Every finding on record at Parsons Hill Rehabilitation & Health Care Center

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose treatment orders included daily wound care, the facility failed to ensure they maintained a complete and accurate medical record, when nursing documentation related to his/her wound care treatments on multiple days in the month of June 2026, was found to be incomplete and/or inaccurate.Findings include:Review of the Facility policy titled, Nursing Documentation, dated February 2016, indicated the following:-The licensed nursing personnel documents information related to the resident's condition and care provided in the resident's medical record.-Treatments: The type and resident/patient response.Resident #1 was admitted to the Facility March 2026, with diagnoses including but not limited to hypothermia (low body temperature), superficial frostbite of hand and foot, and severe sepsis with septic shock (life threatening infection that leads to low blood pressure and acute organ damage).Review of Resident #1's Minimum Data Set (MDS) admission Assessment, dated 04/06/26, indicated he/she was dependent on staff assistance for bathing, dressing, transfers and mobility, had open lesions and had the application of nonsurgical dressings.Review of Resident #1's Physician's orders for the Month of June 2026 indicated he/she had treatment orders related to wound care for the following:-Treatment Order: Location: Right toes 1-3, Vashe (or similar antibacterial wound cleanser), Alginate (absorbent wound dressing) and DPD (dry protective dressing). Change every day shift. Put Lambs wool in between toes.-Treatment Order: Location: Left toes 1-5, Vashe (or similar antibacterial wound cleanser), Iodosorb (antimicrobial gel) and DPD. Change daily on day shift.-Treatment Order: Location: Right second finger, Vashe (or similar antibacterial wound cleanser), Iodasorb and DPD. Change daily on day shift.1. Review of Resident #1's Treatment Administration Record (TAR) for the month of June 2026, indicated for the following dates there was no nursing documentation related to the description or characteristics of the wounds and/or nursing observations or findings related to the completion of these treatments. -6/12/26, 06/15/26 and 06/17/26-day shift: Left toes 1-5, Vashe (or similar antibacterial wound cleanser), Iodosorb and DPD. -6/12/26, 06/15/26 and 06/17/26-day shift: Right second finger, Vashe (or similar antibacterial wound cleanser).Review of Resident #1's Nurses Notes, dated 06/12/26 through 06/17/26, indicated there was no nursing documentation related to his/her wounds specific to the dressing changes that had been completed on 6/12/26, 06/15/26 and 06/17/26 as ordered by the Physician.During an interview on 06/30/26 at 4:10 P.M., Nurse #1 said that Resident #1 (who was on her assignment on 06/12/26, 06/15/26 and 06/17/26, day shift) had refused to have his/her dressings changed. Nurse #1 said that she should have documented Resident #1's refusal but said that she forgot.During a telephone interview on 07/01/26 at 8:00 A.M., the Facility Wound Nurse said that on 06/15/26 she had accompanied the Wound Care Consultant for wound rounds and had documented Resident #1's wound assessment. The Wound Care Nurse said that after Resident #1's wound assessment was completed a temporary dressing was applied. The Wound Care Nurse said she did not administer the prescribed treatment order to Resident #1 on 06/15/26 and that it was the responsibility of his/her assigned unit nurse.During an interview on 06/30/26 at 3:30 P.M., the Director of Nursing said that she expected the nurses to perform dressing changes as ordered by the Physician, document any refusals and notify the Provider of the refusal, but that this had not been done on 06/12/26, 06/15/26 and 06/17/26.2. Further review of Resident #1's Treatment Administration Record (TAR) for the month of June 2026, indicated that for the following dates, although the wound care treatment was signed off on by nursing as having been completed, per staff member interview (with Nurse #4, whose initials were on the TAR) the treatments had actually not been completed and had been signed off on in the TAR in error. -06/17/26: Right toes 1-3, Vashe (or similar antibacterial wound cleanser), Alginate and DPD (dry protective dressing). Documented as completed by Nurse #4.-06/18/26: Right toes 1-3, Vashe (or similar antibacterial wound cleanser), Alginate and DPD (dry protective dressing). Documented as completed by Nurse #4.During a telephone interview on 07/01/26, Nurse #4 said that she worked the 3:00P.M. to 11:00P.M. and 11:00 P.M. to 7:00 A.M. shifts on 06/17/26 and 06/18/26. Nurse #4 said she had never changed Resident #1's dressing on his right toes and did not know why the electronic medical record indicated that she had performed the dressing changes on 06/17/26 and 06/18/26. During a telephone interview on 07/02/26 at 12:00 P.M., the Director of Nurses (DON) said that she had called Nurse #4 and confirmed that she had not changed Resident #1's right foot dressing. The DON said Nurse #4's documentation was supposed to be for monitoring the dressing and not for performing the dressing change but that there was a problem with the electronic medical record. The DON said there was no additional documentation in the medical record to support that Resident #1 's right toe dressing change had been completed on 06/17/26 and 06/18/26, by nursing.

