 141.8lbs-2/20/26: 138lbs-3/4/26: 134.2lbs-3/26/26: 125lbs-3/30/26: 126lbsR13's Nutrition Risk Review dated 3/11/26, printed on 4/1/26, shows that R13 had a weight loss of 5% or more in the last month or loss of 10% more in the last six months and was not on a prescribed weight loss regimen, pureed food intake, has the ability to express ideas and wants and can make decisions regarding tasks of daily life independently, and has no signs or symptoms of possible swallowing disorder.R13's Dietary Progress Note dated 3/28/26, printed on 4/1/26, shows that V4 (Dietary Manager) documented that R13's nutrition is at risk, her diet order is general puree with thin liquids, that R13 may request a mechanical soft diet and a plan to continue diet and supplements as ordered.R13's Care Plan Report printed 4/1/26 does not include a focus area or interventions related to nutrition or weight loss.The facility's Physician Orders-Following Physician Orders (undated) policy shows that it is the policy of the facility to follow the orders of the physician, and the facility will have orders to provide essential care to the resident.

Based on interview and record review the facility failed to have a system in place to verify Certified Nursing Assistants (CNAs) have received the required 12 hours training yearly. This applies to all 63 residents residing in the facility. The findings include:The CMS form 671 dated 3/30/26 showed there were 63 residents residing at the facility.On 4/1/26 at 10:00 AM, this surveyor requested training files for V8, V9, V14-V16, (all Certified Nursing Assistants-CNAs.) The facility was not able to provide documentation verifying that these CNAs received the required 12 hours of annual Inservice training. There was also a sign posted by the time clock dated 11/19/25 for CNAs that included V8 and V9 to complete their required training.On 4/1/26 at 10:20 AM, V8, V9 and V14 all CNAs said they received in-services from the facility but were not sure if they had met the required trainings yet. On 4/1/26 at 10:45 AM, V1 (Administrator) said the facility is in the process of implementing a system to track CNA training hours to ensure completion of the required 12 hours of annual training. The Facility Policy entitled Guidelines for Education in the Facility documents, CNAs must complete 12 hours of in-service training annually, that include: a) dementia management, b) resident abuse protection, c) training that addresses any area of weakness or potential weakness by the individual, d) training needed to carry any special needs resident within the facility's population. There must be a process in place to track staff participation in trainings.

Based on observation, interview and record review the facility failed to ensure the dish machine and 3-part sink was sanitizing at the appropriate concentration. This applies to all 63 residents residing in the facility. The findings include:The CMS-671 long-term care facility application for Medicare and Medicaid dated 3/30/26 shows, 63 residents residing in the facility. On 3/30/26 at 9:27 AM, V6 (Dietary Aide) was washing silverware in the dish machine. V5 (Cook) stated, the dish machine was a low temp, chlorine dish machine. V6 tested the dish machine and the test strip did not change colors. She stated, that was ok. On 3/30/26 at 9:40 AM, V4 (Dietary Manager) stated, they just completed maintenance on the dish machine last week. She tested the dish machine again and the test strip changed to a light grey color barely at 50 ppm (parts per million). V4 stated, it should be at 100 ppm. She checked it again just to make sure and the test strip did not change colors that time, it remained white. On 3/30/26 at 11:40 AM, V4 checked the 3-part sink quat sanitizing solution. The test strip showed, the sanitizing solution was at 100 ppm. V4 stated, it needed more solution and should be at 200 ppm. The facility machine washing and sanitizing (low temperature dishwashing machine) policy (no date) shows, Policy: Dishwashing machines will be operated in accordance with manufacturer's instructions. Dishwashing machines may be used for cleaning and sanitizing tableware, utensils, equipment, pots and pans. Procedure: Dishwashing machines using chemicals (typically chlorine) for sanitizing may be used if the temperature of the wash water is not less than 120 F (Fahrenheit), and the temperatures of the rinse water is not less than 75 F, or less than the temperature specified by the machine's manufacturer. The final rinse will have 50 parts per million (ppm) hypochlorite (chlorine) on dish surface. The final rinse will be tested with the appropriate test strip and the results will be recorded on the Low Temperature Dishwashing Machine Log at the beginning of each washing session for breakfast, lunch and dinner. The facility's 3 compartment sinks (no date) shows, Policy: Dishes and cookware will be cleaned and sanitized after each meal. Procedure: .5. Check sanitation sink frequently using a test strip to assure the level of sanitizing solution is appropriate. Follow chemical manufacturer's guidelines to prepare sanitizing solution. The facility's manufacturer's guidelines for quatsan solution for the 3 compartment sink (no date) shows, Food contact surface sanitizing: This product is an EPA registered sanitizer, disinfectant, virucide, mildewstat, cleaner and deodorizer for use in restaurants, bars, institutional kitchens, food handling and process areas. Designed for use on food processing equipment, dairy processing equipment, utensils and other hard, nonporous food contact surfaces in food processing locations, meat plants, bakeries, beverage plants, restaurants and bars. May be used at a variable dilution rate of .75 - 2 oz. (ounce) per 4 gallons of water (or equivalent use dilution), which yields 150-400 ppm active quat.

Based on observation, interview and record review the facility failed to ensure residents received the correct portion size for the noon meal. This applies to all 63 residents residing in the facility. The findings include:The CMS-671 long-term care facility application for Medicare and Medicaid dated 3/30/26 shows, 63 residents residing in the facility. The facility's menu for 3/30/36 noon meal shows, Turkey Tetrazzini, California blend, dinner roll, cake and beverage of choice. On 3/30/26 at 11:37 AM, V5 (Cook) was plating the noon meal. She used a #6 scoop (2/3 cups/5 1/3 ounce) for the regular turkey tetrazzini (noodles, shredded turkey and sauce) and pureed turkey tetrazzini. The facility's spreadsheet for the noon meal on 3/30/26 shows, regular turkey tetrazzini serving is an 8 ounce spoodle or 2, 4 ounce spoodles, portion size 8 ounces and pureed turkey tetrazzini is 2 #8 scoops (4 ounces/1/2 cup). None of the residents received the correct portion of turkey tetrazzini (mechanical soft was served the same as regular diets). The facility's scoop size color chart shows, a #6 scoop is 5 1/3 ounces and 2/3 cups. On 3/30/26 at 12:49 PM, V5 (Cook) stated, she should have served 2 scoops of the #6 scoop for both (which still wasn't the correct portion size). The facility's accuracy of quality of tray line service (no date) shows, Policy Tray line positions and set up procedures will be planned for efficient and orderly delivery. All meals will be checked for accuracy by the food and nutrition services staff, and by the service staff prior to serving the meal to the individual. Procedure: .6. Each meal will be checked for: .c. Proper portion sizes.

Based on interview and record review the facility failed to ensure as needed (PRN) psychotropic medications had a stop date for 4 of 5 residents (R4, R24, R9 and R49) reviewed for psychotropic medications in the sample of 17.The findings include: 1.R4's Physician Order sheet (POS) shows an order dated 3/21/26 for alprazolam 0.5 milligram (mg) per peg tube every 8 hours as needed for anxiety, with no stop date. R4's POS also shows an order dated 3/29/26 for Ativan 0.5 milliliters (ml) 2mg/ml every 2 hours as needed for anxiety and 0.5 ml by mouth every 6 hours for agitation and restlessness, with no stop date. 2. R24's POS shows and order dated 3/4/26 for Ativan Oral Tablet 1 mg, give 1 tablet by mouth every 6 hours as needed for restlessness, with no stop date. On 4/1/26 at 10:30 AM, V2 (Director of Nursing) said she was in charge of the psychotropic meds making sure as needed psychotropic meds have stop dates of 14 days. If the medication needs to be longer than 14 days, the physician should be informed to evaluate the need for the medication. 3. R9's Physician Order Summary shows active orders for lorazepam 1 mg (psychotropic medication/ anti-anxiety), give 1 tablet by mouth every 4 hours as needed for restlessness effective 12/29/2025, and for olanzapine 10 mg (psychotropic medication/ anti-psychotic) inject 5 mg intramuscularly every 8 hours as needed for agitation effective 1/14/2026. There is no stop date for either of the medications. R9's Medication Administration Record (MAR) shows R9 received lorazepam on March 5, 10, 11, and 2 doses on March 19. R9's Electronic Medical Record (EMR) failed to show documented assessments and new orders every 14 days for psychotropic/anti-psychotic medication. 4. R49's Physician Order Summary shows active orders for olanzapine 5 mg intramuscularly every 8 hours as needed for anxiety/agitation effective 8/6/25. There is no stop date for the medication. R49's EMR failed to show documented assessments and new orders every 14 days for psychotropic/anti-psychotic medication. The facility provided Psychotropic Drug Usage policy (undated) states, Residents receiving psychotropic medications will have gradual dose reductions and behavioral interventions implemented unless contraindicated. Residents who receive PRN (as needed) psychotropic medications will be evaluated if the medication is extended longer than 14 days and the rational will be documented in the resident's medical record. In the event the medication is an anti-psychotic the prescribing practitioner will assess the resident for a continued need.

Based on interview and record review the facility failed to carry out a physician order as prescribed and failed to increase a residents antipsychotic medication contributing to a significant medication error. This failure resulted in a R10 missing 48 doses of the medication increase. This applies to 1 of 5 residents (R10) reviewed for unnecessary medications in the sample of 17. The findings include:R10's face sheet shows she has the following diagnoses: Schizoaffective Disorder Bipolar type, unspecified dementia and post- traumatic stress disorder.R10's current care plan initiated [DATE] shows she has a serious and persistent mental illness and requires the use of psychotropic medication to help manage anxiety, neurosis and insomnia and staff should carry out the medication management regimen as prescribed. R10's care plan also shows she requires strategies to deal with hallucinations and delusions. A Physician Progress Note completed by V18 (Nurse Practitioner) on [DATE] shows that R10 reported having auditory and visual hallucinations of deceased people causing her distress. R10 also told V18 that these hallucinations have occurred recently despite the current medication regimen. V18's progress note for R10 shows she increased the Latuda (antipsychotic medication) from 20 Milligrams (MG.) to 40 MG. in the morning and continue with 80 MG in the evening to help alleviate her psychotic symptoms. R10's Physicians Order Summary (POS) shows an order effective [DATE] for Latuda 20 MG. daily and Latuda 80 mg. also daily. R10's Medication Administration Summary (MAR) shows In Feb. and [DATE] the Latuda doses that R10 received were Latuda 20 MG. at 8 AM and 80 Mg. also was given at 8 AM not 8 PM as ordered. The 40 MG. dose increase was also not carried out onto the POS or MAR. R10's POS also shows she does not have any PRN (as needed) medication ordered to be given if she was having increased hallucination symptoms. On [DATE] at 10:46 AM, V2 (Director of Nursing) said unfortunately this order was missed and the Nurse Practitioners were writing orders on paper and giving them to the nurses. V2 said the orders should be carried out when received by the physicians and she is the person responsible for reviewing the Physician Progress notes when they receive them to be sure everything is followed. On [DATE] at 1:35 PM, V18 said I am not surprised they missed the orders they didn't do alot of things there. I ordered the medication for R10 because she was having auditory and visual hallucinations despite being on the current Latuda dose, so I increased the medication to try to eliminate those. The negative outcome of this would be unfortunately it would not lessen her symptoms and she would still have the hallucinations.The facility provided not dated Physician Orders policy states, It is the policy of the facility to follow orders of the physician. 'As assessments are completed, orders will be received from the physician to address significant findings of the assessments.

Based on observation, interview, and record review the facility failed to ensure that staff performed proper hand hygiene after removing gloves during wound care to prevent cross contamination for 1 of 17 residents (R2) reviewed for infection control in the sample of 17.The findings include:R2's Face Sheet printed on 4/1/26 shows R2 was admitted to the facility on [DATE] with diagnoses that included other specified local infections of the skin and subcutaneous tissue and pressure ulcer of sacral region, stage 4.R2's Order Summary Report dated 4/1/26 showed R2 requires wound care every dayshift and as needed and enhanced barrier precautions related to R2 having wounds.On 4/1/26 at 11:08 AM, an Enhanced Barrier Precaution (EBP) sign on R2's door showed staff must clean their hands and wear gloves and gown for high-contact resident care activities that included wound care. V3 (Assistant Director of Nursing-ADON) and V14 (Certified Nursing Assistant-CNA) performed hand hygiene with hand sanitizer (waterless alcohol-based agent), donned gloves and gowns and entered the room to perform wound care. V3 and V14 positioned R2 on R2's left side. V3 and V14 then removed their gloves and donned new gloves, but no hand hygiene was performed. V3 prepared the supplies and dressing needed for wound care. V3 then removed the dressing from R2's sacrum and coccyx area, which was saturated with yellowish brown drainage. V3 then removed gloves and donned new gloves without performing hand hygiene. V3 cleansed the wound, removed and donned new gloves, but no hand hygiene was performed. V3 applied a new dressing to the wound and performed additional cleansing to buttocks with application of barrier cream, then removed and donned new gloves did not perform hand hygiene. R2 was repositioned in bed. V3 then removed gloves but did not perform hand hygiene.Directly after exiting R2's room, V3 stated she would usually bring in hand sanitizer but forgot it on the wound cart outside of R2's room. V3 stated that hand hygiene is to be performed after each removal of gloves, prior to donning new gloves and hand sanitizer may be used unless hands are visibly soiled in which hands would then be washed.The facility's Infection Control: Hand Hygiene Guideline (undated) showed that the scope of the guideline includes all individuals that partake in the resident plan of care are to perform hand hygiene, wash or sanitizer, allowing hands to completely dry prior to applying gloves or interacting with a resident.

Based on observation, interview, and record review the facility failed to administer medications as ordered. There were 33 opportunities with 2 errors resulting in a 6.06% error rate. This applies to 1 of 2 residents (R37) observed during medication pass.The findings include: On 3/31/26, V3 (Assistant Director of Nursing) was continuously observed completing medication pass from 8:33 AM to 9:00 AM. On 3/31/26 at 8:33 AM, V3 administered medication to R37. Two (2) medications were not administered, Allopurinol and Benztropine. V3 said the medications were not in the cart and she had to reorder them from the pharmacy. V3 said these medications are not in the facility on site medication supply. R37's Physician Order Summary shows active orders for R37 to receive Allopurinol 100 MG (Milligrams) give 2 tablets daily for gout and for Benztropine Mesylate 1 MG two times a day. R37's Medication Administration Summary shows R37 should receive the Allopurinol at 8:00 AM, and Benztropine at 8:00 AM and 8:00 PM.The facility provided not dated Medication Administration policy shows medication should be administered as ordered to help residents overcome illness and to relieve and prevent symptoms.

Based on observation, interview and record review the facility failed to ensure a resident was supervised during medication administration for 1 of 17 residents (R20) reviewed for Pharmacy Services in the sample of 17.The findings include: On 3/30/26 at 9:33 AM R20 was in her room lying in bed, next to her on her bedside table were 2 clear medication cups with pills inside. One cup had a large white pill, and the second cup had 7 pills inside including 2 large white pills, 1 pink pill, 1 green pill, 1 blue pill and 2 small white pills. R20 said Sometimes they leave the pills in here for me to just take and sometimes they don't, it depends on who the nurse is. On 3/31/26 at 8:51 AM, V3 (Assistant Director of Nursing) said, medications should not be left at a resident beside nurses should observe the resident take the medication. There are no residents who have orders that they can self-administer medications and R20 should have been supervised while she took her medication. R20's Medication Administration Record (MAR) shows she takes the following oral medications at 8:00 AM: Acidophilus 100 Milligrams (MG.), Amlodipine 5 MG., Levothyroxine 150 Micrograms (MCG.), Lisinopril 5 MG., Omega 3 1000 MG., Toprol XL 25 MG., Glyburide 5 MG., Metformin HCL 500 MG., and Dicyclomine HCL, 20 MG.R20's Physician Order Summary does not show any order to self-administer medications. The facility provided not dated Medication Administration policy shows that nurses should remain with the resident during medication administration.

Based on interview and record review the facility failed to treat a resident with dignity and respect for 1 of 17 residents (R4) reviewed for dignity in the sample of 17.The findings include:On 3/30/2026 at 10:55 AM, during family interview, V13 (R4's POA and daughter) said R4's (on hospice) family were all here at the facility due to R4 transitioning (actively declining towards end of life). V13 said there was an incident over the weekend that R4's nurse refused for R4 to get up even when R4 was wanting to get up. V13 said the nurse (V11- License Practical Nurse-LPN) ignored the request. V13 stated these are my mom's last days, and if she wanted to get up, she should be gotten up V13 said V11 (LPN) was arguing with her, and she was sure R4 heard all that. V13 stated 'this was reported to the DON (Director of Nursing V2). On 3/30/26 at 12 PM, V12 (License Practical Nurse-LPN) said she was at the facility last Friday (3/27/26) and witnessed V13 and V11 (LPN) arguing regarding R4 getting up, this was done by R4's room, the argument can be heard through the hallways and nurse's station. V12 said R4 who is on hospice had been wanting to get up lately, they should have just gotten R4 up.On 3/31/26 at 12:27 PM said V11 (LPN) said she thought R4 was not supposed to be up per V2's direction. V11 confirmed this made R4's family upset.On 3/31/26 at 2PM, V2 (Director of Nursing) said staff should have honored the resident's and family's requests and ensured they were treated with respect.The facility policy entitled Dignity (undated) shows that staff will always be polite and respectful. Staff will not speak in a manner that that could be interpreted as a minimally condescending/critical or argumentative.

Based on interview and record review the facility failed to ensure resident's were free from physical abuse for 2 of 3 residents (R1 and R2) reviewed for Abuse in the sample of 3. The findings include: R1's electronic face sheet accessed on 6/27/25 show R1 has diagnoses that include hemiplegia and hemiparesis affecting right side. Anxiety and delusional disorder. R1's facility assessment dated [DATE] show R1 is alert and able to verbalize his needs. R2's electronic face sheet accessed on 6/27/25 show R2 has diagnoses that include traumatic subdural hemorrhage, drug induced parkinsons, and anxiety disorder. R2's facility assessment dated [DATE] show R2 has no cognitive impairment with BIMS of-15 The Facility Reported Incident (FRI) as final dated 6/10/25 (date of incident as 6/6/25) documents, R1 and R2 were in the dining room at their separate tables. R2 began yelling towards the direction of R1's table. R1 came towards R2 making contact with R2's right forearm. R1 lost his balance fell backwards and hit his head on cooler. Body assessment done with no injuries or complaint of pain. R1 and R2 denied police involvement. R1's MD ordered for R1 to be sent to the hospital for eval. CT scan of head with no evidence of acute intracranial process and cervical spine completed with no acute fractures or dislocation of cervical spine. R1 and R2 feel safe at the facility . On 6/27/25 at 9:30 AM, R1 was alert in his room, R1 stated He (R2) started it, we were both in the dining room, he was mouthing off at me, so I went to him and pushed him, I hit him!. he hit me back then I lost my balance and I fell. On 6/27/25 at 11:30 AM, R2 said regarding the incident on 6/6/25, it was during supper, he came at me saying things to me so I told him to F----ed off!, that's when he hit this arm (contracted right arm) I hit him back. He hit me again, so I hit back until they separated us. He fell , then got up and started hitting me again. Then R2 brought this surveyor to the dining room to show where the incident happened. R2 said he was at table 6 and R1 was in table 12. Table 6 and table 12 were next to each other. Camera's were noted in the dining room. On 6/27/25 at 12 PM, this surveyor watched the video surveillance with V1 (Administrator) and V4 (Human Resources.) Video surveillance showed, that both R1 and R2 were in the dining room sitting in their table. R1 got up and walked towards R2. R2 was sitting in his wheelchair in his table. R1 hit R2 numerous times, R2 hit back. R1 fell backwards, V3 (License Practical Nurse-LPN) was now at the scene. R1 got up and again hit R2 while V3 was trying to stop R1. V3 was unable to stop R1 from hitting R2. V4 (Human Resources) and V6 (Cook) were noted to be walking towards R1 and R2. V3 took R2 away in his wheelchair while R1 left the dining room. On 6/27/25 at 10:30 AM, V3 (LPN) said she was the nurse on 6/6/25 when the incident happened. V3 said she was at another table attending to another resident. I turned and I saw R1 approaching R2's table, I yelled, hey stop!, and went towards them. R1 lost his balance and fell backwards hitting his head in the milk cart behind him. R1 got up himself and left the dining room. When a resident hit another resident that is abuse. On 6/27/25 at 10:40 AM, V4 (Human Resources) said on 6/6/25 she was at the facility that evening. It was around suppertime when she heard somebody yelling really loud coming from the dining room hey! stop! V4 said she got up and went to the dining room and saw R1 hit R2's forearm so she hurriedly pulled R2 away from R1. V4 said she called V1 (Administrator) to notify her of the incident. V4 said when a resident hit another resident that is abuse. On 6/27/25 at 10 AM V6 (Cook) said on 6/6/25, he was on break when he heard someone yelling loud coming from the dining room. V6 said he went back to the kitchen then to the dining room. V6 said he saw R1 standing over R2, with R1's hands on R2's chest either pushing R2 or holding R2's shirt. The Nurse (V3) was trying to go in between R1 and R2 yelling stop! stop! Another staff came (V4) and pulled R2 away. V6 said when R1 saw him, R1 stopped and left the dining room probably because he saw another man. V6 said Abuse is when a resident hit another resident. On 6/26/25 at 2PM, V1 (Administrator) said both R1 and R2 have behaviors, there's a company that will be starting soon to come to the facility and provide group therapy to residents with behaviors The Facility on Abuse with a revised date of 1/2019 show, it is the policy of this facility to prohibit and prevent resident abuse neglect exploitation mistreatment and misappropriation of resident property and a crime against a resident in the facility. Physical abuse- hitting, slapping, pinching, kicking, it also include controlling behavior through corporal punishment.