Based on record review, and interview, the facility failed to ensure four Residents (#7, #14, #1, and #71) out of a total sample of 29 residents were seen by a Physician at the required regulatory frequency for Physician visits.Specifically, the facility failed to ensure that Residents #7, #14, #1, and #71 were seen by a Physician for alternating visits with the Nurse Practitioner (NP) every 60 days as required, after the Residents were in the facility for 90 days. Findings include: 1.Resident #7 was admitted to the facility in February 2021 with diagnoses including Diabetes Mellitus II with Hyperglycemia, Hypo-Osmolality, Hypernatremia, and Major Depressive Disorder. Review of Resident #7's clinical record on 4/28/26 did not provide any evidence that Resident #7 had been seen by an Attending Physician since January 2025. 2.Resident #14 was admitted to the facility in August 2014 with diagnoses including Paranoid Schizophrenia and Major Depressive Disorder. Review of Resident #14's clinical record on 4/28/26 did not provide any evidence that Resident #14 had been seen by an Attending Physician since December 2024. During an interview on 4/28/26 at 12:15 P.M., the Director of Nursing (DON) said Physician progress notes were documented in the electronic medical record (EMR) under the Practitioner tab. The surveyor and the DON reviewed Resident #7's and Resident #14's electronic medical records and the DON said that there were no Physician progress notes documented in Resident #7's or Resident #14's EMR. The DON also said that she was unsure of when either of the Residents had been seen by the Attending Physician. During a follow-up interview on 4/28/26 at 1:04 P.M., the DON said that all residents should be seen by an Attending Physician every sixty days. The DON said that Resident #7 was last seen by an Attending Physician in January 2025, and Resident #14 was last seen by an Attending Physician in December 2024. The DON did not provide any evidence that Resident #7 or Resident #14 had been seen by an Attending Physician as required. 3. Resident #1 was admitted to the facility in March 2022 with diagnoses including Type 2 Diabetes Mellitus, Undifferentiated Schizophrenia, Chronic Kidney Disease Stage 3A, and Dysphagia. Review of Resident #1's medical record on 4/28/26 did not provide any evidence that Resident #1 had been seen by an Attending Physician since May 2025. 4. Resident #71 was admitted to the facility in January 2020 with diagnoses including Idiopathic Aseptic Necrosis of Left Femur, Major Depressive Disorder, Anxiety Disorder, and Elevated [NAME] Blood Cell Count. Review of Resident #71's medical record on 4/28/26 did not provide any evidence that Resident #71 had been seen by an attending physician since May 2025. During an interview on 4/29/26 at 7:50 A.M., the Director of Nursing (DON) said that Physician progress notes were documented under the Practitioner tab in the electronic health records for Residents #1 and #71. The DON said that she reviewed Resident #1 and #71's record and there was no evidence of Physician progress notes. The DON said that Residents #1 and #71 should have Physician visits every thirty to ninety days. The DON said Physician visits were important to ensure that Resident #1 and #71's plan of care was being followed and implemented as ordered. During an interview on 4/29/26 at 12:30 P.M., the Clinical Nurse Specialist (CNS) said that Residents #1 and #71 should have had a Physician visit every ninety days. The CNS said that it was important for the Physician to see Residents #1 and #71 to ensure that treatment and care are being followed as ordered for the Residents.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were stored in accordance with accepted professional standards of practice, as required, for one (Greendale Unit) medication cart, out of three medication carts reviewed.Specifically, for the Greendale Unit medication cart, the facility failed to properly secure medications and ensure the medication cart was sanitary and free of debris. Findings include:Review of facility policy titled Medication Storage Room/Medication Cart Policy, dated February 2018, included:-All licensed personnel are responsible for ensuring the cleanliness of the medication cart/med room at all times and at the end of the shift.-Medications are stored primarily in a locked mobile medication cart which is accessible only to licensed nursing personnel-The medication cart is to be kept locked at all time(s) when not in use by the nurse.-The medication cart is to be locked when stored in the medication room or some other location.-Medication carts will be cleaned at least weekly and daily as needed On 4/27/26 at 9:45 A.M., the surveyor observed an unlocked and unattended medication cart in the Greendale Unit hallway. The surveyor observed a resident in a wheelchair pass in close proximity to the front of the medication cart. The surveyor observed the top drawer of the medication cart with medications stored was easily accessible to unauthorized persons. The surveyor remained at the medication cart until Nurse #4 returned. During an interview at the time, Nurse #4 said she had not noticed the surveyor standing by her medication cart. The surveyor and Nurse #4 reviewed the medication cart and removed over 25 assorted loose pills and paper debris from the bottom of the resident specific medication card drawer. Nurse #4 said she left the medication cart to go into an adjacent room to give a resident their medication. Nurse #4 said she must have forgotten to lock the medication cart, but she usually does lock the medication cart when she steps away. Nurse #4 said the correct thing to do when she stepped away from the medication cart was to lock the cart, but she had not done so. Nurse #4 said that there should not be loose pills in the drawer. Nurse #4 said that it was the responsibility of all Nurses to keep the medication cart clean and to remove any pills that drop into the drawer. Nurse #4 said the expectation was that the drawers would be clean, but they were not. During an interview on 4/27/26 at 11:00 A.M., the Director of Nursing (DON) said that the medication cart should be secured at all times when the responsible Nurse steps away from the cart, and that it was the responsibility of all licensed Nurses accessing the medication cart to keep the cart clean and free of debris. Please Refer to F842

Based on record review, and interview, the facility failed to ensure that one Resident (#3) of five applicable residents sampled for unnecessary medications, out of a total sample of 29 residents, was free from unnecessary psychotropic (medication that affect how the brain works and causes changes in mood, awareness, thoughts, feelings, perception and behaviors) medications.Specifically, for Resident #3, the facility failed to monitor for potential side effects and evaluate the Resident's response to Seroquel (Quetiapine - antipsychotic medication), Klonopin (Clonazepam - benzodiazepam medication), Ativan (Lorazepam - benzodiazepam medication), and Zoloft (Sertraline - antidepressant medication) medications, placing the Resident at risk for unidentified medication side effects and/or complications. Findings include: Review of the facility policy titled Psychotropic Medication, dated April 2015, included but was not limited to: *Each resident's drug regimen will be free from unnecessary drugs. Administration of psychoactive medications will focus on the individual needs of the resident and will be prescribed only when necessary and clinically indicated to treat specific conditions and symptoms as diagnosed and documented. -Obtain Physician order for each psychoactive medication. Ensure that supportive diagnosis and target behaviors are documented and clearly identify the use of the medication is necessary and warranted.-Monitor target behaviors daily for Antipsychotic, Antidepressants, and Anxiolytics using a behavior monitoring tool. -Monitor the resident's response to the medication and for any potential adverse consequences of the medication. -Care plan the psychoactive medication use, supportive diagnosis, goals of therapy, target behaviors and pharmacological and non-pharmacological approaches, inclusive, but not limited to behavioral interventions.