Based on interview and record review, the facility failed to identify and investigate an allegation of sexual abuse for two residents (R1 and R3); and failed to protect (R1 and R3) from any further possible alleged sexual abuse. These failures led to R1 and R3 to withdraw from socialization and daily activities. R1 and R3 remained in their rooms to avoid contact with the alleged perpetrator (R2). These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 05/26/2025 when R1 and R3 reported R2 was making sexually explicit remarks to them. The allegations were not investigated immediately and R2 had continued access to R1 and R3. R1 and R3 remained fearful and caused R1 and R3 to withdraw socially in an effort to avoid R2. While the Immediate Jeopardy was removed on 5/30/25, the facility remains out of compliance at a severity level two while additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits. Findings Include: The Facility's Abuse Prevention Program, dated 01/2019, documents This facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies, family members, legal guardians, friends, or other individuals. This policy will define how the investigation of abuse allegations and mistreatment or crimes will be conducted and outline the process of reporting, investigating, and arriving at a conclusion or disposition of the allegation. The Facility's Abuse Prevention Program, dated 01/2019, documents Sexual abuse: Including, but not limited to, sexual harassment, sexual coercion, or sexual assault. The Facility's Abuse Prevention Program, dated 01/2019, documents Employees are required to immediately report any incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment, or a crime against a resident they observe, hear about, or suspect to the Administrator if available or an immediate supervisor who must immediately report it to the Administrator. In the absence of the Administrator, reporting can be made to the DON (Director of Nursing). Any incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment or a crime against a resident is reported to covered individual, covered individuals are notified annually of these reporting requirements. All resident, visitors, volunteers, family members, or others are encouraged to report their concerns or suspected incidents of potential abuse, neglect, exploitation, or mistreatment to the Administrator or an immediate supervisor who immediately reports the allegation to the Administrator. The Facility's Abuse Prevention Program, dated 01/2019, documents All incidents, allegations or suspicion of abuse, neglect, exploitation, misappropriation of property, or a crime against a resident will be documented. Any incident or allegation involving abuse, neglect, exploitation, misappropriation of resident property, or a crime against a resident will result in an abuse investigation. Residents who allegedly mistreated another resident will be immediately removed from contact with that resident during course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, approaches, and placement, considering his or her safety, as well as the safety of the other residents and employees of the facility. R1's Medical Record documents she was admitted to the facility on [DATE] with diagnoses to include but limited to Anxiety, Paranoid Schizophrenia and Auditory Hallucinations. R1's MDS (Minimum Data Set) Assessment, dated 5/13/25, documents R1 BIMS (Brief Interview for Mental Status) indicates a score of 14 out of possible 15; indicating R1 is cognitively intact. R1's MDS documents that R1 had no hallucinations or delusions. R1's MDS documents R1 did not have any physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, or any other behavioral symptoms not directed towards others. R3's Medical Record documents she was admitted to the facility on [DATE] with diagnoses to include but not limited to Epilepsy, Major Depressive Disorder recurrent severe with psychotic symptoms, Schizoaffective Disorder depressive type, Moderate Intellectual Disabilities and Delirium due to known physiological condition, Auditory Hallucinations, and Post-Traumatic Stress Disorder. R3's MDS (Minimum Data Set) Assessment, dated 5/13/25, documents R3's BIMS (Brief Interview for Mental Status) indicates a score of 15 out of possible 15, indicating R3 is cognitively intact. R3's MDS documents that R3 had no hallucinations or delusions. R3's MDS documents R3 did not have any physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, or any other behavioral symptoms not directed towards others. R3's current Care plan, dated 2/18/25, documents (R3)'s history indicates that she has experienced significant trauma during her lifetime and is a trauma survivor. She reports a history of sexual assault/sexual violence as well as the death of her husband. Reinforce with the caregiving team that trauma refers to experiences that cause intense physical and psychological stress reactions. On 5/27/25 at 1:30 PM, R1 stated (On 5/26/25, R2) told me that we (R1 and R3) could masturbate while he masturbates. (R2) also told me to get online and buy a dildo so he can keep me happy with it. We told (V5 Activities Aide) that (R2) was scaring us and saying sexual stuff to us. She (V5/Activity Aide) told us to tell management when they came in on Tuesday. We (R1 and R3) told (V5) that we were scared of (R2) and that we were staying in our room so he couldn't get to us. He has said kind of inappropriate things to us since we have gotten here but he got really bad over the weekend. On 5/27/25 at 1:30 PM, R3 stated (R2) scares me. He said he wants to have sex with me. I have been abused and raped in the past and do not want that to happen again. R3 was tearful and visibly agitated. I don't have to listen to someone talk to me like that, I loved my husband, he is dead now, that does not mean I am available for sex. I told (R2) I just wanted to be friends with him, but he kept trying to tell me that I should want to have sex with him. R3 stated R2 was saying inappropriate things on and off all weekend. On 5/27/25 at 1:30 PM, R4 stated that R1 and R3 complained to her about R2 saying sex stuff on Monday 5/26/25, and R4 stated she took them (R1 and R3) to (V5/Activity Aide) and told them to tell her so they did not have to hide in their room. (V5) told us there was nothing she could do and that we should tell management in the morning. (V5) told me (R4) that I needed to quit stirring up trouble. On 5/27/25 at 2:00 PM, V5 (Activity Aide) confirmed that R1, R3 and another resident (R4) came to her on 5/26/25 at an unknown time and told her that (R2) was saying sexually inappropriate things to them. V5 stated I don't even know what all he supposedly said. V5 stated that R3 told her that she (R3) was scared and was staying in her room to avoid (R2). V5 stated I told her that was a good idea, and she (R3) should just leave him alone. There was no management staff in the facility because it was Memorial Day. What was I going to do? I am not management in the building. They need to tell management or the charge nurse. I did not know who to call, that is why I told them (R1, R3 and R4) to report it the next day. V5 confirmed that she did not alert anyone else of the complaint, nor did V5 talk to any staff members or other residents regarding the allegation. V5 stated (R4) likes to spread rumors, she likes to keep those two (R1 and R3) worked up. V5 was unable to give any examples of what rumors R4 had spread or any disturbance that R4 had caused in the facility. V5 stated I don't know, she is always listening getting into other people's business. R4's Medical Record documents that she was admitted on [DATE] with diagnoses to include but not limited to Cerebral Infarct, Major Depression, and Insomnia. R4's MDS (Minimum Data Set) Assessment, dated 4/16/25, documents R4's BIMS score of 15 out of 15, indicating R4 is cognitively intact. R4's MDS documents R4 had no hallucinations or delusions. R4's MDS documents R4 had no physical behavioral symptoms directed towards others, verbal behavioral symptoms directed toward others, or other behavioral symptoms not directed towards others. On 5/27/25 at 1:30 PM, R1 stated, (R3) has been very upset and hiding in our room. Everyone (staff) seems to think that (R4) has told us to try to get (R2) in trouble and she has not. (R3) has a long history of abuse and rape so I believe she is triggered at this point. (R2) should not be allowed to say things like that to any women. They (V1 Administrator) and (V4 Social Services Director) told us that we always have the right to walk away from conversations that we don't want to be a part of. I told them we (R1 and R3) are scared, that they need to make him (R2) behave, not us. We told (V17/Certified Nurse Aide) and she seemed to be the only one who actually cared. On 5/27/25 at 2:15 PM, V7 (Certified Nurse Aide/CNA) confirmed that R1, R2, R3, and R4 all currently reside on the same hallway in the facility. On 5/27/25 at 1:00 PM, V1 (Administrator) provided all abuse allegations investigated by the facility in the past three months. There was no investigation regarding R1 and R3's allegation of sexual abuse by R2 from 5/26/25. V1 did provide a Concerns/Compliments/Questions/Suggestions form dated 5/28/25 signed by V4 (Social Services Director) that documents (R3) reported to writer that (R2) was talking about sex to her. The form documents Response/Resolution: discussed with (R3) about walking away from conversations she does not want to be part of. On 5/27/25 at 2:45 PM, V4 (Social Services Director) stated she had received the written statements left under management personnel's door when she (V4) arrived at work at approximately 8:30 AM - 8:45 AM on 5/27/25. V4 confirmed that R1, R2, R3 and R4 all reside on the same hallway. V4 was not able to provide any names of other residents or staff members she interviewed after she spoke with R1, R2 and R3 regarding the 5/26/25 incident. V4 confirmed that R3 said she upset when V4 spoke with her, V4 stated but she is always upset about something. R3's Nurse's Note dated 05/27/2025 at 1:13 PM entered by V4 (Social Service Director) documents (R3) approached writer reporting a male resident was talking to her about sex in general. Stated he said to her how can you live without sex? Instructed (R3) to remove herself from these types of conversations if she feels uncomfortable. Reported to writer male resident did not touch her. V1 (Administrator) written statement, dated 5/26/25, documents On 5/26/25 at approximately 11:30 PM I received a phone call from (V14 Certified Nurse Aide) stating that residents (R1 and R3) reported that (R2) had made sexual comments to them. I told (V14) to leave statements from them under my door. V1 confirmed that she did not speak to any other staff member other than V14 on 5/26/25 at around 11:30 PM. V1 confirmed that she did not instruct any staff members to increase monitoring or to begin an investigation with other staff members or residents. V6 (Licensed Practical Nurse) written statement documents On 5/27/25 at approximately 1:00 AM (V17/Certified Nurse Aide) reported (R2) was in (R1 and R3)'s room touching their arms, rubbing their shoulders and making statements such as are you bored, just sitting around here let's go to my room, do you want to have sex, let's go have sex. The women (R1 and R3) told staff about this incident during ice pass tonight, but when the female residents told (V5/Activities Aide) about the incident earlier in the day, (V5) informed the women to tell management or the nurse. The CNA reported it immediately to the nurse (V18/Registered Nurse) before I (V6) arrived and was told 'that's not my problem'. The female residents (R1 and R3) seemed very upset and tearful about this incident. R1's Nurse's Note, dated 5/27/25 at 2:20 AM, documents CNAs reported that during ice pass, 2 female residents stated that this resident was making statements such as are you bored just sitting here, let's go to my room, do you want to have sex, let's go have sex while touching/rubbing both female resident's arms and shoulders. Residents felt like second shift didn't care-they were very tearful and upset about this incident. R3's Nurse's Note, dated 5/27/25 at 2:23 AM and signed by V6 (Licensed Practical Nurse) documents CNAs reported that during ice pass, resident stated a male resident came into her bedroom making statements such as 'are you bored just sitting here, let's go to my room, do you want to have sex, let's go have sex' while touching/rubbing arms and shoulders. This resident appears to be tearful and upset at this time. A written statement signed by V17 (Certified Nurse Aide), V14 (Certified Nurse Aide), and V15 (Certified Nurse Aide) documents during ice pass and first round (on third shift) on 5/26/25 (R1) and (R3) told us that (R2) has been making unwanted sexual advances towards them they stated he told aren't you bored around here? Let's go to my room and have sex. The ladies (R1 and R3) stated they reported it to (V5/Activities Aide) and she told them she would have to tell nursing staff and management about the situation. Both female residents (R1 and R3) were very upset about the issue as well. We (V17, V14, and V15) tried to tell the nurse (V18/Registered Nurse) around 11:00 PM and she said she was leaving, and it wasn't her problem. On 5/29/25 at 12:00 PM, V15 (Certified Nurse Aide) confirmed that she herself and V14 and V17 all reviewed and signed the written statement from 5/26/25. V15 confirmed that V14 (Certified Nurse Aid) reported the allegation to V18 (Registered Nurse) and V18 stated it was not her problem and that she was leaving. V15 reported that V18 then gathered her belongings and left the facility. V15 stated that she was not aware of any ongoing issues with any of the mentioned residents (R1, R2, R3 and R4). V15 stated that V14 (Certified Nurse Aide) then began calling all management staff regarding the incident and that V1 (Administrator) finally called back and said to just leave written statements under her door. V15 stated that she has never been questioned about her written statement or any further concerns from any member of staff at the facility as of 5/29/25 at 12:00 PM. You are the first to ask me any questions about this. On 5/29/25 at 2:15 PM V14 (Certified Nurse Aide) confirmed that she herself and V15 and V17 all reviewed and signed the written statement from 5/26/25. V14 stated that R1 and R3 reported to all three CNAs (V14, V15 and V17) that R2 was in their room rubbing their shoulders and saying inappropriate sexual stuff to them and was making them very uncomfortable. I told (V15 and V17) we need to stop what we are doing and report this. We all three went to (V18/Registered Nurse) and she said she was not reporting anything because she was off at 11:00 PM and it was almost 10:45 PM. That upset all of us, so I started calling the on-call nurse who was V3 (Assistant Director of Nursing) approximately 6 times with no answer or return call, I tried (V2/Director of Nursing) twice with no answer and V1 (Administrator) answered on the second call. But even after I told V1(Administrator) that V18 refused to call her and that R1 and R3 were scared V1 only said well leave a written statement under my door. There is no way for me to know if any of this actually happened but what happened to protecting the residents? I specifically told (V1/Administrator) that (R1 and R3) were scared of (R2). No one came in, no one spoke to (R1 and R3) and reassured them they were safe or anything. I still have not been questioned by anyone at the facility about my written statement. You are the first person to ask any questions about this. On 5/30/25 at 10:00 AM V17 (Certified Nurse Aide) confirmed that she herself and V14 and V15 reviewed and signed the written statement from 5/26/25. V17 stated R1 and R3 reported to all three CNAs that R2 was rubbing their shoulders and saying aren't you bored? Don't you want to go have sex with me? V17 stated that all three CNAs reported R1 and R3's concerns to V18 (Registered Nurse) who stated it was not her problem because she was almost off work. V17 stated that V14 (Certified Nurse Aide) then started calling management staff to report both the fact that the nurse would not report the incident and that R1 and R3 were scared of R2. R2's Medical Record documents that he admitted to the facility on [DATE] with diagnoses to include but not limited to unspecified intracranial injury with loss of consciousness of unspecified duration, cerebral aneurysm non-ruptured, depression, mood disorder due to known physiological condition, insomnia and anxiety. R2's MDS (Minimum Data Set), dated 5/7/25, documents R2's BIMS (Brief Interview for Mental Status) was 15 of 15, indicating R2 is cognitively intact. R2's MDS documents R2 had no hallucinations or delusions. R2 had no physical or verbal behavioral symptoms directed at others or other behavioral symptoms not directed towards others. R2's current Care Plan, dated 7/26/2024, documents (R2) exhibits sexually inappropriate behavioral symptoms related to lack of self-respect, poor self-worth, feelings of inadequacy, Behavioral symptoms are manifested by making crude, sexually oriented, profane or suggestive remarks. Conduct an evaluation of the sexually oriented behavioral symptoms to determine what (R2) is communicating through the behavior, provide supportive interventions needed when inappropriate behavior is observed/reported. On 5/30/25 at 11:44 AM, V1 (Administrator) was notified of the Immediate Jeopardy. On 6/3/25, the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. R1 and R3 were moved to another unit away from R2 on 5/28/25. 2. R1 and R3 were seen by Psychiatric Provider on 5/30/25. 3. Trauma assessments updated R1 and R3 on 5/28/25. 4. R2's increased location monitoring, every fifteen minutes, starting 5/27/25 at 6:00 PM was reviewed. 5. R2's behavior monitoring started 5/30/25 for inappropriate behaviors, such as sexual misconduct and inappropriate touching of others, was added to the medication administration record, monitored by nurse was reviewed with no inappropriate behaviors documented for R2 since 5/30/25. 6. Inservice for the department heads done by V19 (Regional Director of Operations). 7. Education/Inservice sign in logs for all staff reviewed for 5/30/25. 8. Education/Inservice regarding abuse policy sign in log for V1 (Administrator) dated 5/28/25 reviewed 9. Education/Inservice regarding abuse policy sign in log for V5 (Administrator) dated 5/28/25 reviewed 10. Quality Assurance Meeting Minutes dated 5/30/25 regarding the abuse policy and the Immediate Jeopardy citation were reviewed. 11. On 6/3/25 at 9:45 AM R1 and R3 were in their new room and both R1 and R3 stated they felt safe in the facility.

Based on observation, interview, and record review the facility failed to follow their policy and procedures for discharge planning for three residents (R1, R2, and R3) and unplanned discharge for three residents (R1, R4, and R5) of four residents reviewed for discharge in the sample of six. Findings include: The facility's undated, Unplanned Discharge policy and procedure, documents: Policy: For purposes of providing the safest discharge possible, the facility will advise residents of the risks of early, unplanned discharge, and provide appropriate referrals and discharge instructions whenever possible. Discharge Against Medical Advice (AMA) procedure documents to obtain and witness residents' signature on AMA form. If resident refuses to sign, consider AWOL (Absent Without Official Leave) procedure documents: Resident not returning from pass, LOA (leave of absence), or outside appointments as scheduled will be considered AWOL. Resident who leaves the facility with staff knowledge, without following proper procedure and/or without signing AMA will be considered AWOL. This policy documents the Social Worker or Nurse will: Notify Adult Protective Services (APS), if applicable and Make necessary attempts to locate the resident's whereabouts. The Social Service Director (SSD) Job Description, dated 1/29/24, documents the SSD Must assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis; safeguard the health, safety, and welfare of all residents of the facility. The person holding this position is delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures. The essential job functions include: Communicates with the elderly with communication problems and relay their needs/concerns to family, facility, and community agencies. 1. The Progress Note for R1, dated 5/9/25 at 12:00 PM, documents R1 is alert and oriented to person, place, time and event and able to make her needs known. R1 reported to Nursing she was leaving via local community transport and did not say where she was going. The Progress Note for R1, dated 5/9/25 at 9:15 PM, documents the day shift reported R1 left the facility via local community transport and at 9:00 PM, R1 had not returned. At 9:15 PM R1's closet was checked revealing all R1's belongings were gone. There are no Progress Notes documenting Adult Protective Services were notified or that anyone tried to locate R1. The Progress Note for R1, dated 5/10/25 at 6:34 AM, documents a night shift CNA/Certified Nursing Assistant called reporting seeing R1 at a local fast-food restaurant with her belongings in a shopping cart that was parked outside the entrance of the establishment. On 5/13/25 at 9:30 AM, R1 was not residing in the facility. On 5/13/25 at 12:00 PM through 12:45 PM, Upon arrival to the local fast-food restaurant this writer noted a shopping cart at the corner of the building, on the entrance side of the establishment, filled with plastic bags with a blue beach chair on top of the cart. Upon entering establishment this writer noted R1 sitting in dining booth, wearing a black hooded sweatshirt with hood pulled up on her head, unkempt, messy, and disheveled, with her legs elevated resting on the booth's seat and with foul odor present. R1 was talking to herself, raising her arms and pointing into the air. Approached R1 in attempt to interview and R1 made no eye contact and did not respond to this writer. On 5/13/25 at 1:30 PM, V5 LPN/Licensed Practical Nurse stated on 5/9/25, at supper time, she asked if R1 had returned to the facility and was told no. On 5/13/25 at 2:00 PM, V8 Receptionist stated R1 was signed out of the facility on 5/9/25 and did not return. On 5/14/25 at 1:36 PM, V10 (R1) Friend stated she just found out she was listed as an emergency contact for R1, her telephone has not been disconnected, and she was not notified on 5/9/25 by the facility that R1 had left the facility and not returned. V11 (R1's) Friend is listed as R1's first emergency contact and was not notified of R1 leaving the facility either. V10 stated she received two missed calls from R1 the night of 5/9/25 and on 5/12/25 was notified by a friend that R1's shopping cart was located outside a local fast-food restaurant. V10 and V11 visited R1 at the local fast-food restaurant on 5/13/25 and R1 said no one has spoken to her from the facility. On 5/13/25 at 11:30 AM, V2 DON (Director of Nurses) stated on Friday night (5/9/25) V2 received a telephone call from the facility that R1 had not returned from her outing on 5/9/25. V2 DON stated the police were not called, no one went to look for R1, R1 never came back to the facility, and was discharged . On 5/14/25 at 9:30 AM, V1 Administrator stated she received a telephone call the night of 5/9/25 that R1 had gone out and didn't return to the facility. V1 Administrator stated nothing else was done after R1 left the facility, there is no investigation, police were not called, and no one looked for R1. 2. The Progress Note for R4, dated 10/21/24 at 10:45 AM documents R4 left with friend to go to doctors' appointment. The Progress Note for R4, dated 10/22/24 at 9:41 AM documents R4 was absent from the facility. The Progress Note for R4, dated 10/22/24 at 11:49 AM documents R4 was contacted and R4 stated she would go to the local emergency room for evaluation before returning to the facility. The Progress Note for R4, dated 10/22/24 at 6:00 PM documents R4 has not returned to the facility and if not back by 8:30 PM would be discharged . There are no Progress Notes indicating Adult Protective Services were notified or that anyone tried to locate R4. On 5/15/25 at 12:45 PM V4 SSD confirmed R4 signed out of the facility on 10/21/24, did not return, and nothing else was done. V4 SSD stated R4 was alert and oriented and it was her right not to return to the facility. On 5/14/25 at 9:33 AM, V1 Administrator confirmed R4 left the faciity on [DATE], did not return to the facility, there is no investigation, police were not called, and no one looked for R4. 3. The Progress Note for R5, dated 10/1/24 at 8:15 AM documents R5 wanting to leave facility AMA, understands risks of leaving, refuses to sign AMA paperwork. The Progress Note for R5, dated 10/1/24 at 12:03 PM documents exit alarm sounded and R5 was noted outside with his belongings. Attempts were made to redirect back inside but R5 refused, stating he would become physically aggressive with staff. On 5/15/25 at 12:48 PM, V4 SSD confirmed R5 left the facility AMA with his personal belongings on 10/1/24 without signing AMA paperwork and nothing else was done. On 5/15/25 at 9:35 AM, V1 Administrator confirmed R5 left the faciity on [DATE] AMA and refused to sign AMA paperwork, did not return to the facility and nothing else was done. On 5/15/25 at 2:00 PM, V1 Administrator confirmed Adult Protective Services should have been notified of R1, R4, and R5's AWOL status and staff should have looked for R1 and R4. The facility's undated Discharge Planning Policy, Protocol, and Procedure documents its purpose: To identify appropriate candidates for inclusion in active discharge planning facilitating the transition to a less structured environment and to coordinate adequate supportive community care services. This nursing facility strongly emphasizes preparation and preparedness. The goals and objectives include: To anticipate and minimize potential problems related to discharge; To assist families and significant others in preparing for discharge; To assure the involvement of the Social Work staff in assessing discharge potential, documenting significant information related to discharge and coordinating community health care services. The Social Service Director Job Description, dated 1/29/24, documents the SSD assists in planning, developing, organizing, implementing, evaluating, and directing social service programs. Must assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. The person holding this position is delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures. The essential job functions include: Coordinates discharge planning and maintain ongoing notes regarding discharge planning for appropriate residents. 4. The current Care Plan for R1, documents R1 would like to return to the community and live independently. The Quarterly Care Plan for R1, dated 4/19/25, documents there is no active discharge planning occurring for R1. The Progress Notes for R1 do not include any Social Service notes or further discussion regarding active discharge planning being done for R1 after 2/27/24. On 5/13/25 at 12:40 PM, V4 SSD stated R1 stated she did try to help R1 on 2/27/24 with filling out paperwork with the housing authority but R1 backed out and there has been nothing else since then. 5. The current Care Plan for R2 documents R2 expressed the desire to move to a less structured environment, discharge potential and planning needs have been assessed, and R2 demonstrates self-sufficiency skills. The Admission MDS (minimum data set) Assessment for R2, dated 2/12/25, documents R2 is cognitively intact and R2's overall goal is to discharge to the community and no active discharge planning occurring. The Discharge Planning Review for R2, dated 5/12/25, documents: R2's discharge potential as Fair; Discharge Status as Personal residence with support services.; and Discharge Plan as Do not initiate. The Progress Notes for R2 do not include any Social Service notes or active discharge planning being done for R2. On 5/13/25 at 1:42 PM, R2 was walking up the hallway independently, was clean, well kept, and without odors. R2 stated she is staying in the facility until she can find a three-bedroom house. R2 stated she has been asked about her discharge plan, but no one is helping her to get out of the facility. 6. The current Care Plan for R3 documents R3 expressed the desire to move to a less structured environment, R3's discharge potential and discharge planning needs have been assessed and R3 demonstrates self-sufficiency skills. The Quarterly MDS Assessment for R3, dated 4/16/25, documents R3 is cognitively intact with no discharge planning occurring. The Discharge Planning Review for R3, dated 4/6/25, documents: R3's Discharge Potential as Fair; Discharge Status as Personal residence with support services; and Discharge Plan as Do not initiate. On 5/13/25 at 1:48 PM, R3 was walking up the hallway independently, was clean, well kempt, and without odors. R3 stated she wants to find a place to live, the facility is aware, and she has asked for help but not getting it. On 5/15/25 at 12:40 PM V4 SSD stated discharge planning is different for every resident and is based on the resident's cognition and done case by case. If a resident is alert and oriented and choses to leave, they have the right to leave if they want to. If a resident or family member is helping a resident with discharging from the facility V4 SSD does not interfere but if asked to assist she will. Once a resident says they are ready or want to leave, V4 will then start the discharge plan, and the documentation would be found in the resident progress notes. V4 SSD stated R2 and R3 are related and are wanting to discharge together and is not sure what their plan is. V4 stated if R2 and R3 want her help she would help them but R2 and R3 have not asked her. V4 SSD confirmed there is currently no discharge plan in place for R2 and R3 and there was no active discharge plan in place for R1 prior to R1 leaving the facility.

Based on interview and record review the facility failed to ensure a resident's bed was in the low position and the mat was on the floor to prevent injury from falling out of bed. This applies to 1 of 3 residents (R3) reviewed for safety in the sample of 3. The findings include: R3's Incident Report dated 3/22/25 at 6:50AM states, Resident was lying on the floor next to the bed on his left side with his right arm underneath him. Blood noted to hand and when assessed it was from laceration to right eyebrow. When resident asked if he fell out of bed he nodded and said yes and was pointing at something he was reaching for a drink. The facility Final Investigation Report dated 3/22/25 states, Facility completed its investigation and it was determined thru multiple interviews with staff and resident that resident became impulsive and impatient, did not request for staff assistance when attempting to retrieve an item, subsequently fell and sustained an open area to the right eyebrow requiring sutures . R3's Progress Notes dated 3/22/25 at 7:37 AM state, Resident was laying on floor of room next to his bed. (Mechanical Lift) sling was on bed as someone had put it under him and bed was left in high position. Bleeding noted to right eyebrow. Resident sent to ER (emergency room ). and at 10:39 AM Returned from ER. CT (CAT scan) of cervical spine and head without contrast. X- Ray of right hip and pelvis. Sutures to right eyebrow and bruising noted upon return. R3's Progress Notes dated 3/22/25 at 2:48 PM state, Resident assisted to bed and complains of right leg pain. Previous X- Ray done at ER with no findings. PRN (As needed) pain pill given and explained to resident he is going to be sore from falling from bed to floor. R3's Progress Notes dated 3/23/25 at 5:53 AM state, Stayed in bed tonight. Sutures intact above right blackened eye. Complains of pain to eye area, right knee and left side, pain pills bring relief and sleepiness. On 5/6/25 at 2:25PM V8 (Night shift CNA- Certified Nursing Assistant) stated, I left about 6 AM, I heard about the fall later. We often get him up on night shift and sometimes we get him ready but if I don't have anyone to help me because you need two staff to use the (Mechanical Lift) then I will just leave him in the bed. I don't think I would have left the bed in the high position. I don't recall doing that. On 5/6/25 at 3:30 PM V9 (Day Shift CNA) stated, (R3) is a midnight get up so I didn't even go in there when I got there. I was down the hall getting someone else up and I had to go find help because she is a (Mechanical Lift) transfer. I went down the hall and I saw him lying on the floor next to his bed. His bed was kind of high up and there was no mat on the floor. He is supposed to have a mat. I saw he was bleeding so I ran to get the nurse. The (Mechanical lift) sling was lying on the bed like it had been under him. He said he was reaching for his pop when he fell off the bed. On 5/7/25 at 10:10 AM V7 (RN- Registered Nurse) stated, The CNA (V9) came to the nurse's station and said (R3) was on the floor. I went to the room and he was on the floor. The bed was in the high position and there was no mat on the floor. It was like the night shift CNA got the (Mechanical Lift) sling under him and got ready to get him up and then never went back to get him up. He had a cut above his right eye and I sent him to the ER. He got sutures and had some bruising when he came back but I didn't notice anything else different about him. He is very difficult to understand. He points to things when he has pain but that is about all. He is dependent for care and uses a (Mechanical Lift) for transfers. R3's EMR (Electronic Medical Record) shows his current care plan as: (V3) is at Risk for Falls as evidenced by the following risk factors and potential contributing Diagnosis: CVA (Cerebrovascular Accident) with Right Hemi, COPD (Chronic Obstructive Pulmonary Disease), Atrial Fibrillation, CHF (Congestive Heart Failure), Epilepsy, Neuralgia and Neuritis, Cervicalgia, BPH (Benign Prostatic Hypertrophy), Depression, Anxiety,and HTN (Hypertension). The Interventions include: 5/7/2023--Place my bed in the lowest position while I'm in bed and 7/18/2022 Apply Floor Mats to the side of my bed.

Based on interview and record review the facility failed to provide evening snacks for seven of seven residents (R7, R8, R15, R28, R33, R45, R55) reviewed for evening snack provision in the sample of 32 residents. Findings include: The facility's HS (evening/hour of sleep) Snacks policy, dated 8/8/2024, documents the following: Snacks are available to residents to offer nourishment at HS. The Food & Nutrition department will send snacks to the nursing stations at HS. Residents may be offered snacks such as graham crackers, cookies, fig newtons, pudding, applesauce (according to the resident's diet order and/or preferences.). The Food & Nutrition department will maintain a system or snack list for labeling & delivering snacks to those residents that receive scheduled snacks as part of their plan of are/preference. Resident Council Meeting Minutes, dated 10/28/24, documents concerns that Snacks and Coffee are not being passed out. On 4/7/25 at 9:45am, during the Survey Group Meeting, every attending resident stated that evening snacks are not being given to residents very often. R7 stated, We don't get evening snacks very often. R33 stated, Sometimes we do get (evening snacks) and sometimes we don't. R28 stated, They either don't bring them or they are delivered late, when we're asleep and we can't eat them. On 4/8/25 at 1:15pm, R8, R15 and R55 verified evening snacks are not being offered on a regular basis. On 4/8/25 at 2:50pm V16 Dietary Manager stated evening snacks should be passed every day around 6:30pm.

Based on interview and record review the facility failed to provide a copy of the bed hold policy for residents discharging to the hospital, for two of four residents (R53 and R56) reviewed for bed holds, in the sample of 32. Findings include: The facility's Bed Hold policy, revised 11/28/2016, documents It is the policy of the facility to provide the Resident, Resident's family member and/or the Resident's legal representative, if applicable, in written form and/or by telephone conversation prior to transfer to a hospital or prior to a Resident beginning therapeutic leave, for a duration of 24 hours or longer; certain information regarding the Resident's facility bed status and how the bed will be held. A copy of the Bed Hold policy given to the Resident, Resident's family member and/or the Resident's legal representative will be placed in the Resident's record. This will be documented in the resident's record. R53's medical record documents that R53 was hospitalized on [DATE], 12/3/24 and 3/15/25. R53's medical record does not contain documentation of written notice to R53 or R53's resident representative, of the facility bed hold policy. On 4/7/25 at 10:00am, V2, Director of Nursing, verified that R53 was not given the bed hold policy at the time of the discharge to the hospital. On 04/08/25 at 11:14am, V1 Administrator, stated that the bed hold policy given to the residents on discharge to the hospital should be uploaded into the medical record under the documents tab. V1 verified that R53 did not have any bed hold policy paperwork in his medical record. 2. R56's Progress note for time of transfer, dated 1/18/24 at 1:18 PM, documents R56 was transferred to the local hospital with paramedics for evaluation for pain in both hips and legs after a fall. R56's medical record does not document a bed hold policy was provided to R56 upon being transferred to the hospital on 1/18/25. On 4/9/2025 at 11:00 AM, V1 (Administrator) confirmed R4 was sent to the hospital on 1/18/2025. V1 stated I searched for proof of my nurse that day giving notice of transfer and Bed hold policy, but she did not do it. The nurse working that day should have done it, it is something we missed.

Based on interview and record review, the facility failed to ensure one allegation of abuse was immediately reported to the facility abuse coordinator for one of one resident (R19) reviewed for abuse in the sample of 32. FINDINGS INCLUDE: The facility policy, Abuse Prevention Program, dated (revised) 01/2029 directs staff, It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment and misappropriation of resident property and a crime against a resident in the facility. The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or an allegation of suspected abuse or neglect of a resident by a third party. Employees are required to immediately report any incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment or a crime against a resident they observe, hear about or suspect to the (facility) administrator. The facility form, Concerns, dated 3/23/25 and completed by V8/Social Services Director documents, (V11/R19's daughter) called with concerns over (R19) getting a shower after loose stools. Staff educated. Discussed occurrence with CNAs (Certified Nursing Assistants). On 4/7/25 at 1:33 P.M., R19 stated, A while back, in the evening, I had a bad accident. I had loose stools and it was all over my clothes, the toilet, the floors and the walls. I was really embarrassed. One of the CNAs (I don't remember which one) said to me, 'Oh my lord, I have to clean up this shit.' It made me feel really bad. I didn't mean to do it. I can't help it. She told me I need to get up out of my chair and clean it up myself. The other two CNAs were laughing at me. On 4/7/25 at 2:33 P.M., V5/Licensed Practical Nurse stated, I worked the weekend of March 22/23, 2025 and I recall an incident where (R19) had a large, loose stool and had made quite a mess. (R19) didn't tell me about it, but her daughter (V11) called me, later that day. (V11) said (R19) had called her and was very upset and crying and said she had an accident and when the three CNAs were cleaning her up they were laughing and yelling at her. It's not uncommon for R19 to get upset and call her daughter and not tell the nurse if something is bothering her. I did call (V2/DON) and report it to her, right after (V11) called me. On 4/7/25 at 3:25 P.M., V2/Director of Nurses stated, I call the nurses on the weekends to remind them to have the CNAs give (R19) her shower. She gets a shower on Tuesdays and Saturdays. Her daughter (V11) is very particular about (R19's) care. I can't remember if (V5/LPN) called me about the incident involving (R19) on 3/23/25, but I think R19's daughter (V11) texted me. I didn't report the incident to (V1/Administrator). On 4/8/25 at 12:13 P.M., V14/Social Services Director stated she did not report the incident of potential abuse involving R19 to the facility abuse coordinator (V1/Administrator).

Based on observation and record review, the facility failed to investigate an allegation of abuse for one of one resident (R19) reviewed for abuse, in the sample of 32. FINDINGS INCLUDE: The facility policy,Abuse Prevention Program, dated (revised) 01/2019 directs staff, It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment and misappropriation of resident property and a crime against a resident in the facility. Upon learning of the report, the Administrator shall initiate an incident investigation. On 4/7/25 at 1:33 P.M., R19 stated, A while back, in the evening, I had a bad accident. I had loose stools and it was all over my clothes, the toilet, the floors and the walls. I was really embarrassed. One of the CNAs (I don't remember which one) said to me, 'Oh my lord, I have to clean up this shit.' It made me feel really bad. I didn't mean to do it. I can't help it. She told me I need to get up out of my chair and clean it up myself. The other two CNAs were laughing at me. On 4/7/25 at 2:33 P.M., V5/Licensed Practical Nurse stated, I worked the weekend of March 22/23, 2025 and I recall an incident where (R19) had a large, loose stool and had made quite a mess. (R19) didn't tell me about it, but her daughter (V11) called me, later that day. (V11) said (R19) had called her and was very upset and crying and said she had an accident and when the three CNAs were cleaning her up they were laughing and yelling at her. It's not uncommon for R19 to get upset and call her daughter and not tell the nurse if something is bothering her. I did call (V2/DON) and report it to her, right after (V11) called me. On 4/8/25 at 3:02 P.M., V1/Administrator stated, I wasn't made aware of an allegation of potential abuse involving (R19) that occurred on 3/23/25. I don't have an investigation.

Based on interview and record review, the facility failed to perform a PASRR (Pre-Admission Screening and Resident Review) rescreen after the emergence of a newly diagnosed severe mental illness for two of two residents (R19 and R54) reviewed for PASRR screening, in the sample of 32. Findings include: The facility policy, Guidelines For PASRR Process, dated 5/17/2023 documents, PASRR is a federally mandated process that requires all states to pre-screen all residents regardless of their payer source or age who are seeking admission to a Medicaid funded nursing facility. PASRR has three goals (including) To ensure residents receive the required services for mental illness. Residents who are confirmed to have Mental Illness are evaluated to determine the need for specialized services, and appropriate placement options are reviewed. 1. R19's (facility) Face Sheet documents that R19 was admitted to the facility on [DATE] with the following diagnoses: Generalized Anxiety Disorder, and Schizoaffective Disorder, Bipolar Type. R19's Notice of PASRR, dated 4/10/23 documents, No Level 11 required- No Serious Mental Illness. 2. R54's (facility) Face Sheet documents that R45 was admitted to the facility on [DATE] with the following diagnoses: Bipolar Disorder Generalized Anxiety Disorder and Major Depressive Disorder. R54's Notice of PASRR, dated May 13, 2024 documents, No level 11 required- No Serious Mental Illness. On 4/7/25 at 2:27 P.M., V8/Social Services Director verified that R19 and R54 had not had a PASRR rescreen upon the emergence of a newly diagnosed severe mental illness.

Based on interview and record review, the facility failed to have sufficient nursing staff on 12/8/23. This failure resulted in cares not being provided timely, and R3 becoming tearful to staff, crying, and stating she feels like a burden. Findings include: Facility Assessment Tool, dated 12/1/23, documents, General Staffing plan to ensure that we have sufficient staff to meet the needs of the residents at any given time. CNAs (Certified Nursing Assistant) day shift 4-7, and One restorative aide. Facility Resident Rights pamphlet, undated, documents, The facility must care for you in a manner and environment that promotes your quality of life. Facility staffing sheets provided by V1, Administrator, documents on 12/8/23 day shift, the following nursing staff were present: V22 nursing from 9:41am-3:52pm; V23 nursing from 5:58am-6:25am; V14 CNA from 5:57am-2:28pm; V24 nursing from 5:58am-6:25am; V15 nursing from 5:57am-6:25am; V26 5:50am-10:00am; On 12/28/23 at 10:45am, R2 was alert and oriented, clean and in bed, and stated, There is not enough staff working here; they use agency staff, and the staff is ok here, but not enough. R2's electronic medical record documents R2 is dependant on staff for cares. On 12/28/23 at 10:55am, R3 was in bed in her room, alert and oriented and stated, I am a quadriplegic and require two persons and they don't have enough staff; sometimes I get dressed; call lights can be on for over an hour; I have been here 1.5 years; the staff here is ok but I have stopped asking for things because there is not enough of them and I feel like a burden (at that same time R3 became tearful and crying); I soaked the bed and linens on 12/8/23 because I was not changed; I wear a brief but I soak through it on 12/8/23 head to toe. At the same time resident was interviewed she was tearful and stated that it didn't matter any more. R3's electronic medical record documents R3 is quadriplegic and dependant on staff for cares. On 12/28/23 at 12:00pm, R1 was in bed, alert and oriented and stated, On 12/8/23 there were only two nurse aides (V4 and V14) in the whole facility, where one was on the locked unit per policy. (V4) was not certified until just recently; I can have my call light on for 15-20 minutes up to 1.5 hours, depending on who is working; I can't get out of bed without two people. R1's electronic medical record documents R1 is quadriplegic and dependant on staff for cares. On 12/28/23 at 12:40pm, V10, HR (human resources)/BOM (Business Office Manager) stated, I was doing the CNA/nursing schedule. We have 5-6 CNAs on day shift with restorative and transport who is a CNA. We have been using agency since August or September for Nurses and CNAs. Our CNAs work 8 hour shifts from 6-2 with 5-6 CNAs, 2-10 with 5-6 CNAs, and 10-6am with 3-4 CNAs. We go by the state guidelines. On 12/28/23 at 1:30pm, V2, DON/Director of Nursing, stated, I do the nurse staffing and we had COVID-19 on 12/8/23 in the facility. We try to have five CNAs on first shift, and I did not work 12/8/23 on the floor. On 12/29/23 at 2:00pm, V4, Housekeeping/CNA, stated, I worked on 12/8/23 from 6am-4pm, me and (V14) were the only CNAs. (V1) did not come in because of something with her child. C-hall is a secured unit and supposed to have a CNA down there at all times. There was no CNA on C-hall on 12/8/23, because we had no staff. (V1) did come in on 12/8/23 from 12-1pm and collected lunch trays, but did not perform any cares. On C-hall (V11) Activity Director, (V8) Housekeeping, and (V3) SSW/Social Service Worker were down C-Hall monitoring residents on 12/8/23. (V14) worked on 12/8/23 until 2pm and I worked until 4pm. I am a new CNA; just finished schooling. V4's Health Care Worker Registry provided by V1, Administrator, documents V4 completed CNA/Certified Nurse Aid training on 12/7/23, and Competency Evaluation (certified) was completed on 12/12/23. On 1/2/24 at 10:45am, V8, Housekeeping, stated, I am not a CNA, I work in housekeeping. On December 8th, they needed help taking care of the residents on C hall. Me, (V11), and (V3)were on C-Hall answering call lights and monitoring residents. (V1) was not here on 12/8/23. On 1/2/24 at 9:00am, V14, Transport/CNA, stated, I worked 12/8/23 until 2:45pm, (V4) and I providing cares for the residents for the whole building. The two nurses were here. We changed and fed residents, and the nurses passed trays. On 12/8/23, we couldn't get residents out of bed, dressed, perform incontinent cares, do every two hour checks on residents, and answer call lights in a timely manner with just two of us. On 12/8/23, (R3) was incontinent head to toe when we went to change her, and she was tearful, crying, and stated she feels like a burden. On 1/2/24 at 11:30am, V18, Ombudsman, stated, There are staff shortages all the time, and staffing has been bad since June 2023. On 1/2/24 at 11:55am, V12, R3's daughter/POA (Power Of Attorney), stated, On 12/8/23, when I was on C-wing visiting mom, there were no CNA's on the wing. (V8) Housekeeping was there and answered moms call light, but what good was she when she can't do personal cares. Mom is not getting what she needs if there is no staff. On 1/2/24 at 1:00pm, R3 was alert and oriented and verified on 12/8/23, V11, Activity Director, V4, nurse aid, and V8, Housekeeping, were the only staff on C-hall, with no certified nurse aides because no certified nurse aides were available. On 1/4/24 at 9:00am, V1, Administrator, stated, We use shift key and clipboard agency, and December 8th we only had two of our own CNA's. On 1/5/24 at 10:36am, V1, Administrator, stated On 12/8/23, (V4) and (V14) were CNA's on the flo.r, I had management and department heads helping out as well, my son had an appointment that day, and HR/Human Resources, who is not here anymore, is a CNA and helped out; her primary duty that day was HR.