-Review the care plan with interdisciplinary team (IDT) when a resident is admitted on psychoactive medications, quarterly, annually and as needed for changes in resident status and revise as necessary.-Review should include verification that adequate indications for use of the psychotropic medication exist, the medications are not being used for extended duration, and residents are free of duplicate therapy and being monitored for adverse consequences, per current professional standards of practice and in accordance with Federal and State guidelines. Review of the facility policy titled Nursing Documentation, dated February 2016, included but was not limited to: *The licensed nursing personnel documents information related to the resident's condition and care provided in the resident's medical record. -Document all untoward reactions related to medications, treatment, therapy. Resident #3 was admitted to the facility in March 2025 with diagnoses including Bipolar Disorder, Depression, Agoraphobia with Panic Disorder, and borderline personality disorder. Review of the Minimum Data Set (MDS) Assessment, dated 3/3/26, indicated Resident #3:-was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of a possible score of 15. -was understood by others and understand others.-received an antipsychotic medication and the antipsychotic was administered on a routine basis. Review of Resident #3's April 2026 Physician orders indicated:-Ativan (Lorazepam) Oral Tablet 0.5 milligrams (mg). Give 1 tablet by mouth every 24 hours as needed for Anxiety for 30 days, initiated 4/23/26.-Clonazepam Oral Tablet 1 mg. Give 1 mg tablet by mouth three times a day for Anxiety, initiated 12/12/25-Clonidine Hydrochloride (HCl) Oral Tablet 0.1 mg. Give 1 mg tablet by mouth at bedtime for Anxiety, initiated 3/10/25-Hydroxyzine HCl Oral Tablet 25 mg. Give 1 tablet by mouth three times a day for Anxiety related to Bipolar Disorder, Unspecified, initiated 2/9/2-Seroquel (Quetiapine Fumarate) Oral Tablet 100 mg. Give 1 tablet by mouth one time a day for mood related to Bipolar Disorder, Unspecified Borderline Personality Disorder, initiated 3/10/25-Seroquel Oral Tablet 400 mg. Give 400 mg by mouth at bedtime for mood related to Bipolar Disorder, Unspecified, initiated 3/10/25-Zoloft (Sertraline HCl) Oral Tablet 100 mg. Give 200 mg by mouth one time a day for depression, initiated 3/10/25 Review of Resident #3's medical record failed to indicate Physician orders or nursing interventions to monitor for potential side effects for Ativan, Clonazepam, Clonidine, Hydroxyzine, Seroquel and Zoloft medication use. During an interview on 4/28/26 at 9:30 A.M., Nurse #2 said that Nurses administering psychotropic medications to residents should monitor side effects which include anxiety and depression symptoms such as crying, lack of energy, sleeping too much and refusing to eat. The surveyor and Nurse #2 reviewed Resident #3's medical record and Nurse #2 said that there were no Physician orders or interventions to monitor and document psychotropic medication side effects for Resident #3. Nurse #2 said that it was important that medication side effects were monitored and documented to ensure treatment adherence and prompt intervention. During an interview on 4/28/26 at 10:15 A.M., the Director of Nursing (DON) said her expectation for nursing staff administering psychotropic medications was that nursing staff should monitor and document side effects. The DON said that monitoring for medication side effects ensures that the medication was effective and any side effects could be communicated to the Physician for prompt intervention. The DON also said that Resident #3 should have had a Physician order, care plan and interventions addressing the need for care and services related to psychotropic medication use, but there were none.

Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#147), of one applicable resident receiving dialysis (process that filters wastes, salts and fluid from your blood when the kidneys are unable to work adequately) services, out of a total sample of 29 residents.Specifically, for Resident #147, the facility failed to ensure:-medications were administered timely when the Resident attended regularly scheduled dialysis treatments. -that the facility staff administered the Mircera Injection Solution Prefilled Syringe Medication (a long-acting medication used to treat anemia) as ordered and notified the Physician when the medication was unavailable from the pharmacy, placing the Resident at risk for low blood count.-that the facility staff administered the Romiplostim (used to increase platelet counts to reduce the risk of bleeding) as ordered and notified the Physician when the medication was unavailable from the pharmacy, placing the Resident at risk for low platelet count.-that Sevelamer (medication to lower phosphorus levels in the blood) medication was administered as ordered by the Physician with meals, causing the Resident to miss the scheduled Sevelamer doses at breakfast on Tuesdays, Thursdays, and Saturdays.-that the facility staff accurately monitored the total daily fluid intake, placing him/her at risk for complications related to fluid overload. Findings include:Review of the facility policy titled, Hemodialysis, revised April 2015, indicated:-If resident is placed on fluid restriction, monitor intake. Resident #147 was admitted to the facility in April 2026 with diagnoses including cirrhosis of liver, End Stage Renal Disease (ESRD), Thrombocytopenia, Diabetic Retinopathy and Major Depressive Disorder.Review of Resident #147's April 2026 Physician orders indicated:-Hemodialysis every Tuesday, Thursday and Saturday at 5:30 A.M.-Micera Injective Solution Prefilled Syringe, inject 225 micrograms (mcg) subcutaneously in the morning every Monday, and Friday related to Anemia, start date 4/17/26.-Romiplostim Subcutaneous Solution reconstituted 250 mcg, inject 0.5 milliliters (ml) in the morning every Monday related to Thrombocytopenia, start date 4/20/26.-Insulin Lispro Injection Solution 100 Unit/ml, inject 5 units subcutaneously with meals related to Type 2 Diabetes, start date 4/14/26.-Sevelamer Carbonate Oral Tablet 800 mg, give 4 tablets by mouth with meals related to End Stage Renal Failure, start date 4/14/26.-Fluid Restriction 1500 ml, start date 4/14/26. Review of Resident #147's April 2026 Medication Administration Record (MAR), indicated:>Micera Injective Solution Prefilled Syringe, inject 225 mcg subcutaneously in the morning every Monday, and Friday related to Anemia, start date 4/17/26. At 10:00 A.M., the Micera medication was documented as (9) - indicating see progress notes on the following dates:-Friday, 4/17/26.-Monday, 4/20/26.-Friday, 4/24/26.>Romiplostim Subcutaneous Solution reconstituted 250 mcg, inject 0.5 milliliters (ml) in the morning every Monday related to Thrombocytopenia, start date 4/20/26.At 10:00 A.M., the Romiplostim medication was documented as (9) - indicating see progress notes on 4/20/26.>Insulin Lispro Injection Solution 100 Unit/ml, inject 5 units subcutaneously with meals related to Type 2 Diabetes, start date 4/14/26.At 8:00 A.M., the Insulin medication was documented as (3) - indicating Resident #147 was not available on the following dates:-Thursday 4/16/26.-Tuesday, 4/21/26.-Saturday, 4/25/26.>Sevelamer Carbonate Oral Tablet 800 mg, give 4 tablets by mouth with meals related to End Stage Renal Failure, start date 4/14/26.At 8:00 A.M., the Sevelamer medication was documented as (3) - indicating Resident #147 was not available on the following dates:-Tuesday, 4/21/26.-Saturday, 4/25/26.-Monday, 4/27/26.Further Review of Resident #147's April 2026 MAR indicated:-Fluid Restriction 1500 ml.