Based on observation, interview, and record review ,the facility failed to monitor the cooling down process of an undated, cooked pork roast on [DATE] at 5:58 am, and attempted to serve it for the noon meal on [DATE]; failed to wear the proper PPE (Personal Protective Equipment) during the preparation of food and during the sanitation of resident utensils; failed to date cooked food items to ensure use before expiration; failed to discard expired food; and failed to monitor and record the required refrigerator, freezer, and milk cooler temperatures, food temperatures of served foods, and the required dishwasher sanitation levels. As a result of these failures, a serious potential of adverse outcome is likely to occur in an outbreak of foodborne pathogen illness when undated/ outdated food, observed on the initial kitchen tour on [DATE], and the facility was preparing the pork roast to be served for the noon meal on [DATE]. These failures have the potential to affect all 55 residents residing in the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level 2, as the facility implements the following: The facility Dietary Manager needs to be re-educated on cooling of cooked potentially hazardous foods. All facility Dietary Staff need to be educated on the process to follow when cooling down cooked foods to prevent the growth of pathogens A process to ensure facility Cool Down Logs for dietary staff to use are readily available. A Quality Assurance Plan needs to be developed to monitor Cool Down Logs. All kitchen staff need reeducated on the implementation and use of cool down logs Findings Include: The facility policy, Cooling Foods, dated ,d+[DATE], directs staff, The facility will follow sanitary and acceptable techniques of cooling Potentially Hazardous Foods. The rapid cooling process will reduce the growth of pathogens in the temperature danger zone. Cooked foods are cooled rapidly within 2 hours, from 135 degrees to 70 degrees, and within 4 more hours to the temperature of approximately 41 degrees. The total time for cooling should not exceed 6 hours. Several factors including thickness/density of the food, size of food and storage containers will be considered as they can affect the cool down process. The facility policy, Leftover Food, dated ,d+[DATE], directs staff, The facility will follow safe handling and storage of leftover foods. Leftover foods will be kept out of the temperature danger zone following the cooling process. Foods will be rapidly cooled and documentation of rapid cooling will be maintained. Label leftover foods with the common name, date and time of storage. Items can be stored for up to 7 days and then discarded. The facility policy, Glove Use, dated ,d+[DATE], directs staff, The facility will practice safe food handling and avoid cross contamination through proper use of gloves. Single-use gloves should be used and bare-hand contact must be avoided when handling ready to eat foods. The facility policy, Employee Health and Personal Hygiene, dated ,d+[DATE], directs staff, Food service employees shall maintain good personal hygiene and be free from communicable illnesses and infections while working in the facility. Hair restraints will be worn at all times. The facility policy, Dating and Labeling, dated ,d+[DATE], directs staff, The facility will follow safe handling and storage of potentially hazardous foods. Potentially hazardous foods will be stored, dated and labeled in the refrigerator and held at at 41 degrees for a maximum of 7 days. The (undated) facility policy, General Preparation and Cooking Practices directs staff, The facility will follow sanitary practices in food preparation and cooking to keep food safe. Identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby prevent foodborne illness. The facility policy, Sanitizing Buckets, dated ,d+[DATE], directs staff, The facility will use sanitizing buckets with wipe cloths to sanitize preparation and food service areas. The facility will follow manufacturer's recommendation on the amount of sanitizing solution to use. Sanitizing concentration will be checked using a test kit. Quaternary Ammonia: ,d+[DATE] PPM (Parts Per Million). The facility policy, Storage of Refrigerated/Frozen Foods, dated ,d+[DATE], directs staff, The facility will follow safe handling and storage of refrigerated and frozen foods. Monitoring of food temperatures and functioning of the refrigeration/freezer units will be in place. The facility Week AT A Glance Menu for [DATE] documents for the facility Noon Meal: Garlic Herb Pork Roast, New Potatoes in Jackets, Seasoned Green Beans, Frosted Yellow Cake. On [DATE] at 6:53 am, the facility Dishmachine Temperature Log, dated [DATE], documents, Please log wash and rinse temperatures when washing dishes, prior to utilizing the dishmachine to ensure that the wash and rinse temperatures are properly monitored and controlled. No breakfast, lunch or supper wash or rinse temperatures are documented after [DATE]. At that time, V30/Dietary Aid verified the missing documentation. On [DATE] at 6:53 am, the facility Dish Machine PPM (Parts Per Million) Log, dated [DATE], does not contain documentation the facility dish machine was checked on [DATE] for the Noon Meal and Dinner Meal, or on [DATE] for the Breakfast Meal, Noon Meal, or Dinner Meal. On [DATE] at 6:53 am, the facility Dietary Department Temperature Log, dated [DATE], does contain documentation the facility kitchen refrigerator, storage room refrigerator, dining room refrigerator, freezer and milk cooler on [DATE] was checked. V31/Dietary Aid verified the missing documentation. At that time V30/Dietary Aid stated, Sometimes we forget to do the logs and fill them in when we remember. On [DATE] at 5:53 am, V29/Cook and V30/Dietary Aid were present in the facility kitchen. V30, Cook, was placing cooked sausage in the facility blender with ungloved hands. V30/Dietary Aid was washing dishes with the facility dishmachine. V30 had no hair restraint covering her hair. On [DATE] at 6:00 am, an observation of the facility refrigerator in the kitchen contained: undated, cooked sausage patties in a plastic bag, a 5# container of Low Fat Cottage Cheese, ,d+[DATE]/full with an outdate of [DATE], a 5 X & metal container of undated cooked ground meat and a ,d+[DATE] # undated, cooked pork roast, covered in foil. At that time, V30/Cook verified the presence of the out-dated and undated food and the pork roast. At that time, V30/Cook stated, I cooked it yesterday ([DATE])afternoon. I am serving it for lunch today. I don't have a cool- down log. I have never seen a cool down log. No completed Food Temperature Log for facility served food, after [DATE], was available. On [DATE] at 7:34 am, the filled kitchen cleaning bucket, located on the countertop, was checked for the required solution with V4/Dietary Services Manager. The Quandary Ammonia solution did not register on the test strip. (Normal: 200 PPM). At that time, V4/Dietary Services Manager verified the test result, and disposed of the cleaning solution. On [DATE] at 7:35 am, V4/DSM verified the undated, cooked pork roast in the facility kitchen refrigerator, and also verified no cool down log for the cooked pork roast was available or completed. At that time, V4/ DSM stated the cool down logs were printed from her computer, if, and when they were needed. V4/DSM also stated she is the only Dietary staff member who has access to print the cool down logs. At that time, V4/DSM was unable to produce any cool down logs for prior use, in the past year. V4/DSM stated, We never use them (cool down logs) because we don't cook food ahead of time. We cook it the day it is to be served. On [DATE] at 9:30 am, the undated, improperly cooled pork roast was cooking in the facility oven. At that time, V29/Cook stated, I'm reheating the pork roast to serve for lunch today. On [DATE] at 11:15 am, V29/Cook stated, The pork roast is still heating up. The ground pork roast is in the steam table. On [DATE] at 11:18 am, surveyor notified V4/Dietary Services Manager the facility was unable to serve the undated, improperly cooled pork roast to the facility residents for the meal. At that time, V4/DSM stated, Why can't we serve the pork roast? At that time, it was explained again, the pork roast was improperly cooled down on [DATE]. On [DATE] at 11:59 am, V31/Cook stated, I removed the pork roast from the oven around 2:00 P.M. ([DATE]) and placed it on top of the stove to cool. I placed it in the refrigerator at 7:00 P.M. At that same time, V31/Cook stated she did not use a cool down log during the time the pork roast sat on the stove top until she placed it in the refrigerator, nor did she check the temperature of the pork roast at any time. The facility Resident Census and Conditions Report for Medicare and Medicaid Services (CMS), dated [DATE] and signed by V9/Minimum Data Set Assessment Coordinator, documents 55 residents currently reside in the facility. The Immediate Jeopardy began on [DATE] at 2:00 pm, when V31/Cook removed the pork roast from the oven, placed it on top of the stove, and failed to monitor the temperature of the pork roast during the required time/temperature cool down process. V1/Administrator was notified of the Immediate Jeopardy on [DATE] at 11:50 A.M. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: All residents have the potential to be affected by the alleged deficient practice. The Dietician re-educated the Dietary Manager and all Dietary staff on [DATE] on the process to follow when cooling down cooked foods to prevent the growth of pathogens and proper documentation on the cool down logs. A initial audit was done on [DATE] on the logs and outdated food. Outdated food was removed on [DATE]. The Dietician in-serviced the Dietary Manager on [DATE] on having cool down logs readily available/accessible at all times for dietary staff in the kitchen. Additionally, the Dietician in-serviced the Dietary Manager on [DATE] and all dietary staff were in-serviced on [DATE] on the following: 1) Wearing proper personal protective equipment during food preparation and sanitation of resident utensils 2) Dating cooked food items to ensure use before expiration and checking daily and discarding expired food, 3) Recording refrigerator, freezer and milk cooler temperatures, 4) Taking and recording food temperatures of foods being served 5) Understanding the required dishwasher sanitation levels and corresponding documentation. Compliance related to this plan will be conducted by the Administrator/dietician/designee 7 days per week. This monitoring will include weekend days. Afterwards, this monitoring will continue 3 days weekly for a period of not less than 3 months to ensure ongoing compliance. After that, random monitoring will occur ongoing. Any concerns will be addressed if found. A member of the Regional Team, (RDO/RNC), will review the audits weekly x 4 weeks for additional oversight to ensure that any needed follow up occurred. Any concerns will be addressed if found. Any Dietary staff who fail to comply with the aforementioned in-servicing will be further educated and/or progressively disciplined as indicated. No staff will work in the Dietary department after [DATE], unless they have been in-serviced. This includes newly hired staff. This education will be conducted by the Dietary Manager/Dietician/ designee. All monitoring done by facility staff as well as by Regional Team staff (RDO/RNC) will be presented to the QAPI Committee at their weekly meetings. Any concerns will have been addressed. However, any patterns will be identified. If indicated, an Action Plan will be written by the QAPI Committee. Any Action Plan will be monitored weekly by the Administrator until resolved. A member of the Regional Team, (RDO/RNC), will attend the QAPI meetings either in person or remotely for a period of not less than 3 months to serve as additional oversight, reference and support. Note: When the facility is placed back into substantial compliance, QAPI meetings will go to monthly. An Ad-Hoc QAPI meeting was held for the IDT on [DATE], conducted by the Administrator, with input from the Regional Team, (RDO/RNC), to discuss the points of this allegation of compliance.

Based on interview and record review, the facility failed to ensure necessary gastrostomy equipment was available, failed to administer gastrostomy tube feeding per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in R98 suffering respiratory distress, being hospitalized with new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in an Immediate Jeopardy. While the Immediacy was removed on 9/30/21, the facility remains out of compliance at Severity level two while the facility is in the process of educating the Medical Director, reviewing the new gastrostomy and [CONDITION(S)] process, and initiating the Quality Assurance Audit tools for compliance. Findings include: The facility Enteral Tube Care and Feeding policy and procedure, Revised 11/01/11, documents (Procedure: 1. Verify Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Residual Check: Residual is verified prior to each feeding and every 8 hours during feedings and PRN; If intolerance symptoms are noted contact MD (Medical Doctor) for further instruction .2. If aspirate exceeds 60cc (cubic centimeters) , instill contents into irrigation container and continue to aspirate. 3. Note total amount of aspirate: If total amount exceeds 100cc: Re-feed contents to maintain fluid and electrolyte balance. Hold tube feeding and or medication administration. Evaluate for abdominal pain, fullness, nausea, vomiting, or gastric distention. Notify physician for any physical signs and symptoms. Recheck residual in one hour. If residual still exceeds 100cc notify physician . 9. Monitor for signs of aspiration, i.e. temperature > (greater than) 100 degrees F (Fahrenheit), increased respiratory rate, wheezing, cyanosis, GI (gastrointestinal) contents in pulmonary secretions; if noted stop feeding and notify physician . Suggested Documentation: Any unusual observation or resident complaints along with subsequent interventions including physician notification. The facility's undated [CONDITION(S)] Care Guidelines policy and procedure, documents I. Scope a. The nurse is responsible for evaluating for proper artificial airway care. b. The nurse directs the unlicensed personnel to: 1) Immediately report any changes in respiratory status, level of consciousness, dislodgement of [CONDITION(S)] tube, and any abnormal drainage . III. Procedure a. Evaluation 1) Observe for excess secretions, soiled or damp [CONDITION(S)] ties, diminished airflow and signs or symptoms of airway obstruction that would require suctioning. 2) Evaluate vital signs, oxygen saturation, lung sounds, and the ability to clear airway. 3) Evaluate understanding of and ability to perform own [CONDITION(S)] care. 4) Validate when [CONDITION(S)] care was last performed . d. Recording and reporting 10 Record respiratory evaluations before and after care; type and size of [CONDITION(S)] tube; frequency and extent of care; type, amount, color, and odor of drainage; resident tolerance and understanding of procedure as applicable. The facility's Tracheal Suctioning policy and procedure, Effective Date: 8/24/2016, documents Policy Statement: Tracheal suctioning is a component of [MEDICATION(S)] hygiene therapy. It involves the mechanical aspiration of pulmonary secretions from a resident with an artificial airway. Licensed Clinicians with demonstrated competence may provide tracheal suctioning of adults with artificial airways, as ordered by resident's physician . 9. Using sterile-gloved dominant hand, insert catheter into the [CONDITION(S)] tube to the predetermined depth. Do not force if any resistance is encountered. 10. Apply intermittent suction by quickly opening and closing suction port, while withdrawing the catheter, using a rotating motion. Entire suctioning procedure shall not exceed 10 seconds in duration. 11. Have the resident take sigh breaths two to three times to oxygenate and re-expand the lungs. 12. Assess effectiveness of suctioning. If adventitious sounds are present, you encounter ventilating difficulty repeat suctioning. 13. If secretions are tenacious, introduce 1-3 mL (milliliters) of sterile saline solution into the airway. Perform suctioning as described above. 14. The following shall be monitored prior to, during and after suctioning: Breath sounds, oxygen saturation: skin color, pulse oximeter, if available, respiratory rate and pattern, hemodynamic parameters: pulse rate, sputum characteristics: Color, volume, consistency, cough effect. Following suctioning: 15. The resident should be instructed to take several deep breaths (sigh) to re-expand and improve oxygenation status. An Ambu-bag may be needed to facilitate this. 16. Monitor the resident for adverse reactions . Documentation: Heart rate, respiratory rate, breath sounds, color, consistency and amount of sputum, Residents tolerance to the procedure, whether or not sterile saline was instilled to mobilize secretions. The facility's undated Change in Resident's Condition or Status policy and procedure, documents Policy: It is the policy of the facility to ensure that the resident's attending physician and Representative are notified of changes in the resident's condition or status. Procedure: 1. The nurse will notify the resident's attending physician when: .There is a significant change in the resident's physical, mental or psychological status. There is a need to alter the resident's treatment plan significantly . 2. Unless otherwise instructed by the resident (if the resident is alert and oriented and their own representative) the nurse will notify the resident's representative when: . There is a significant change in the resident's physical, mental or psychosocial status . It is necessary to transfer the resident to the hospital. 3. A significant change in condition is a decline or improvement in the resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions and Impacts more than one area of the resident's health status . 4. Except in medical emergencies, notification will be made within 24 hours of a change occurring in resident's condition or status. During medical emergencies such as unstable vital signs, respiratory distress, uncontrolled bleeding and unresponsiveness 911 will be notified for transport to the hospital. 5. If the resident's physician does not respond to calls of a resident condition status change, the facility Medical Director will be notified to obtain orders and this will be documented. 6. The nurse will record in the resident's medical record any changes in the resident's medical condition or status. The Face Sheet for R98, documents R98 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/26/21 at 11:00 am, R98 was not in the facility, and the facility's Resident Room Roster, dated 9/25/21, documents R98 is currently in the hospital. The facility Admission Screening from the local hospital, dated 9/17/21, includes the following documentation: Reason for admission: L (Left) MCA (middle cerebral artery) stroke M2/3 (Sylvian and Cortical segments of brain) occlusion s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Intubated due to respiratory failure 8/14. [CONDITION(S)] placement 8/16. 8/25 went for [CONDITION(S)] tube exchange due to bleeding. Patient is a new [CONDITION(S)] and peg (gastrostomy feeding tube), patient has right side [CONDITION(S)] and is needing a short stay care. The physician Order Summary Report for R98, documents the following physician orders: 9/20/21 Nothing by Mouth (NPO) diet, 9/20/21 [MEDICATION(S)] 1.5 75cc/hr continuous every shift, and [CONDITION(S)] care every shift. The Progress Notes for R98, dated 9/21/21 at 10:29 pm, documented by V4, LPN, documents Resident has had 3 large loose stools, telehealth notified, new order for [MEDICATION(S)] 2 mg (milligrams) every 6 hours as needed. To give bolus 250cc water and have CMP and CBC lab drawn for tomorrow. (Local laboratory) called and notified of need of services. The Progress Note for R98, dated 9/22/21 at 4:38 am, documented by V4, LPN, documents, Resident had large tan emesis orally and through [CONDITION(S)] tube. Skin warm and dry color pale pink. Emesis looks like color and consistency of g-tube feeding. HOB (head of bed) elevated. Bowel sounds present all quads (quadrants). While cleaning resident up resident had 2 more large emesis orally. Communicated with telehealth through I pad, waiting for call back from a provider. The Progress Note for R98, dated 9/22/21 at 5:00 am, documented by V4, LPN, documents B/P 180/110, pulse 120, resp (respirations) 24, O2 sats 80% room air, temp (temperature) 97, blood sugar 450. No call back from providers, Telehealth called again, DON called, ADON called. No DNR found in chart. Family called, message left. Resident continues to have projectile emesis. No call back from telehealth providers. Resident sent to (local) ER (emergency room ) for eval (evaluation) and treat (treatment). The Progress Note for R98, dated 9/22/21 at 7:41 am, documented by V4 LPN, documents (Local) ER called, told resident would be admitted to a Hospital, not sure which one with DX (diagnosis) of possible aspiration Pneumonia. The Weights and Vitals Summary document for R98, documents R98's vital signs on 9/22/21 at 4:57 am as: Blood Pressure 180/110 Diastolic High of 89 exceeded and Systolic High of 139 exceeded; Pulse 120 bpm (beats per minute) - new onset and High of 100.0 exceeded; Respiration 25 breaths/min (per minute); O2 (oxygen) sats (saturations) at 80% ([CONDITION(S)]) Low of 90.0 exceeded. The local Hospital Medical Record for R98, dated 9/22/21, documents Upon presentation to the (local hospital) (R98) was placed on 3 L (liters) oxygen, labs were significant for a lactic acidosis of 5, leukocytosis of 17 . Chest x-ray with right sided middle lobe infiltrate and lower lobe infiltrate indicating aspiration pneumonia . Looks dry, lethargic . Active Problems: .1. Severe [CONDITION(S)] secondary to Aspiration pneumonia from suspected Gram-negative etiology, this was resulted from patient's vomiting likely related to possible overfeeding verses intolerance to the feed. Leukocytosis, lactic acidosis. 2. Acute respiratory insufficiency secondary to pneumonia. 3. Nausea and vomiting. 4. Old [CONDITION(S)] ([CONDITION(S)]-Stroke) with right-sided [CONDITION(S)], status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The local Hospital Discharge Summary for R98, dated 9/24/21, documents Discharge Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] .Acute respiratory insufficiency, and Nausea and vomiting. Hospital Course (findings/results/procedures): . sent from nursing facility for evaluation of from [CONDITION(S)] nausea and vomiting. (R98) was found to have severe [CONDITION(S)] secondary to aspiration pneumonia and acute respiratory insufficiency which was initially treated with IV fluids and [MEDICATION(S)]. Continued to have lactic acidosis. G-tube feeding was discontinued as this was thought to be the cause of aspiration . Patient was accepted for inpatient hospice for further care. On 9/26/21 at 6:00 am, V4, LPN (Licensed Practical Nurse), stated on 9/21/21 V4 worked from 9:00 pm 9/21/21 through 6:00 am on 9/22/21, and was the nurse who sent R98 to the local hospital on 9/22/21 at 4:30 am. V4 stated (R98) had a new g-tube (gastrostomy- feeding tube) and [CONDITION(S)] ([CONDITION(S)]-artificial airway). V4 stated on 9/21/21 at 10:30 pm, R98 had loose stools. V4 called R98's doctor, got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V4 stated V4 turned off R98's g-tube, administered the medication and the water bolus through R98's g-tube, and turned (R98's) feeding back on. V4 stated at around 11:30 pm, V5 and V6, CNA's (Certified Nursing Assistants), notified V4 R98 was vomiting from R98's mouth and R98's [CONDITION(S)] but his vital signs were good. V4 stated V4 cleaned up (R98), and did not shut off R98's g-tube feeding because R98 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V4 stated on 9/22/21 around 4:15 am, V4 went in to give (R98) his morning medications and (R98) was vomiting again from R98's mouth and [CONDITION(S)], and R98 had another loose stool. V4 stated V4 cleaned (R98) up, and suctioned the opening of his [CONDITION(S)], I did not do deep suctioning, and called the on-call service for a Physician. V4 stated (R98's) blood pressure was 180/110, pulse 120 bpm (beats per minute), respirations were elevated, his SpO2 (blood oxygen saturations) was only 80%, and blood sugar was high at 450. V4 stated V4 looked in (R98's) chart and noted R98 was a not a DNR (Do Not Resuscitate). V4 stated the on call service couldn't find a doctor to call V4 back, so V4 called V2, DON (Director of Nursing), and told V2, DON, V4 was sending (R98) to the hospital. V4 stated R98's g-tube feeding was almost done; R98 had a continuous feeding order, and V4 did not stop (R98's) g-tube feeding until the EMT (Emergency Medical Transporter) instructed V4 to do so on the way out of the facility with (R98). V4 stated, My biggest concern was trying to get (R98) to stop throwing up. When asked V4, LPN, why she didn't stop (R98's) g-tube feeding when R98 began vomiting at 11:30 pm, why V4 did not do deep suctioning of R98's [CONDITION(S)], and why V4 did not call R98's Physician at 11:30 pm, she stated, Honestly, I didn't think of shutting his feeding off. I was most concerned about getting him to stop throwing up. V4, LPN, stated (R98) would not be returning to the facility and would be going on Hospice (end of life services). On 9/26/21 at 6:15 am, V5, Certified Nursing Assistant (CNA), stated V5 and V6, CNAs, worked together the night (R98) was sent to the hospital. V5 stated, On 9/21/21 at 11:00 pm, (R98) started throwing up, vomit was coming from (R98's) mouth and (R98's) [CONDITION(S)], and (V5) reported to (V4 LPN). (V4) came down and looked at (R98) but that was it. V5 CNA stated, We kept checking on (R98) every hour or so and kept telling (V4, LPN) that (R98) didn't look good, but V4 didn't do anything. V5 CNA stated, On 9/22/21 at 4:00 am, (R98) started throwing up again, and vomit was still coming out of (R98's) mouth and (R98's) [CONDITION(S)]. V5 stated she reported it to V4, LPN, and V4 ended up sending R98 to the hospital. V5 stated, (R98's) vital signs were very elevated and (R98) was not doing well. V5 stated, I even called (V2, DON) after I got home from work and told (V2) that we kept telling (V4 LPN) that (R98) wasn't doing well, and (V4) didn't do anything. V5 also stated, (V4, LPN) never shut off (R98's) g-tube feeding during the night, and never came into (R98's) room when the EMT came to get (R98). V5 stated the EMT removed (R98's) feeding bag from the IV pole, laid it on top of (R98) and wheeled (R98) to the Nurses station where V4, LPN, was so V4 could disconnect it. On 9/26/21 at 6:25 am, V6, CNA, stated, V6 and V5, CNAs, told V4, LPN, each time (R98) had a loose stool and was throwing up, and that R98 wasn't doing well. V6 stated, I finally told (V4, LPN) she was going to have to do something, that's when (V4) got off the phone with pharmacy and sent (R98) to the hospital. V6, CNA, confirmed R98's g-tube feeding continued to infuse during the night shift. On 9/26/21 at 9:00 am and 9:08 am respectively, V15, LPN, and V7, RN (Registered Nurse), stated if a resident with a g-tube and [CONDITION(S)] is vomiting orally and through the [CONDITION(S)], the resident's feeding should be shut off, resident lung sounds should be assessed, resident should be suctioned, and the doctor should be called. On 9/21/21 at 8:15 am, V15 stated V15 checks residual by pulling back enough to see there's feeding in the syringe, and pushes it back through, and doesn't think the residuals are charted in the residents medical record. V15 also stated, If having trouble reaching a resident's doctor then we are to call (V22, Medical Director). On 9/27/21 at 8:30 am, V2, DON (Director of Nursing), stated V4, LPN, called V2 on 9/22/21 at 4:30 am, and reported R98 was having an emesis from his mouth and [CONDITION(S)], and V4 couldn't get a hold of a doctor, and was sending R98 to the hospital. V2 stated (R98) was admitted to the hospital with aspiration pneumonia and discharged from the hospital on Hospice services. V2, DON, stated V2 did not receive any other calls from V4, LPN, during the night, and was unaware R98 had vomited earlier in the shift. V2, DON, stated V4, LPN, should have stopped (R98's) g-tube feeding, performed deep suctioning, and should have notified V2 and (R98's) Physician after (R98's) first episode of vomiting at 11:30 pm on 9/21/22. On 9/28/21 at 9:28 am, V4, LPN, stated V4 hung a 1,000 ml (milliliter) new bottle of feeding around 10:30 pm on 9/21/21 because (R98's) bottle was empty. V4 stated (R98's) pump was set to infuse at a rate of 75 cc per hour. V4 stated V4 checked g-tube placement and residual by pulling back on the syringe until V4 saw some feeding come into the syringe, and then pushed the feeding back in. V4 stated V4 does not know how much residual there was because V4 did not measure it. V4 stated, We do not chart residual, it's just something we do. V4 stated there was about 50 ml of feeding left in (R98's) bottle of feeding when the ambulance came to get him. When asked how a 1,000 ml of feeding infused between 10:30 pm and 4:30 am she stated, I don't know. V4 stated, I ran the pump at 75 cc/hr, like the nurse I followed told me in report. When asked if she checked the order, V4, LPN, did not answer, and stated the g-tube pump was set at 75 cc/hr (hour). When questioned about which pump was used, V4, LPN, stated, Well, I hung the bottle by gravity. When asked why she originally said it was on a pump, V4 stated, Because we should have had a pump, but it never came in. When questioned how V4 infused 75 cc/hr per gravity, V4, LPN, did not answer. When asked why V4 didn't stop the feeding when R98 began vomiting orally and from his [CONDITION(S)] on 9/21/22 at 11:30 pm, V4 stated, I didn't think about it. When asked about suctioning R98, V4 stated V4 did not do deep suctioning but went down 4 or 5 centimeters to suction with the long thin suctioning tube. V4 stated V4 did not suction R98 at 11:30 pm when R98 first vomited and stated, I just suctioned once in the morning. V4 stated V2, DON, was aware there was not a g-tube feeding pump in the facility for R98 at the time he was admitted to the facility, and his g-tube feeding was being infused by gravity, and V3, LPN QA (Quality Assurance) Nurse, told V4 in report to run (R98's) g-tube feeding by gravity. V4 also stated V4 did not report to V2, DON, or R98's Physician when R98 began vomiting on 9/21/21 at 11:30 pm. On 9/28/21 at 10:00 am, V2, DON, stated R98 was admitted on [DATE], in the late afternoon and that is when V2 was made aware there was no g-tube pump for R98 in the facility. V2 stated one was ordered, and V11, R98's PCP (Primary Care Physician), was notified. V2, DON, stated the nurses are to check placement and residual per policy. V2 stated V2 is unsure if this charted in the residents medical record as V2 just started working at the facility on 9/20/21. V2, DON, stated V16, Admissions Coordinator, got the referral from the hospital portal, and V13, MDS (Minimum Data Set) Coordinator, reviewed R98's admission screening, and gave the ok to admit R98. On 9/28/21 at 10:05 am, V3, LPN, QA and ICP (Infection Control Preventionist) Nurse, stated V3 relieved V15, LPN, and worked the floor from 6:00 pm to 10:00 pm on 9/21/21, and R98's feeding was being done by gravity because there was not a g-tube feeding pump available for (R98). V3 stated V3 calculated the rate of infusion by counting the feeding drops for 15 seconds and multiplied times four, until V3 reached what would be considered 75 cc's an hour, and V3 cannot recall the exact number of drops used. V3 stated there was already a g-tube feeding bag hanging when V3 came in, and V3 did not have to hang any new feeding for (R98) during V3's four hour shift. V3 stated a 1,000 ml plastic bottle of feeding would be opened and poured into a plastic bag because the facility didn't have any spike sets for the plastic bottles during the time (R98) was in the facility. V3 stated V3 gave nursing report to V4, LPN, and told V4 what the nurses were doing. V3 also stated (R98) did have one loose stool, V3 performed deep suctioning once, and there were no complications with (R98's) g-tube or [CONDITION(S)] during V3's four hour shift. V3, LPN, also stated V16, Admissions Coordinator, did not tell anyone (R98) had a g-tube and [CONDITION(S)] so no one knew until (R98) was admitted on [DATE]. V3 stated V3 was on vacation the week of (R98's) screening for admission, and V3 didn't come back to work until Monday 9/21/21, the day (R98) was admitted . V3 stated the facility does not chart residuals for residents with g-tubes. V3 confirmed there is no documentation of R98's g-tube feeding being infused by gravity, drops calculated, or (R98's) Physician being notified. V3 stated, (R98's) doctor should have been notified at the time of his admission to the facility, and the residual and placement checks for g-tubes should be on the residents MAR (Medication Administration Record) and/or TAR (Treatment Administration Record). V3 stated, :The g-tube feeding pump that was ordered for (R98) arrived at the facility today (9/28/21). On 9/28/21 at 10:35 am, V16, Admissions Coordinator, stated V16 pulls the resident's history and physical, medication list, and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . V16 stated, If approved by financial and nursing then we can admit, and usually V3, LPN/QA/ICP Nurse, gives the clinical ok, but V3 was on vacation. V16 stated V13, MDS Coordinator, ended up giving the clinical approval by email documenting, Ok clinically and has a lot going on. V16 stated everyone should be reading the screening because V16 is not a Nurse and has to wait for nursing approve before she can admit a resident. On 9/28/21 at 10:45 am, V13, MDS Coordinator, stated V13 did give the ok clinically for (R98) to come to the facility, and did see he had a [CONDITION(S)] and g-tube. V13 stated, (V3,LPN QA/ICP) is the one who generally orders the supplies, or the DON does if (V3 LPN QA/ICP) is not here. V13 stated there was a interim DON at the time, and V13 stated, I only accept or deny. V13 stated V13 accepted (R98's) referral a day or two prior to R98 coming, and everyone would have known R98 was coming. V13 also stated, If I had known we didn't have the supplies I would not have accepted him, until we did. V13 stated V13 does recall V16, Admission Coordinator, asking about supplies for (R98), but doesn't know any more than that. V13 stated, I was not aware we didn't have a g-tube pump. We usually always have a g-tube pump. I assumed we had the supplies needed because no one said we didn't. On 9/28/21 at 12:11 pm, V12, EMT (Emergency Medical Transporter), stated V12 entered the facility early morning of 9/22/21, answering the 911 call. V12 stated when V12 entered the facility, V4, LPN, was sitting at the nurses station filling out paperwork. V12 stated V12 asked V4 where the patient was, and V4 told V12 to wait for V4 to complete the paperwork. V12 stated, I was called to the facility for an emergency situation with a resident vomiting from his [CONDITION(S)] and mouth and wanted to get to the resident and check his airway. V12 stated one of the CNA's walked V12 down to (R98's) room, and another CNA was already in the room. V12 stated (R98) was lying in bed with the plastic bag of feeding still connected, hanging from an IV pole, without a pump, infusing by gravity, and the feeding bag was empty. (R98) did not have any oxygen on at the time. V12 stated V12 took (R98's) g-tube feeding bag off the IV pole and took it, along with (R98), to the nurses station, and had the nurse disconnect (R98) from the feeding. V12 stated, The nurse's arrogance and non-emergent attitude concerned me that this resident was not being cared for adequately and was suffocating. V12 stated (R98) was not actively vomiting; however his pharynx was covered with thick tan colored residue, (R98) was in severe respiratory distress, and his SpO2 was only 80%. V12 stated V12 suctioned (R98) and got massive amounts of think, tannish secretions from (R98's) [CONDITION(S)]. V12 stated V12 put a non-rebreather mask (oxygen mask that allows for the delivery of higher concentration of oxygen) on (R98) and the highest he could get (R98's) oxygen level up to was 90%. V12 stated, This whole situation was concerning to me. On 9/28/21 at 12:50 pm, V3, QA/ICP Nurse, stated V3 was On vacation the week (R98) was approved for admission and (R98) came the following Monday, on my first day back from vacation. V3 stated, (V2, DON) started this day, and the Corporate Nurse came in too. V3 stated V3 had not checked V3's email, so was not aware of (R98's) pending admission. (V15, LPN) received report from the hospital, and that's when we knew he had a [CONDITION(S)] and g-tube. (V13, MDS Coordinator) gave the ok clinically but does not normally get supplies. V3 stated if the nurse isn't able to get a hold of the resident's physician, they can call V22, Medical Director. V3 also stated, The residual and placement checks for g-tubes should be on the resident MAR (Medication Administration Record) and the feeding bag and syringe changes should be on the resident TAR (Treatment Administration Record). On 9/28/21 at 1:15 pm, V14, LPN, stated V14 worked on 9/20/21, and charted the initial Nursing Note that R98 had arrived at the facility to help V15, LPN out, who was (R98's) admitting Nurse. V14 stated, (V15, LPN) got report from the transferring hospital, and we didn't known R98 had a [CONDITION(S)] until that time. We had respiratory therapist come to ensure we had everything we needed. I think we a had a pump for (R98). I didn't see (R98) and didn't hear we didn't have one. On 9/28/21 at 1:15 pm, V15, LPN, stated V15 was the nurse that got report for (R98's) admission from the hospital near shift change, which was the first V15 had heard (R98) had a g-tube and a [CONDITION(S)]. V15 stated there was no g-tube feeding pump in the facility at that time, and (R98) came to the facility without any g-tube feeding, but she was able to get (R98's) feeding changed from [MEDICATION(S)] to [MEDICATION(S)], because that was what the facility had in stock. V15 stated V15 did not initiate (R98's) g-tube feeding so V15 does not know how it was infusing. V15 stated the facility does not usually give g-tube feeding by gravity, but the facility didn't end up having a g-tube pump for R98's feeding so it was hung by gravity. V15 stated V15 did not call (R98's) doctor regarding R98's feeding being hung by gravity, and is unsure if anyone did. On 9/28/21 at 12:40 pm, V17, MDS Consultant, stated the residual and placement checks for g-tubes should be documented on the resident MAR (Medication Administration Record). On 9/28/21 at 2:39 pm, V11, PCP (Primary Care Physician) for R98, stated R98 was admitted to the facility on [DATE] and went back out to the hospital on 9/22/21. V11 stated from what V11 can see, the first text came through from on call service on 9/21/21 at 10:49 pm asking for a PRN (as needed order) for [MEDICATION(S)] for (R98's) loose stools, and it was given along with follow up order, labs and a flush order. The next text came through at 5:29 am that the facility nurse reported R98 was having emesis from R98's [CONDITION(S)] and g-tube and was requesting [MEDICATION(S)], and there was no response from the on call physician at that time or at 5:53 am. V11 stated V11 is unsure why the Provider on call did not respond back. At 6:02 am, a text was sent to another on-call physician and at 9:00 am, V2, DON, said (R98) had been discharged to the hospital. V11 stated V4 LPN absolutely should have shut off R98's feeding after the first emesis at 11:30 pm and notified me. V11 stated V11 was unaware of R98's feeding running by gravity and that is not ok. I would have changed the order. V11 also stated V11 was never notified that the facility did not have a g-tube feeding pump to infuse (R98's) feeding. When V11 was asked if these actions could have caused R98's Aspiration Pneumonia and [CONDITION(S)] he stated, Absolutely and I should have been notified. The Immediate Jeopardy was identified on 9/28/21 at 4:44 pm. The Immediate Jeopardy began on 9/20/21 when the facility admitted R98 and failed to have available equipment to administer R98's gastrostomy feeding. The facility failed to assess R98, stop R98's gastrostomy feeding and suction R98's respiratory [CONDITION(S)] tube after R98 began vomiting from his mouth and [CONDITION(S)] and failed to notify R98's Physician on 9/21/21 at 11:30 pm that R98 was vomiting orally and through [CONDITION(S)]. V1, Administrator, was notified of the Immediate Jeopardy on 9/29/21 at 10:17 am. The surveyor confirmed through observation, interview, and record review the facility took the following actions to remove the immediate jeopardy: 1. On 9/30/21, there is an available feeding pump in the facility and two more feeding pumps on order. 2. On 9/30/21, all Registered Nurses and Licensed Practical Nurses were educated by V2, DON, and V19, Regional Nurse Consultan,t on suctioning [CONDITION(S)], cleaning [CONDITION(S)] site, cleaning non disposable inner cannula, [CONDITION(S)] obstruction, and replacing inner cannula. 3. On 9/30/21, V2, DON, and V19, Regional Nurse Consultant, educated all Registered Nurses and Licensed Practical Nurses on enteral gastrostomy feeding. 4. On 9/30/21, V2, DON, and V19, Regional Nurse Consultant, educated all Registered Nurses and Licensed Practical Nurses on emergency assessments and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. On 9/30/21, V2, DON, and V19, Regional Nurse Consultant, educated all Registered Nurses and Licensed Practical Nurses on emergency assessments to include suctioning, cleaning, obstruction, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER]

Deficiencies at this level require two Deficient Practice Statements. A. Based on observation, interview, and record review, the facility failed to provide emergency assessment of a resident with a gastrostomy feeding tube and respiratory [CONDITION(S)] tube who was vomiting both orally and through the [CONDITION(S)] ([CONDITION(S)]) for one (R98) of two residents reviewed for quality of care. This failure resulted in R98 being hospitalized for [CONDITION(S)] and Pneumonia. B. Based on observation, interview and record review, the facility failed to wear required PPE (Personal Protective Equipment) into a yellow zone for one (R6) of five residents reviewed for infection control in the sample of 23. Findings include: A. On 9/26/21 at 11:00 am, R98 was not in the facility, and the facility's Resident Room Roster, dated 9/25/21, documents R98 is currently in the hospital. The Face Sheet for R98 documents R98 was readmitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/22/21 at 4:38 am, V4, Licensed Practical Nurse (LPN), documents the first note of R98 having any emesis as: Resident had large tan emesis orally and through [CONDITION(S)] tube. Skin warm and dry, color pale pink. Emesis looks like color and consistency of g-tube feeding. HOB (head of bed) elevated. Bowel sounds present all quads (quadrants). While cleaning resident up, resident had 2 more large emesis orally. Communicated with telehealth through I pad, waiting for call back from a provider. The Weights and Vitals Summary document for R98, documents R98's vital signs on 9/22/21 at 4:57 am as: Blood Pressure 180/110 Diastolic High of 89 exceeded and Systolic High of 139 exceeded; Pulse 120 bpm (beats per minute) - new onset and High of 100.0 exceeded; Respiration 25 breaths/min (per minute); O2 (oxygen) sats (saturations) at 80% ([CONDITION(S)]) Low of 90.0 exceeded. The local Hospital Medical Record for R98, dated 9/22/21, documents Upon presentation to the (local hospital) (R98) was placed on 3 L (liters) oxygen. Active Problems: .1. Severe [CONDITION(S)] secondary to Aspiration pneumonia from suspected Gram-negative etiology, this was resulted from patient's vomiting likely related to possible overfeeding verses intolerance to the feed. The local Hospital Discharge Summary for R98, dated 9/24/21, documents Discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospital Course (findings/results/procedures): . sent from nursing facility for evaluation of [CONDITION(S)] nausea and vomiting. (R98) was found to have severe [CONDITION(S)] secondary to aspiration pneumonia and acute respiratory insufficiency which was initially treated with IV fluids and [MEDICATION(S)]. Continued to have lactic acidosis. Tube feeding was discontinued as this was thought to be the cause of aspiration . Patient was accepted for inpatient hospice for further care. On 9/26/21 at 6:00 am, V4 stated V4 did not shut R98's enteral g-tube feeding off on 9/21/21 at 11:30 pm after R98's first emesis, because R98 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V4 explained V4 did not disconnect R98 from R98's g-tube feeding until the EMT (Emergency Medical Transporter) instructed her to do so on 9/22/21 at 4:30 am, upon the EMT exiting the facility with (R98). V4 stated, Honestly, I didn't think of shutting his feeding off. I was most concerned about getting him to stop throwing up. On 9/26/21 at 6:00 am, V4, LPN (Licensed Practical Nurse), stated V4 did not perform any suctioning for R98 on 9/21/21 at 11:30 pm after R98 vomited from his mouth and [CONDITION(S)], because V4 was most concerned at the time of stopping R98's diarrhea. V4 stated V4 did not suction R98 until 9/22/21 at 4:30 am, and stated My biggest concern was trying to get (R98) to stop throwing up. On 9/28/21 at 9:28 am, V4, LPN, stated she performed superficial suctioning 4 or 5 centimeters down for R98, one time during her shift on 9/22/21 at 4:30 am. On 9/26/21 at 6:00 am, V4, LPN (Licensed Practical Nurse), stated V4 did not notify R98's Physician that R98 was vomiting from R98's mouth and [CONDITION(S)] on 9/21/21 at 11:30 pm, because V4 was most concerned about stopping R98's diarrhea. V4 stated V4 did not report R98's vomiting orally or through his [CONDITION(S)] to a Physician during her scheduled shift, and V4 stated V4 does not know and did not notify R98's Physician R98's g-tube feeding was infusing by gravity. On 9/26/21 at 6:15 am and 6:25 am, V5 and V6, CNA's (Certified Nursing Assistants), respectively stated they worked on 9/21/21 with V4, LPN, from 10:00 pm through 9/22/21 at 6:00 am. V5 and V6, CNA's, stated they reported R98's loose stools, vomiting from R98's mouth and [CONDITION(S)], that R98 did not look well, and V4, LPN, did not do anything until 9/22/21 at 4:30 am. V5 confirmed V4, LPN, hung a new bag of feeding on 9/22/21 at about 11:00 pm, the g-tube feeding infused continuously through the night, and the bag was empty on 9/22/21 at 4:30 am. On 9/27/21 at 8:30 am, V2, DON, stated V4, LPN, should have stopped R98's g-tube feeding, performed deep suctioning, and notified (V2) and R98's Physician on 9/21/21 at 11:30 pm. On 9/28/21 at 10:00 am, V2, DON, stated the nurses are to check g-tube placement and residual per policy. On 9/28/21 at 9:28 am, V4, Licensed Practical Nurse (LPN), stated on 9/21/21 at 10:30 pm, V4 hung a new 1,000 ml (milliliter) bottle of feeding, because (R98's) bottle was empty. The g-tube feeding pump was set to infuse at a rate of 75 cubic centimeters per hour (cc/hr). V4 checked g-tube placement and residual by pulling back on the syringe until V4 saw some feeding come into the syringe, and then pushed the feeding back in R98's feeding tube. V4 stated V4 does not know how much residual feeding there was because (V4) did not measure it, and the residual is not charted. It's just something we do. V4 stated there was about 50 ml of feeding left in (R98's) bottle of feeding when the ambulance came to get him on 9/22/21 at 4:30 am. During the same interview, when asked how a 1,000 ml of feeding infused between 10:30 pm and 4:30 am at 75cc/hr?, V4 stated I don't know. When V4 was asked if V4 checked the order, V4 did not answer, and stated the g-tube pump was set at 75 cc/hr. During this same interveiw, when questioned about which pump was used, V4, LPN, stated Well, I hung the bottle by gravity. When asked why V4 originally said it was on a pump, V4 stated, Because we should have had a pump, but it never came in. When questioned how V4 infused 75 cc/hr per gravity, V4, LPN, did not answer. When asked why V4 didn't stop the feeding and call R98's physician when R98 began vomiting orally and from his [CONDITION(S)], V4 stated, I didn't think about it. When asked about suctioning R98, V4 stated on 9/21/21 at 11:30 pm, V4 did not suction R98 and on 9/22/21 at 4:30 am, V4 performed superficial suctioning 4 or 5 centimeters down. V4 stated V2, Director of Nursing (DON) was aware there was not a g-tube feeding pump in the facility, and R98's g-tube feeding was being infused by gravity. On 9/28/21 at 2:39 pm, V11, R98's PCP (Primary Care Physician), stated V4, LPN, absolutely should have shut off R98's feeding after R98's first emesis at 11:30 pm and notified me, and V11 stated he was unaware of R98's feeding running by gravity and that is not ok. I would have changed the order. V11 also stated V11 was never notified the facility didn't have a g-tube feeding pump for R98's feeding. The facility's undated Change in Resident's Condition or Status policy and procedure, documents Policy: It is the policy of the facility to ensure that the resident's attending physician and Representative are notified of changes in the resident's condition or status. Procedure: 1. The nurse will notify the resident's attending physician when: .There is a significant change in the resident's physical, mental or psychological status. There is a need to alter the resident's treatment plan significantly . 2. Unless otherwise instructed by the resident (if the resident is alert and oriented and their own representative) the nurse will notify the resident's representative when: . There is a significant change in the resident's physical, mental or psychosocial status . It is necessary to transfer the resident to the hospital. 3. A significant change in condition is a decline or improvement in the resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions and Impacts more than one area of the resident's health status . 4. Except in medical emergencies, notification will be made within 24 hours of a change occurring in resident's condition or status. During medical emergencies such as unstable vital signs, respiratory distress, uncontrolled bleeding and unresponsiveness 911 will be notified for transport to the hospital. 5. If the resident's physician does not respond to calls of a resident condition status change, the facility Medical Director will be notified to obtain orders and this will be documented. 6. The nurse will record in the resident's medical record any changes in the resident's medical condition or status. The facility Enteral Tube Care and Feeding policy and procedure, revised 11/01/11, documents (Procedure: 1. Verify Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Residual is verified prior to each feeding and every 8 hours during feedings and PRN; If intolerance symptoms are noted contact MD (Medical Doctor) for further instruction . 2. If aspirate exceeds 60cc, instill contents into irrigation container and continue to aspirate. 3. Note total amount of aspirate: If total amount exceeds 100cc: Re-feed contents to maintain fluid and electrolyte balance. Hold tube feeding and or medication administration. Evaluate for abdominal pain, fullness, nausea, vomiting, or gastric distention. Notify physician for any physical signs and symptoms. Recheck residual in one hour. If residual still exceeds 100cc (cubic centimeters)notify physician . 9. Monitor for signs of aspiration, i.e. temperature > (greater than) 100 degrees F (Fahrenheit), increased respiratory rate, wheezing, cyanosis, GI (gastrointestinal) contents in pulmonary secretions; if noted stop feeding and notify physician . Suggested Documentation: Any unusual observation or resident complaints along with subsequent interventions including physician notification. The facility's undated [CONDITION(S)] Care Guidelines policy and procedure, documents I. Scope a. The nurse is responsible for evaluating for proper artificial airway care. b. The nurse directs the unlicensed personnel to: 1) Immediately report any changes in respiratory status, level of consciousness, dislodgement of [CONDITION(S)] tube, and any abnormal drainage . III. Procedure a. Evaluation 1) Observe for excess secretions, soiled or damp [CONDITION(S)] ties, diminished airflow and signs or symptoms of airway obstruction that would require suctioning. 2) Evaluate vital signs, oxygen saturation, lung sounds, and the ability to clear airway. 3) Evaluate understanding of and ability to perform own [CONDITION(S)] care. 4) Validate when [CONDITION(S)] care was last performed . d. Recording and reporting 10 Record respiratory evaluations before and after care; type and size of [CONDITION(S)] tube; frequency and extent of care; type, amount, color, and odor of drainage; resident tolerance and understanding of procedure as applicable. The facility's Tracheal Suctioning policy and procedure, Effective Date: 8/24/2016, documents Policy Statement: Tracheal suctioning is a component of [MEDICATION(S)] hygiene therapy. It involves the mechanical aspiration of pulmonary secretions from a resident with an artificial airway. Licensed Clinicians with demonstrated competence may provide tracheal suctioning of adults with artificial airways, as ordered by resident's physician . 9. Using sterile-gloved dominant hand, insert catheter into the [CONDITION(S)] tube to the predetermined depth. Do not force if any resistance is encountered. 10. Apply intermittent suction by quickly opening and closing suction port, while withdrawing the catheter, using a rotating motion. Entire suctioning procedure shall not exceed 10 seconds in duration. 11. Have the resident take sigh breaths two to three times to oxygenate and re-expand the lungs. 12. Assess effectiveness of suctioning. If adventitious sounds are present, you encounter ventilating difficulty repeat suctioning. 13. If secretions are tenacious, introduce 1-3 mL (milliliters) of sterile saline solution into the airway. Perform suctioning as described above. 14. The following shall be monitored prior to, during and after suctioning: Breath sounds, oxygen saturation: skin color, pulse oximeter, if available, respiratory rate and pattern, hemodynamic parameters: pulse rate, sputum characteristics: Color, volume, consistency, cough effect. Following suctioning: 15. The resident should be instructed to take several deep breaths (sigh) to re-expand and improve oxygenation status. An Ambu-bag may be needed to facilitate this. 16. Monitor the resident for adverse reactions . Documentation: Heart rate, respiratory rate, breath sounds, color, consistency and amount of sputum, Residents tolerance to the procedure, whether or not sterile saline was instilled to mobilize secretions. B. The facility's policy, Covid-19 PPE (Personal Protective Equipment) Zones Guidelines, reviewed 9-22-21, documents B. Yellow Zone: Residents in the Yellow Zone should be in a private area if bed capacity/space allows. 1.) Gown, N95 mask, face shield or goggles, gloves as usual. C. Blue Zone (located in Yellow Zone): 1.) Gown, N95 mask, face shield or goggles, gloves as usual. C. Green Zone: 1.) Surgical mask. Gloves as usual. On 9/26/2 at 5:55 am, R6's door had a yellow zone isolation sign, and and a bin, containing PPE was just outside of R6's open door. V4, LPN (Licensed Practical Nurse), stood at the isolation bin at R6's door, put gloves on and entered R6's room without a gown or face shield, and V4's N95 mask was pulled down to her chin, exposing both V4's mouth and nose. On 9/26/21 at 6:00 am, R6 stated the staff do not always have their masks covering their mouth and nose or don't wear a mask, do not always have a face shield on, and do not always have a gown or gloves on when they come into R6's room. On 9/26/21 at 6:25 am, V4, LPN, stated R6 is in a yellow zone isolation room because R6 is a readmission to the facility, and is being quarantined as potentially exposed to COVID-19 prior to admission, but is currently asymptomatic. V4 stated V4 should have put on a gown and had a face shield on, but was only going into (R6's) room to give (R6) a shot. V4 also stated the N95 mask should always be covering the mouth and nose. On 9/27/21 at 8:35 am, V2, DON, confirmed V4, LPN, should have utilized all PPE when entering R6's yellow zone room.

Based on observation, interview, and record review, the facility administrator lacked the knowledge regarding the regulatory definition of abuse which led to the failure to ensure policies and procedures of abuse were followed when abuse occurred on a locked dementia unit. The administrator hindered the fact finding process by instructing staff to omit information concerning acts of abuse. The Administrator's failures resulted in multiple instances of abuse of residents on the dementia care unit and placed all residents on the locked unit at risk for physical, verbal and psychological abuse from the time R1 was admitted until the day of his discharge. These failures have the potential to affect all residents in the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 8/1/2019, the facility remains out of compliance at a Severity Level 2 because additional time is needed to monitor the efficacy of staff training and corporate oversight. FINDINGS INCLUDE: The facility abuse policy, Abuse Prevention Program, dated (revised) 01/2019, documents, Employees are required to immediately report any incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment or a crime against a resident they observe, hear about, or suspect to the administrator if available or an immediate supervisor who must immediately report it to the administrator. Upon learning of the report, the administrator or in the absence of the administrator, the DON (Director of Nurses) shall initiate an incident investigation. (Definitions) Abuse: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, psychological well-being. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Any incident, or allegation involving abuse, neglect, exploitation, misappropriation of resident property, or a crime against a resident will result in an abuse investigation. The (facility) Administrator Job Description (undated) describes the job duties of the facility administrator as, The administrator leads and directs the overall operation of the facility in accordance with resident needs, federal and state government regulations. Demonstrates knowledge of all (State) Department of Public Health rules and regulations and provides adequate instruction regarding such rules and regulations to appropriate staff. R1's Progress Notes, dated 5/8/19 through 7/18/19, document the following episodes of physical abuse to multiple residents and staff: 1.) 5/13/19 at 12:02 P.M., (R1) verbally sing (ing) curse words at another resident. Yelling. (R1) interlocked arms with another resident and spoke about fighting the other resident. Yelling and cursing. 2.) 5/14/19 at 12:30 P.M., Staff report that dementia resident (R1) was aggressive towards dementia resident (R3). It was reported there was yelling in residents' room. Staff noted (R3) was on the floor with (R1) hovering over (R3). (R3) was noted to have an abrasion on (R3's) right arm and bottom lip. 3.) 5/14/19 at 1:08 P.M., (R1) was observed in (R2's) room. (R1) had (R2) by the foot. 4.) 5/19/19 at 4:39 A.M., (R1) awake and ambulating into dining room. (R1) immediately starts antagonizing another (unidentified) resident (R7), mocking him, attempting to hit him and swearing at him. When staff intervened, (R1) hit, slapped and choked staff. (R1) was attempting to go into another resident's room. When staff would ask (R1) to leave the room (R1) would attempt to keep entering the room and attempt to get resident out of bed. Then (R1) would yell and curse at resident. (R1) would lunge at staff and bruised staff's arms and wrists. Police called to intervene and removed (R1) from staff's back as (R1) was pulling her hair. 5.) 5/21/19 at 7:30 P.M., (R1) observed in hallway on unit holding onto (R4's) wrists and saying to (R4) get out of here before I kill you. 6.) 5/27/19 at 11:34 A.M., CNA reported that (R1) and (R2) were in an altercation. (R1) had hold of (R2's) left arm. 7.) 5/27/19 at 9:03 P.M., (R1) agitated, attempted to grab another (unidentified) resident (R8). (R1) twisting and pulling staff's arm, threatening to break arm. (R1) came up behind staff and grabbed staff by the back of the head and started to squeeze, threatening to break staff's face. Police called. 8.) 5/31/2019 at 3:17 P.M., (R1) hostile, swinging at staff. Several staff members attempted to show (R1) to (R1's) room or commons area. (R1) grabbing this nurses hands tightly, attempting to knee this nurse in stomach. 9.) 7/7/19 at 11:32 A.M., Staff stated that (R1) had hold of (R2) and was not wanting to let go. She was distraught and crying afterwards. 10.) 7/13/19 at 4:10 P.M., (R1) agitated, violent towards (R4). On 7/24/19 at 9:02 A.M., V14/Registered Nurse stated, On (MONTH) 13th, (R1) had (R4's) arms pinned down and was yelling and cursing at (R4). I was afraid (R1) was going to hurt him. I brought (R4) out of the unit and had (R4) sit in a chair at the nurse's station. (R4) was visibly shaken, but calmed down once I got him away from (R1). On the 14th (May 14, 2019) (R1) was once again fixated on (R2). (R1) would stalk (R2), like (R1) was trying to corner (R2). (R1) had (R2) by the arm and I had to physically break it up. (R1) was really angry that day, throwing chairs and trying to push the tables against people. I finally called (R1's) doctor and said we have to do something else, (R1's) getting worse and (R1) is going to hurt someone. 11.) 7/14/19 at 1:30 P.M., (R1) wandering, physically aggressive (with R2), verbally aggressive, hitting staff, raising fists at staff and other residents. On 7/23/19 at 10:53 A.M., V18/ R6's son stated, I've seen (R1) on many occasions when I come to visit (R6). (R1) is a tall, intimidating (person). (R1) wanders around, mumbling to himself, kind of like (R1's) looking for a fight. There was one incident, a week or so ago when I came to visit (R6). (R6) had just finished eating (R6's) lunch, so I pushed (R6) back to (R6's) room. (R1) kept walking by (R6's) room and looking in. (R1) looked real threatening. After awhile (R1) came into (R6's) room and I told (R1) to get out. (R1) turned towards me like (R1) was going to start something, but right then a nurse came into the room and literally had to pull (R1) out. Then it got very scary, (R1) kept trying to kick at the nurse and was yelling and cussing at her. I was very concerned about my mother's safety. I even sent a message to (V1) Administrator to call me about it, but (V1) never called me back. 12.) 7/18/19 at 7:45 P.M., Informed of an altercation between (R1) and (V4) Licensed Practical Nurse where (R1) was escorted out of the facility in handcuffs and (V4) was taken to the ER (emergency room ) via ambulance. On 7/20/19 at 12:04 P.M., V5/Certified Nursing Assistant stated, (R1) has been aggressive since (R1) came here. (R1) scares me. One time (R1) threw me up against the wall and said you are going to die. On the night of (7/18/19) when (V4) Licensed Practical Nurse got hurt, I was working with (V6) Certified Nursing Assistant. (R1) was agitated all night, picking on other residents and being intimidating to them. We finally had to call (V4) down to walk with (R1). Me and (V6) were putting another resident to bed and we heard pounding. (V6) ran to (R1's) room and screamed for me. I ran into (R1)'s room and (V4) was passed out on the bathroom floor and (V6) was holding (R1) down on the bed. I called 9-1-1 and then tried to help (V4). (V4) would come to, then pass out again. (V4) looked like (V4) was having [MEDICAL CONDITION]. It was the most awful thing I have ever seen. I can't stop thinking about it. I really do believe (R1) would have killed (V4). On 7/23/19 at 9:35 A.M.,V1/Administrator stated, I am the (facility) abuse coordinator. V1/Administrator also stated, I did not do an abuse investigation into all of (R1's) physical abuse towards other resident's (R2, R3 and R4). I thought (R1) was having behaviors. I did not think it was abuse. The incident on (MONTH) 13th, I felt was just (R1's) behaviors. I looked at the cameras for the incident on (MONTH) 27th, but I couldn't see (R1) and (R2) clearly. There weren't any injuries, so I didn't investigate it as abuse. I thought it was just (R1) having behaviors. I was notified of the incident between (R2) and (R1) on (MONTH) 7th; I figured it was just another behavior of (R1). I can't remember if the nurse notified me of (R1) being physical with residents on (MONTH) 13th and (MONTH) 14th. If (V14) said she did, then I don't have an investigation for those days. I did not report them to your agency. On 7/20/19 at 9:00 A.M., V3/Certified Nursing Assistant (CNA) stated, We have told (V1/Administrator) about (R1) being mean to the other residents, but nothing gets done. Everybody is afraid of losing their jobs. We have been told by (V1) that if we discuss all of these things about (R1) that we would be putting the facility at risk, because they didn't document all of them. On 7/20/19 at 11:02 A.M., V6/Certified Nursing Assistant stated, (V1/Administrator) has never had me give a statement about any of the incidents of violence I have seen (R1) do to residents or other staff. I have witnessed him assault (R2) many times. I am scared to be seen talking to you. I don't want to lose my job. I have been told not to discuss this with you by (V1). On 7/20/19 at 12:20 P.M., V5/Certified Nursing Assistant stated, I have never been asked about any of these times or asked to write a statement (for an abuse investigation). I'm scared to talk to you. I don't want to lose my job. (V1/Administrator) has told us to tell you we don't know anything or else the facility would be in trouble. On 7/25/19 at 11:43 A.M. V4/Licensed Practical Nurse (LPN) had bruises covering both wrists extending up the arm, approximately 4 inches on each side. A prominent contusion was visible to V4's left forehead. Bilateral discoloration was present under both of V4's eyes. At that time, V4/Licensed Practical Nurse stated, Am I in trouble. (V1/Administrator) keeps telling me that I am the reason you are here and the facility is going to get into a lot of trouble if I tell you the truth. We have been told so many times not to chart certain things that will get us in trouble, by (V1). One time, (V1) even erased the charting I did in a resident's chart because (V1) said it was too damaging for the facility. (V1) would come down to the nurse's station and tell us what to chart in the resident's chart. A couple of days after an incident involving (R1) and (R2), I was told in report that (R1) had choked (R2) into the ground. (V1) wouldn't let (R2) go to the hospital, but the next day (R2) was totally non-responsive in bed. The nurse was told not to chart anything about it. (V2/Director of Nurses) begged (V1) not to admit (R1). (V1) even came up to the hospital ER (emergency room ) (after the incident of 7/18/19) and came into my room, even after they told (V1) not to. (V1) kept telling me all I had was a panic attack. I was physically assaulted. Now (V1) is telling me I better not tell you everything or the facility is going to be in trouble. They said you are here because of me. An Immediate Jeopardy was identified to have begun on 5/13/19. On 7/31/19 at 1:45 P.M., V1/Administrator was notified of the Immediate Jeopardy. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1) The facility administrator was re-educated on but not limited to the facility policy and procedure on abuse, the responsibilities of the abuse coordinator, reporting and investigation of any and all abuse allegations, and the importance of immediate protection of all residents. Return demonstration was provided after this re-education on 7/31/19. Re-education provided by the Regional Director of Operations. The facility administrator was re-educated on the definition of abuse per the federal regulations and examples were provided to differentiate behaviors and abuse. Emphasized what is abuse and what a behavior is. This education was completed on 7/31/19. 2) The regional consultant team will rotate and provide daily supervision to the acting Administrator. This includes the regional director of operations, VP of nursing, and regional nurse consultants. The acting administrator will be re-educated daily on but not limited to the abuse policy, differentiating behaviors from abuse, guiding and providing overall direction to the rest of the staff. The job description will be reviewed daily and the administrator will be monitored daily by a senior leadership staff member. Began 7/31/19 and continues with acting Administrator. 3) The administrator (V1) was removed from the facility on 8/1/19.

Based on observation, interview, and record review, the facility failed to ensure that six of 12 residents (R2, R3, R4, R6, R7 and R8) in the sample of 12 were free from physical, verbal, and mental abuse. Between 5/13/2019 and 7/14/2019, R1 repeatedly committed physical, verbal, and mental abuse when R1 choked, hit, threatened with bodily harm, restrained by holding resident limbs or pinning shoulders to the wall, throwing/pushing furniture, yelling or cursing at residents residing in the locked dementia unit. Residents who were not direct targets of the abuse witnessed these abusive acts, placing them at risk for psychological harm. R1 physically assaulted staff who intervened on behalf of the residents. R1 slapped staff, pulled their hair, and choked V4 to the point of unconsciousness. R3 sustained abrasions to his arm and lip when abused by R1. These failures resulted in an Immediate Jeopardy being called on 7/31/19 at 1:45 P.M. While the immediacy was removed on 8/1/2019, the facility remains out of compliance at a Level 2. FINDINGS INCLUDE: R1's (State) Police Criminal History Record, dated (MONTH) 7, 2019, documents, Aggravated Domestic Battery with Bodily Harm and Interference with Reporting Domestic Violence. Committed to Special Facility (prison). R1's Pre-Admission Information form, dated (Anticipated admitted ) (MONTH) 8, 2019, documents, Late Onset Alzheimer's with Behavioral Disturbances. This same form documents, Alert, Forgetful, Speaks Normally, Combative, Verbally and Physically (abusive), Behaviors. R1's Face Sheet documents that R1 was admitted to the facility's locked dementia unit on 5/8/19 with the following Diagnoses: [REDACTED]. R1's Progress Notes, dated 5/9/19, documents, (R1) has HX (history) of physical aggression. R1's medical record shows no documentation that interventions were put into place to address R1's criminal background, or R1's restlessness and agitation when R1 was admitted to the facility's locked dementia unit. The locked dementia unit consists of a straight hall with a nurses room, a storage room, a medication room and a beauty shop room on the left side beyond the locked doors with an open activity room/dining room across from these rooms. Beyond the double doors are 11 resident rooms, one of which is private and ten are double resident rooms. R1's Progress Notes, dated 5/13/19 at 12:02 P.M., documents, Resident verbally sing (ing) curse words at another resident. Yelling. (R1) interlocked arms with another resident and spoke about fighting the other resident. Yelling and cursing. Separated residents. The facility Incident Report, dated 5/14/19 at 12:30 P.M., documents, Staff report that dementia resident (R1) was aggressive towards dementia resident (R3). It was reported there was yelling in residents' room. Staff noted (R3) was on the floor with (R1) hovering over (R3). (R3) was noted to have an abrasion on (R3's) right arm and bottom lip. Vitals obtained by nurse. Physician and Families notified. Administrator (V1) and DON (V2) notified. Well being checks on both parties initiated. R1 moved to (another room on the unit). This same report documents, Conclusion: It was reported from witnesses that there was yelling in residents' room (R1 and R3). Upon entering room, (R3) was on floor with (R1) hovering over (R3), residents were immediately separated. (R3) was moved to another room on the unit. Well being checks have identified increased aggressive behavior from (R1), none for (R3). (Psychiatric Services) NP (Nurse Practitioner) has been notified. R1's Progress Notes, dated 5/14/19 at 1:08 P.M., documents, (R1) was observed in (R2's) room. (R1) had (R2) by the foot. Released when confronted by staff. (R1) removed from room. During interview on 7/25/2019 at 11:43 A.M., V4 (Licensed Practical Nurse) stated, I wasn't the assigned nurse for (the unit) on (MONTH) 14th. Around 1:08 P.M., I happened to be walking by (R2's) room and I saw (R2) sitting on the bed and (R1) leaning over and holding (R2) by the foot. I wasn't sure what was going on, but I was concerned that (R1) had ahold of (R2) like that. I was able to talk (R1) into coming out of the room with me. That's all I did, was take (R1) out of the room. I didn't report it to anyone, I charted it. R1's Progress Notes, dated 5/19/19 at 4:39 A.M., documents, (R1) awake and ambulating into dining room. (R1) immediately starts antagonizing another (unidentified) resident (R7), mocking him, attempting to hit him and swearing at him. When staff intervened, (R1) hit, slapped and choked staff. (R1) was attempting to go into another resident's room. When staff would ask (R1) to leave the room, (R1) would attempt to keep entering the room and attempt to get resident out of bed. Then (R1) would yell and curse at resident. (R1) would lunge at staff and bruised staff's arms and wrists. Police called to intervene and removed (R1) from staff's back as (R1) was pulling her hair. R1's Progress Notes, dated 5/21/19 at 7:30 P.M., documents, (R1) observed in hallway on unit holding onto (R4's) wrists and saying to (R4) get out of here before I kill you. Residents were immediately separated and assessed by nurse. No injuries involved to either resident. (R1) placed on frequent checks. Will continue to assess. R1's Progress Notes, dated 5/27/19 at 11:34 A.M., documents, CNA reported that (R1) and (R2) were in an altercation. (R1) had hold of (R2's) left arm. Residents separated, each resident assessed. (V1) notified. R1's Progress Notes, dated 5/27/19 at 9:03 P.M., documents, (R1) agitated, attempted to grab another (unidentified) resident (R8). (R1) twisting and pulling staff's arm, threatening to break arm. (R1) came up behind staff and grabbed staff by the back of the head and started to squeeze, threatening to break staff's face. Police called. R1's Progress Notes, dated 7/7/19 at 11:23 A.M., documents, Staff stated that (R1) had hold of (R2) and was not wanting to let go. She was distraught and crying afterwards. R1's Progress Notes, dated 7/13/19 at 4:10 P.M., documents, Agitated, violent towards (R4). Redirected other residents to safe places. R1's Progress Notes, dated 7/14/19 at 1:30 P.M., documents, (R1) wandering, physically aggressive (with R2), verbally aggressive, hitting staff, raising fists at staff and other residents. R1's Progress Notes, dated 7/18/19 at 7:45 P.M., documents, Informed of an altercation between (R1) and (V4) Licensed Practical Nurse where (R1) was escorted out of the facility in handcuffs and the (V4) was taken to the ER (emergency room ) via ambulance. On 7/20/19 at 12:04 P.M., V5/Certified Nursing Assistant stated, (R1) has been aggressive since (R1) came here. (R1) scares me. One time (R1) threw me up against the wall and said you are going to die. On the night of (7/18/19) when (V4) Licensed Practical Nurse got hurt, I was working with (V6) Certified Nursing Assistant. (R1) was agitated all night, picking on other residents and being intimidating to them. We finally had to call (V4) down to walk with (R1). Me and (V6) were putting another resident to bed and we heard pounding. (V6) ran to (R1's) room and screamed for me. I ran into (R1)'s room and (V4) was passed out on the bathroom floor and (V6) was holding (R1) down on the bed. I called 9-1-1 and then tried to help (V4). (V4) would come to, then pass out again. (V4) looked like (V4) was having [MEDICAL CONDITION]. It was the most awful thing I have ever seen. I can't stop thinking about it. I really do believe (R1) would have killed (V4). On 7/22/19 at 9:15 A.M., V9/Admissions Director stated, (R1) was admitted from (a local nursing facility) because (R1) had a history of [REDACTED]. We knew (R1) had a history of [REDACTED]. On 7/22/19 at 9:46 A.M., V10/Social Services Director stated, (R1) was admitted here on (MONTH) 8th from another home. I ran (R1's) background check on (MONTH) 7th and it came back with a 'Hit' for aggravated domestic battery. I know (R1) had spent some time in prison for this. We didn't get (R1) fingerprinted until (MONTH) 28th. (R1) was admitted to C-Hall and shared a room when he first came in with (R3). We knew (R1) could be aggressive when we admitted (R1), but hoped (R1) would calm down on the locked unit. At that same time, V10/Social Services Director verified that no interventions to address R1's criminal background history or restlessness and agitation were put into place when R1 was admitted to the facility. On 7/22/19 at 10:30 A.M., V11/Licensed Practical Nurse stated, On (7/7/19) (R1) had been following (R2) around. (V16) Certified Nursing Assistant (former employee) and (V17) Activity Assistant (former employee) heard (R2) screaming and found (R1) in the hallway and (R1) had hold of (R2's) shoulders and had (R2) pinned up against the wall. They had to physically remove (R1's) hands from (R2). (R1) wasn't going to let go. On 7/23/19 at 10:53 A.M., V18/ R6's son stated, I've seen (R1) on many occasions when I come to visit (R6). (R1) is a tall, intimidating (person). (R1) wanders around, mumbling to himself, kind of like (R1's) looking for a fight. There was one incident, a week or so ago when I came to visit (R6). (R6) had just finished eating (R6's) lunch, so I pushed (R6) back to (R6's) room. (R1) kept walking by (R6's) room and looking in. (R1) looked real threatening. After awhile (R1) came into (R6's) room and I told (R1) to get out. (R1) turned towards me like (R1) was going to start something, but right then a nurse came into the room and literally had to pull (R1) out. Then it got very scary, (R1) kept trying to kick at the nurse and was yelling and cussing at her. I was very concerned about my mother's safety. I even sent a message to (V1) Administrator to call me about it, but (V1) never called me back. On 7/24/19 at 8:45 A.M., V13/Registered Nurse stated, On (MONTH) 13th, (R1) had (R2's) arms restrained and was yelling and cussing and said (R1) was going to beat (R2) up. On 7/24/19 at 9:02 A.M., V14/Registered Nurse stated, On (MONTH) 13th, (R1) had (R4's) arms pinned down and was yelling and cursing at (R4). I was afraid (R1) was going to hurt him. I brought (R4) out of the unit and had (R4) sit in a chair at the nurse's station. (R4) was visibly shaken, but calmed down once I got him away from (R1). On the 14th (May 14, 2019) (R1) was once again fixated on (R2). (R1) would stalk (R2), like (R1) was trying to corner (R2). (R1) had (R2) by the arm and I had to physically break it up. (R1) was really angry that day, throwing chairs and trying to push the tables against people. I finally called (R1's) doctor and said we have to do something else, (R1's) getting worse and (R1) is going to hurt someone. On 7/24/19 at 11:10 A.M., V15/ R2's daughter stated, (R2) would have been terrified having (R2's) arms restrained and being held up against the wall. I'm sure (R2) was very upset being treated that way. (R2) can't protect herself. Violence of any kind, scared (R2). On 7/25/19 at 11:43 A.M., V4/Licensed Practical Nurse (LPN) had bruises covering both wrists extending up the arm, approximately 4 inches on each side. A prominent contusion was visible to V4's left forehead. Bilateral discoloration was present under both of V4's eyes. At that time, V4/LPN stated, (V2) Director of Nurses begged (V1) Administrator not to admit (R1). We knew (R1's) background. We knew he used to beat (V19) spouse. But (V1) admitted (R1) anyway. (R1) was violent from the time (R1) was admitted and it just escalated. On 7/18/2019 the night (R1) choked me, the other nurse (V7) Licensed Practical Nurse was running late, so I was the only nurse in the building. The two CNAs (V5 and V6) on the locked unit kept calling me because (R1) was acting up. I went down to the unit and (R1) was very agitated, so I walked with (R1). (R1) had hold of my wrists tightly and wouldn't let them go. I was just walking backwards with (R1) and talking calmly to get (R1) to calm down. At one point I thought I would take (R1) out in the courtyard and I opened the door. Evidently (R1) didn't want to go because (R1) yanked me back inside. (R2) was there too and I was trying to place myself in front of (R2) to protect (R2). I asked (R1) if (R1) needed the toilet and (R1) said yes. I was happy to get (R1) out of the hallway, the other residents were watching all of this and they were so upset. When I took (R1) in the bathroom, there was feces on the toilet seat, so I put on a pair of gloves and cleaned it so (R1) could sit down. I turned my back for just a minute to wash my hands and when I turned back, (R1) smashed me in the nose with a plastic soap bottle. It hurt so bad. At that time, (R1) grabbed me by the hair and slammed my head repeatedly into the door frame. I kept trying to open the door between the rooms so I could get away. I forgot they locked that door so (R1) couldn't get to the resident in that room. I was stuck. The last thing I remember is (R1) grabbed the stethoscope around my neck and choked me. I woke up on the bathroom floor and someone was trying to get my vitals. When the residents on the unit saw me on when I came back to work, some of them were crying. They were so upset at what (R1) did to me. They said they feel so bad that they couldn't protect me from (R1). On 7/31/19 at 1:45 P.M., an Immediate Jeopardy was identified to have begun on 5/13/19 when R1 began abusing other residents and the facility failed to take actions to prevent further abuse. On 7/31/19 at 1:45 P.M. V1/Administrator was notified of the Immediate Jeopardy. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1) R1 was immediately discharged to the hospital and an emergency involuntary notice of discharge was issued on 7/18/2019. 2) All Residents were re-assessed for risk for harm and aggression on 7/31/19 and care plans were updated for all resident on the memory care unit and outside of the unit. Completed on 7/31/19. 3) Staff were re-educated on but not limited to the facility abuse policy and procedure on 7/31/19 and 8/1/2019. The re-education emphasized identifying abuse and protecting residents from the alleged perpetrator. Re-education provided with return demonstration of understanding. Started on 7/31/19 and will complete on 8/1/19. Re-education will be ongoing. Re-education provided by V21(Regional Nurse Consultant, Doctor of Nurse Practice and Registered Nurse), V22 (Licensed Nursing Home Administrator/Clinical Social Worker), V23 (VP of Nursing, Doctor of Nurse Practice and Registered Nurse) and V24 (Licensed Clinical Social Worker). 4) Quality assurance audit is conducted daily to ensure staff are identifying abuse. appropriately and the facility abuse policy and procedure is being followed. Started 7/31/19 and ongoing. This includes daily oversight by the consulting team (V21,V22,V23, and V24).

Based on interview and record review, the facility failed to conduct thorough investigations for at least five separate incidents of alleged physical or verbal abuse which occurred from 5/13/2019 through 7/14/2019. These allegations all involved R1 as the perpetrator with R2, R3 and R4 as the victims. The facility failed to ensure all 11 residents in the locked dementia unit where R1 resided were protected from further abuse during the investigations. These failures resulted in an Immediate Jeopardy being called on 7/31/19 at 1:45 P.M. While the immediacy was removed on 8/1/2019, the facility remains out of compliance at a Level 2 . FINDINGS INCLUDE: R1's Progress Notes, dated 5/13/19 at 12:02 P.M., documents, Resident verbally sing (ing) curse words at another resident. Yelling. (R1) interlocked arms with another resident and spoke about fighting the other resident. Yelling and cursing. Separated residents. R1's Progress Notes, dated 5/27/19 at 11:34 A.M., documents, CNA (Certified Nursing Assistant) reported that (R1) and (R2) were in an altercation. (R1) had hold of (R2's) left arm. R1's Progress Notes, dated 7/7/19, documents, Staff stated that (R1) had hold of (R2) and was not wanting to let go. R1's Progress Notes, dated 7/13/19 at 4:10 P.M., documents, Agitated, violent towards (R4). Redirected other residents to safe places. R1's Progress Notes, dated 7/14/19 at 1:30 P.M., documents, (R1) wandering, physically aggressive (with R2), verbally aggressive, hitting staff, raising fists at staff and other residents. On 7/24/19 at 8:45 A.M., V13/Registered Nurse stated, On (MONTH) 13th (5/13/19), (R1) had (R2's) arms restrained and was yelling and cussing and said he was going to beat (R2) up. I had to physically separate (R1's) hands from (R2). (R1) would grab hold and not let go. I called (V1) Administrator about the incident. On 7/23/19 at 9:05 A.M., V11/Licensed Practical Nurse stated, On Monday (MONTH) 27th (5/27/19) (R1) was being physically aggressive with (R2) and had (R2) by the left arm and wouldn't let go. (R1) was yelling and cussing at (R2). I had to physically remove (R1's) hand. I reported the incident to (V1) Administrator. (V1) did not tell me to start an abuse investigation. (V1) did not come into the facility and start an abuse investigation On 7/23/19 at 9:05 A.M., V11/Licensed Practical Nurse stated, On (MONTH) 7th (7/7/19), (R1) had been following (R2) around. (V13) Certified Nursing Assistant and (V14) Activity Aide heard (R2) screaming and found (R1) had (R2's) shoulders pinned up against the wall. The CNAs separated them. (R2) was crying and was upset. I called (V1) Administrator and reported it. (V1) did not tell me to do an abuse investigation. On 7/24/19 at 9:02 A.M., V14/Registered Nurse stated, On (MONTH) 13th (7/13/19), (R1) had (R4's) arms pinned down and was yelling and cursing. I was afraid (R1) was going to hurt (R4), so I brought (R4) out of the unit and had (R4) sit in a chair at the nurse's station. (R4) was visibly shaken, but calmed down once I got (R4) away from (R1). On the 14th (7/14/19), (R1) was once again fixated on (R2). (R1) would stalk (R2), like (R1) was trying to corner (R2). (R1) had (R2) by the arm and I had to break it up. (R1) was really angry that day, throwing chairs and trying to push the tables against people. I called (V1) Administrator. On 7/23/19 at 9:35 A.M., V1/Administrator stated, I did not do an abuse investigation into all of (R1's) physical abuse towards other resident's (R2, R3 and R4). I thought (R1) was having behaviors. I did not think it was abuse. The incident on (MONTH) 13th I felt was just (R1's)behaviors. I looked at the cameras for the incident on (MONTH) 27th, but I couldn't see (R1) and (R2) clearly. There weren't any injuries, so I didn't investigate it as abuse. I thought it was just (R1) having behaviors. I was notified of the incident between (R2) and (R1) on (MONTH) 7th; I figured it was just another behavior of (R1). I can't remember if the nurse notified me of (R1) being physical with residents on (MONTH) 13th and (MONTH) 14th. If (V14) said she did, then I don't have an investigation for those days. I did not report them to your agency. An Immediate Jeopardy was identified to have begun on 5/13/19. On 7/31/19 at 1:45 P.M., V1/Administrator was notified of the Immediate Jeopardy. The surveyor confirmed through interview and record review the facility took the following actions, which were completed on 8/1/2019, to remove the Immediate Jeopardy: 1) The facility administrator was re-educated on but not limited to the facility policy and procedure on abuse, the responsibilities of the abuse coordinator, reporting and investigation of any and all abuse allegations, and the importance of immediate protection of all residents. Return demonstration was provided after this re-education on 7/31/19. Re-education provided by the Regional Director of Operations, credentials are Licensed Nursing Home Administrator and Clinical Social Worker. The facility administrator was re-educated on the definition of abuse per the federal regulations and examples were provided to differentiate behaviors and abuse. Emphasized what is abuse and what a behavior is. This education was completed on 7/31/19. 2) Quality assurance audit conducted daily to ensure that the administrator is following the abuse policy and procedure of the facility until resolution beginning 7/31/19. This quality assurance will include the Administrator calling the regional director of operations on any and all abuse related allegations to consult and provide direction to ensure all residents are kept safe immediately. 3) Staff and management re-education of facility abuse policy and procedure completed on 8/1/2019. V21 (Regional Nurse Consultant), V22 (Licensed Nursing Home Administrator/LCSW), V23 (VP Nursing) and V24 (LCSW) provided the re-education. 4) Effective 7/31/19, the Social Services Director appointed the abuse coordinator in the event the Administrator is unavailable. The regional director of operations and/or the regional nurse consultant, and/or the VP of nursing services will be available for all and any abuse related allegations for consultation and to provide direction to ensure all residents are kept safe immediately. 5) System revision completed on 7/31/19: a. Re-education provided to staff and management by qualified personnel. b. Quality assurance monitoring daily- to ensure staff are aware of the abuse policy and procedure and feel comfortable reporting and keeping the residents safe c. Any and all abuse related allegations, the administrator will call the senior leadership consultants to discuss and get direction to ensure all residents are kept safe. d. In the absence of the administrator, the Social Services Director will act as the abuse coordinator. 6). An additional re-education on the compliance hotline number provided to staff and the number posted by the employee time clock and nurse's station on 8/1/19. Employees re-assured that retaliation is not tolerated. The compliance hotline number is available for reporting incidents and staff may use this to report incidents anonymously.

Based on interview and record review, the facility failed to provide routine regularly scheduled pain medication for one of six residents (R1) reviewed for pain medication in the sample of ten. This failure resulted in R1 experiencing increased, unrelieved pain and anxiety, and symptoms of opiate withdrawal. Findings include: [MEDICATION NAME] is a synthetic opiate prescribed for moderate to severe pain. It is also commonly used to treat opiate addictions, especially addiction to heroin. [MEDICATION NAME] is a federally designated Schedule II drug, meaning it has a legitimate legal use but also a high likelihood of its users developing a dependence. Symptoms of withdrawal from [MEDICATION NAME] include: Chills, fever, anxiety, muscle aches and pains, nausea or vomiting, sweating, stomach cramps, and diarrhea (retrieved 5/10/19 from https://www.addictioncenter.com/opiates/[MEDICATION NAME]). R1's Medication Review Report dated 5/2019, documents R1's [DIAGNOSES REDACTED]. The Report also documents R1 receives [MEDICATION NAME] HCL Solution 10mg (milligrams)/5 (five) ml (milliliters). Give 20ml by mouth two times per day for pain. R1's Controlled Drug Receipt/Record/Disposition Form dated 5/3/19, documents R1 was sent home on pass with 60ml of [MEDICATION NAME], leaving the amount left as 0 (zero). The facility's Drug Delivery Manifest dated 5/6/19 at 5:50pm, documents R1's next delivery of [MEDICATION NAME]. R1's Medication Administration (MAR) documents R1 received an 8pm dose of [MEDICATION NAME] on 5/6/19. According to R1's MAR, R1 missed three doses of [MEDICATION NAME] on 5/5/19 and 5/6/19. R1's MAR indicated [REDACTED]. On 5/9/19 at 1:55pm, V1, Administrator, stated the facility was out of R1's [MEDICATION NAME] on 5/5/19, and until 5/6/19 at 5:50pm when it was delivered. V1 stated she was unsure why the medication had not been delivered because the label had been pulled for reorder, and a nurse had called to check on its status on 5/5/19. V1 stated the facility has been paying for R1's [MEDICATION NAME], so no prior payment authorization was required. On 5/10/19 at 2:05pm, V11, Pharmacist, stated We called (V5, Primary Care Physician), and received the prescription on 5/5/19 for R1's [MEDICATION NAME]. We saw that it ([MEDICATION NAME]) wasn't covered by R1's insurance, so we didn't send it out to the facility. We didn't realize the nursing home was paying for it. We failed to follow our own protocol-which is to send three to five days' supply if not covered by insurance. On 5/10/19 at 1:25pm, R1 stated (R1) went home for the weekend on 5/3/19 and was given the last three doses of [MEDICATION NAME] remaining in the bottle to take with (R1) (doses for 5/3/19 pm, 5/4/19 am and pm). R1 stated (R1) returned to the facility Sunday at 11:40am, and no [MEDICATION NAME] had been delivered to the facility. R1 stated (R1) missed three doses of [MEDICATION NAME], and did not receive another dose of [MEDICATION NAME] until Monday 5/6/19 at about 6:00pm. R1 stated on 5/5/19 and 5/6/19 (R1) experienced increased, unrelieved pain of (R1's) back, legs, and knees, anxiety, hot and cold flashes, and diarrhea.

Based on observation, interview, and record review the facility failed to implement pressure ulcer prevention interventions, to identify and to treat a pressure ulcer for one (R6) of three residents reviewed for pressure ulcers in the sample of 20. This failure resulted in R6 developing a left heel pressure ulcer. Findings include: The facility Wound Management Program, dated 5/19/17, documents The nursing assistant visually inspects the skin daily and with care. If an area is identified, the nurse is notified and the Stop and Watch tool may be used to communicate this information. Appropriate measures will be instituted. Heels may be elevated off the bed to totally relieve pressure; boots, pillows, etc may be used for this purpose. The facility's Pressure Injury Treatment policy and procedure, dated 5/19/17, documents Suspected Deep Tissue Injury appears as a purple or maroon localized area of discolored intact skin or blood-filled blister and may be preceded by tissue that is painful, firm, mushy, boggy, and warmer or cooler as compared to adjacent tissue. The Medication Review Report for R6, documents the following dated physician orders: 10/15/18 Duoderm to coccyx every day shift every Sunday for prevention and 1/2/19 Check right gluteal fold for Duoderm placement, replace every 3 days until resolved every night shift. On 1/15/19 at 12:55 pm R6 stated, I have a sore on my butt. Sometimes it bothers me. I can't remember how long it's been there. On 1/16/19 at 12:55 pm, R6 did not have physician ordered dressings in place to R6's coccyx or gluteal fold. At this same time, V6 (Certified Nursing Assistant) verified these dressings were not in place. R6's current Interdisciplinary Plan of Care documents (R6) is at increased Risk for alteration in skin integrity. This plan of care lists some interventions as Off load heels PRN (as needed), Weekly measurement & documentation, Initiated upon admission skin protocol for any wounds stages accordingly, Tx (Treatment) per MD (Physician) order, see POS/TAR (Physician order [REDACTED]. This Plan of Care does not mention R6's left medial heel wound. On 1/15/19 at 12:55 pm and 3:37 pm and on 1/16/19 at 12:55 pm R6 was lying in bed on (R6's) right side with bilateral feet touching the bed. On 1/16/19 at 12:55 pm, following incontinence care, R6 cried out Oh my heel, Oh my heel at which time R6's left medial heel was noted to have a deep dark burgundy/purple, fluid filled blister. On 1/16/19 at 1:08 pm, V6 CNA stated (R6) has been complaining of (R6's) left heel being sore and it has been red but it looks worse today and is spongy like a blood blister. V6 CNA stated she reported (R6's) left heel wound to V9 LPN (Licensed Practical Nurse) a couple of weeks ago. The Unit Nurse Skin Review for R6, dated 11/22/18 and 12/12/18 document R6 with reddened heels. R6's medical record contains no further documentation regarding R6's left heel until the Skin Alteration Record dated 1/16/19, which documents; R6's left inner heel with 100% deep purple, closed fluid filled blister measuring 7.0cm (centimeters) by 3.0cm, and documents R6 with complaints of pain at a 7 on the 1-10 pain scale with 10 being the worst pain. On 1/17/19 at 9:44 am, V1 Administrator stated All the staff have been educated about the 'Stop and Watch' program the facility uses to trigger resident assessments. The CNAs are to complete a New Alert for any resident change in condition which then triggers the assessment for the Nurse to do. The CNAs are to also document on their daily sheets which (V1) reviews daily and would then have been informed of R6's left heel wound. V1 stated V6 CNA did not document any concerns regarding R6's left heel on her daily sheets and there have been no New Alerts triggered regarding R6's left heel. V1 also stated that V9 LPN no longer is employed by the facility. On 1/18/19 at 1:30 pm, V10 R6's Primary Care Physician stated 1/17/19 was the first and only notification V10 has had regarding R6's heels and if preventative measures had been placed R6's Deep Tissue Injury may have been prevented.

Based on interview and record review the facility failed to follow proper therapy orders in transferring for one of three residents reviewed for transfers in the sample of three. This failure resulted in R1 being transferred incorrectly which resulted in R1 receiving a displaced heel fracture. Findings include: R1's Physician order [REDACTED]. Nursing Progress Notes for R1, dated as a late entry on 2-10-17 at 2:00pm, by E5 (Registered Nurse/RN), document (E4 Certified Nurse Assistant/CNA) and patient reported to this RN at this time that patient was in shower and was toe touching with left foot and patient states she heard a 'pop' in left foot; patient wound noted to have stitches out at top of left heel wound at this time; moderate amount of active bleeding to left heel noted. On 3-31-17, at 12:27pm, E4/CNA stated that E4 was transferring R1 from a shower chair to a wheel chair after showering and dressing R1. (R1) stood up on her good foot. (E4) was told that (R1) could transfer by using tip-toe on (R1's) bad foot. (R1) was on the tip toe of (R1's) bad foot. We turned and when (R1) went to sit down we heard a pop. R1's radiology report, dated 2-14-17, documents Clinical history: (R1) with history of left calcaneal osteo[DIAGNOSES REDACTED]. Heard pop in shower. This report also documents Impression: Displaced fracture visualized of the posterior and superior calcaneus. On 3-31-17, at 1:45pm, Z1/PT stated that Z1 used Z1's clinical judgement, that R1 had a calcaneus fracture and R1 was told by R1's doctor not to put any weight on it (R1's left foot.) R1 would have been a mechanical lift for transfers and no weight bearing on the left foot. I don't know of any order of toe touch. I wrote an initial evaluation and told (Z2) about her non-weight bearing status. (R1) should have been a (mechanical) lift for a shower. R1's Physical Therapy PT Evaluation and Plan of Treatment, dated 2-1-17, documents Background Assessment: Medical: Precautions/Contraindications: NWB (no weight bearing) LLE (left lower extremity.) This evaluation also documents that R1's static standing is fair and R1's dynamic standing is poor; both with an inability to weight shift. R1's Physical Therapy Treatment Encounter Notes - Therapeutic Activities, dated 2-2-17, are signed by Z2 (Physical Therapy Assistant/PTA) and co-signed by Z1/PT and document to assist (R1) with transfers as she is NWB (no weight bearing) on the LLE (left lower extremity.) On 3-31-17, at 2:00pm, Z2/PTA stated (Z2) goes by the initial eval and the medical contraindication says non-weight bearing and Z2 follows that. Z2 stated that Z2 usually tells the staff who are working with (R1) what the weight bearing status is, but does not normally tell the Director of Nursing (E2). I must not have. Z2 stated that R1 never progressed to toe-touching. I don't remember her ever being a mechanical lift. (R1) was able to transfer by pivoting with help and non-weight bearing on that foot. On 3-31-17, at 2:35pm, E2 (Director of Nursing/DON), stated that E2 was unaware that R1 had a non-weight bearing status. R1 was not transferred by mechanical lift, but by staff - just unsure of weight-bearing status. I guess R1 would have been considered full weight bearing if there was nothing in the orders. Z2 (Physical Therapy Assistant/PTA) never informed E2 of R1's no weight bearing status and we have nothing on the 24 hour report sheets. (Z2) told me they were walking R1 when R1 first came in.

Based on record review and interview the facility failed to provide care without injury for one resident (R3) and failed to follow manufacturer's specifications for strap placement when securing a wheel chair during transport in the facility's van for R2. These failures involve two of four residents reviewed for accidents/injuries in the sample of four. R3 sustained a right femur fracture. Findings include: 1. R3's most recent Minimum (MDS) data set [DATE] notes R3 to be total dependent on staff for bed mobility, transfers in/out of bed, dressing, personal hygiene, and bathing. Facility Incident/Accident Report dated 2/16/12 notes that the E9 (Registered Nurse/RN) was called to R3's room around 1:45 P.M., where R3 was found to have, "right leg noted to be with protrusion noted." Nurse's notes on 2/16/12 at 1:45 P.M. read, "Summoned to room by CNAs (Certified Nurse's Aide), (R3's) right thigh noted to be swollen with hard protrusion, appears to be femur." On 2/29/12 at 9:40 A.M. E9/RN stated that she was called down to R3's room by E3 (CNA) at approximately 1:45 P.M. on 2/16/12. R3 was noted to have what seemed to be her right femur pushing out against her skin. E9 stated that she called E2 (Director of Nursing) down to R3's room to help assess. R3 was then sent to the local hospital for evaluation. E9 stated that she does not know how R3 sustained the fracture. Local hospital History and Physical report dated 2/16/12 notes that R3 came in with a "right leg deformity." "The patient (R3) was evaluated in the emergency room and found to have a displaced and angulated fracture of the proximal shaft of the right femur." Out of the area hospital History and Physical dated 2/27/12 notes that on 2/18/12 R3 was transferred to another hospital to have surgery on her right hip. This same History and Physical notes that on 2/20/12 R3 had an "Open reduction and internal fixation of her (R3) right femur with gamma nail insertion." On 3/1/12 at 8:30 A.M. Z1 (Orthopedic Surgeon) stated that the type of femur fracture R3 sustained could not have happened during routine cares like turning, positioning, transfers and dressing. Z1 said that there had to be some "blunt force" to cause that type of break. On 2/24/12 at 11:00 A.M. E3 (CNA) stated that she had taken care of R3 from 6 A.M. until they found the swollen right leg at 1:45 P.M. E3 stated that R3 had not complained of pain and that she had no idea how R3 sustained that right femur fracture. On 2/24/12 at 11:50 A.M. E4 (CNA) stated that she and E3 had taken care of R3 from 6 A.M. until R3's fractured leg was noted at 1:45 P.M. E4 stated that R3 had been acting more lethargic that day and that R3 was not bearing weight on her legs like she usually would. E4 stated that R3 did not seem as if she was in any pain and that E4 does not know how R3 sustained the right femur fracture. On 2/29/12 at 10:35 A.M. E5 (2nd shift CNA) stated that she had not noticed anything different with R3 and that E5 did not know how R3 sustained the right femur fracture. On 3/1/12 at 2:00 P.M. E6 (3rd shift CNA) stated that she and E7 (CNA) had dressed R3 the morning of 2/16/12 and did not notice anything different regarding R3. E6 states that she does not know how R3 sustained the right femur fracture. On 3/2/12 at 8:40 A.M. E7 (3rd shift CNA) stated that she and E6 had dressed R3 on the morning of 2/16/12 and that they did not notice any injuries to R3 leg. E7 stated that she does not know how R3 sustained the fracture to her right femur. 2. Incident/Accident Report dated 2/9/12 notes that between 1:30 P.M. and 2:00 P.M. R2's "Wheelchair toppled over while in the van." On 2/24/12 at 11:50 A.M. E4 (CNA) stated that on 2/9/12 when she was transporting R2 in the facility van to an appointment, R2 tipped over in the wheelchair when E4 was turning the corner. E4 stated that R2 did not tip all the way over, but fell against the electric gate in the van. E4 stated that management had said after the incident that E4 had placed the safety straps on incorrectly. On 2/24/12 at 2:20 P.M. R2 stated that on 2/9/12 she tipped over in her wheelchair and landed against the van gate with her right shoulder. R2 says her shoulder is not broken but does hurt at times. R2 says she does not know how it happened and that she thought she was strapped in. On 2/29/12 at 10:00 A.M. E8 (Environmental Service Director) stated that E4 had strapped in R2 incorrectly. E8 said that one of the two straps in the back of the wheelchair was hooked in the wrong spot. E8 and E4 both stated that only one strap is to be used in the front of the wheelchair. The "Instructions for use of the restraint system" for the van notes that there is to be two straps in the front of the wheelchair as well as the back.

Based on observation, interview and record review the facility failed to follow their policy on Medication Errors and notify the attending physician of missed [MEDICATION NAME] Patches for one of three residents (R3) reviewed for [MEDICATION NAME] Patches in the sample of three. R3 went without [MEDICATION NAME]es on two separate dates, had an increase in prn (as needed) pain medication, and was unable to carry out usual daily routines. Findings include: The POS (Physicians Order Sheet) for R3 dated 08/01/11 documents the following Diagnoses: [REDACTED]. The same POS for R3 documents the following orders: [MEDICATION NAME] Patch 50mcg (micrograms) apply patch topically every 72 hours, and Tylenol with [MEDICATION NAME] #2 every six hours as needed for pain. The MDS (Minimum Data Set) for R3 dated 12/01/10 documents that R3 is alert and oriented and able to make decisions independently. The MAR (Medication Administration Record) for R3 for the month of August 2011 documents that R3 received a [MEDICATION NAME] Patch 50mcg on 08/09/11. The same MAR for R3 documents that R3 was to receive [MEDICATION NAME] Patches on 08/12/11 and 08/15/11 as ordered. The nurses initials were circled on 08/12/11 and 08/15/11, indicating R3 did not receive the [MEDICATION NAME] Patches as ordered. On 08/17/11 at 10:15 AM E4 ( RN/Registered Nurse) stated, "The nurses circled their initials on those dates indicating (R3) didn't receive them because we didn't have any [MEDICATION NAME] Patches for (R3). The pharmacy did not deliver them. (R3) had the last [MEDICATION NAME] placed on 08/09/11. (R3) has been without the patch now 6 days. We faxed the refill to the pharmacy on 08/09/11. I just called the pharmacy to ask what the hold up was. They are supposed to send them today." The MAR (Medication Administration Record) for (R3) dated 08/01/11 through 08/31/11 documents that (R3) received 5 doses of Tylenol with [MEDICATION NAME] #2 between 08/12/11 and 08/16/11. The same MAR for the dates prior to 08/12/11 shows no documentation of R3 receiving Tylenol with [MEDICATION NAME] #2. The facility Medication Incident Reporting Policy dated 11/20/04 documents the following: "The attending physician will be promptly notified of any medication administration incident. The resident's clinical record will include documentation as follows: a) Type of medication error; b) Name of attending physician and the time of the notification of error; c) Physician's subsequent orders; d) Resident condition for at least 72 hours. All medication incidents will be documented on the designated form." The nurses noted for R3 from the dates of 08/12/11 through 08/16/11 contain no documentation of R3 not receiving the [MEDICATION NAME] Patches as ordered, or documentation of R3's condition for 72 hours. The same nurses notes for R3 contain no documentation of notification of R3's attending physician about the omission of the [MEDICATION NAME]es as ordered. On 08/17/11 at 10:30AM R3 was lying in bed. R3 stated, "I've been hurting more the past week and I don't know why. I haven't had my pain patch in several days. I don't remember when the nurse put it on me last. I've had to ask for my Tylenol with [MEDICATION NAME] a lot and it only helps a little. I have pain in my lower back and from my thighs down my legs. The Tylenol with [MEDICATION NAME] doesn't take the pain away like the pain patches do. I've just been lying down more and hoping rest will make it better, so I haven't been doing as much as I usually do. No one explained to me why I haven't been getting the pain patch. I like to be out and about and sit outside especially when the weather is so nice." On 08/17/11 at 10:15AM E4/RN stated, "If the nurses notes don't have any documentation about R3 not getting the [MEDICATION NAME]es then the doctor was not notified. I will call (R3)'s doctor and report that to him. I didn't do a medication error report." On 08/17/11 at 10:25AM E5 (LPN/Licensed Practical Nurse) stated, "If it isn't in the nurses notes about notifying the doctor of the omitted [MEDICATION NAME]es for (R3) then the doctor was not notified." On 08/17/11 at 10:45AM E1/Administrator stated, "They should have done a Medication Error report. The nurses are new and come from a hospital setting. I will go talk to them and instruct them to fill one out." On 08/17/11 at 11:00AM Z2 (RN/ R3's attending physician's nurse) stated, "The facility should have called us about (R3) missing those [MEDICATION NAME]es. Those calls would have come through me and I didn't receive any call from the facility about this. Doctor should have been notified." On 08/18/11 at 11:10AM Z1(Attending Physician for R3 stated, "I definitely should have been notified of the [MEDICATION NAME] omission for this resident especially with the increased pain and prn medication use. The facility should have called me. I don't know why the pharmacy didn't get it to them."

Based on observation, interview and record review, the facility failed to monitor the placement of a [MEDICATION NAME] to ensure continued administration of the medication in one of two residents (R3) with [MEDICATION NAME]es in the sample of five residents. Findings include: POS (physician's orders [REDACTED].*chart and rotate sites*." On 10/12/11 at 9:50 AM, R3 did not have a [MEDICATION NAME] on his torso or any other area of his body. On 10/12/11 at 9:50 AM, E5/RN (Registered Nurse) verified there was no [MEDICATION NAME] on R3.

Based on observation, interview, and record review the facility pharmacy failed to refill Fentanyl patches for one of three residents (R3) receiving Fentanyl patches in the sample of ten. This failure resulted in increased pain for R3, increased use of prn (as needed) pain medication, and limited R3's daily functioning. Findings include The POS (Physicians Order Sheet) for R3 dated 08/01/11 documents the following Diagnoses: [REDACTED]. The same POS for R3 documents to following orders: Fentanyl Patch 50mcg (micrograms) apply patch topically every 72 hours, and Tylenol with Codeine #2 every six hours as needed for pain. The MDS (Minimum Data Set) for R3 dated 12/01/10 documents that R3 is alert and oriented and able to make decisions independently. The Care Plan for R3 dated 06/29/11 documents that R3 is at risk for alteration in comfort due to arthritis and Restless Leg Syndrome. The MAR (Medication Administration Record) for R3 for the month of August 2011 documents that R3 received a Fentanyl Patch 50mcg on 08/09/11. The same MAR for R3 documents that R3 was to receive Fentanyl Patches on 08/12/11 and 08/15/11 as ordered. The nurses initials were circled on 08/12/11 and 08/15/11, indicating R3 did not receive the Fentanyl Patches as ordered. Facility Medication Re-Reorder Form dated 08/09/11 documents that R3's Fentanyl Patch 50mcg was re-ordered. The same form documents that it was faxed to the facility pharmacy on 08/09/11. On 08/17/11 at 10:15 AM E4 ( RN/Registered Nurse) stated, "The nurses circled their initials on those dates indicating (R3) didn't receive them because we didn't have any Fentanyl Patches for (R3). The pharmacy did not deliver them. (R3) had the last Fentanyl patch placed on 08/09/11. (R3) has been without the patch now 6 days. We faxed the refill to the pharmacy on 08/09/11. I just called the pharmacy to ask what the hold up was. They are supposed to send them today." On 08/17/11 at 10:45AM E1/Administrator stated, "(R3) should not have gone without the Fentanyl. I will call the pharmacy and find out what happened. If they faxed it to the pharmacy on the 9th then it should have been delivered." On 08/17/11 at 11:20AM Z3(RPh/Registered Pharmacist/Managing pharmacist for facility) stated, "Yes it shows we received the fax to refill (R3)'s Fentanyl on 08/09/11. Whoever got that fax here at the pharmacy did not communicate to me about the need for the refill. If I had been told here I would have sent the Fentanyl through our back up service. I got a call just a few minutes ago from the facility and will be sending out the Fentanyl today." On 08/17/11 at 10:30AM R3 was lying in bed. R3 stated, "I've been hurting more the past week and I don't know why. I haven't had my pain patch in several days. I don't remember when the nurse put it on me last. I've had to ask for my Tylenol with Codeine a lot and it only helps a little. I have pain in my lower back and from my thighs down my legs. The Tylenol with Codeine doesn't take the pain away like the pain patches do. I've just been lying down more and hoping rest will make it better, so I haven't been doing as much as I usually do. No one explained to me why I haven't been getting the pain patch. I like to be out and about and sit outside especially when the weather is so nice."