-Total Fluid Intake every shift.Review of the MAR and the 24-hour total fluid intake for 4/13/26 to 4/26/26 indicated:-4/13/26: MAR - 480 ml/ 24-HR total - 1800 ml -4/14/26: 700 ml/ 840 ml4/15/26: 1080 ml/ 1200 ml4/16/26: 880 ml/ 120 ml4/17/26: 310 ml/ (no documentation) 4/18/26: 820 ml/ 120 ml4/19/26: 1140 ml/ 480 ml4/20/26: 600 ml/ 240 ml4/21/26: 1320 ml/ 1200 ml4/22/26: 1880 ml/ 680 ml4/23/26: 840 ml/ 600 ml4/24/26: 1320 ml/1200 ml4/25/26: 860 ml/ 1200 ml4/26/26: 1610 ml/960 ml Review of Resident #147's April 2026 Order Administration Notes in the progress notes indicated:-4/17/26,11:04 A.M., Micera medication - not available.-4/20/26, 11:34 A.M., Micera medication - pending delivery.-4/20/26, 11:34 A.M., Romiplostim subcutaneous medication - pending delivery.-4/24/26, 3:38 P.M., Micera medication - will follow-up. During an interview on 4/26/26 at 8:15 A.M., Nurse #5 said Resident #147 leave the facility for dialysis on Tuesdays, Thursdays, and Saturdays around 5:30 A.M. and return to the facility around 10:30 A.M. Nurse #5 said no medications from the facility were sent to dialysis with Resident #147, and the medications scheduled to be administered in the morning at 8:00 A.M., and 10:00 A.M., when the Resident was out at dialysis, would be administered when he/she returned from dialysis treatment between 10:15 A.M. to 10:30 A.M. Nurse #5 said the Resident's MAR should reflect the times that the Resident's medications were administered and currently the MAR was not accurate relative to the medication administration times. Nurse #5 said she would document the scheduled 8:00 A.M., medication as a (3) to indicate that the Resident was not available for the days when the Resident was out to dialysis. Nurse #5 said she had documented that the Micera medication was pending delivery from the pharmacy and not available but had not notified the Physician about the medications that were not available, but she should have. During an interview on 4/27/26 at 10:08 A.M., the Director of Nursing (DON) said Resident #147 started dialysis treatments after admission to the facility, and that his/her medication administration times should have been adjusted based on his/her dialysis schedule. The DON further said she would have to investigate the Sevelamer, Micera and Romiplostim medications administration. On 4/27/26 at 10:35 A.M., the surveyor and the Assistant Director of Nursing (ADON) reviewed Resident #147's April 2026 fluid intake documented on the MAR shift totals and the 24-hour fluid total intake. The ADON said the documented total fluid intake per shift from 4/13/26 to 4/26/26 was calculated inaccurately. The ADON said that accuracy of monitoring and recording of fluid restrictions was important so that residents are provided with what is ordered by the Physician. The ADON said the 24-hour intake totals of Resident #147's fluid intake did not match every shift fluid intake documented by the Nurses. During a follow-up interview on 6/25/25 at 11:23 A.M., the DON said she was unsure if the Provider was made aware that morning medications scheduled for 8:00 A.M. and 10:00 A.M. on dialysis days were given after the Resident's return from dialysis prior to the surveyor interviews or that the Sevelamer medication (scheduled for 8:00 A.M. with breakfast) was not being administered as ordered for the breakfast meal on the days (Tuesday, Thursday and Saturday) Resident #147 was at dialysis. During a follow-up interview on 4/27/26 at 3:15 P.M., the Regional Nurse said the facility policy should have been followed relative to dialysis and medication timing for Resident #147. The Regional Nurse said the facility should have coordinated with the Resident's dialysis clinic relative to his/her medications and should have adjusted the medication administration times on dialysis days. The Regional Nurse further said the Physician should have been notified when the medications were held and were not available for administration, but they had not.

Based on observations, interviews, and record review, the facility failed to maintain accurate records of controlled substances (drugs or chemicals that the government regulates for its manufacture, possession, and use, that are classified into schedules based on their potential for abuse) for one Controlled Substance Book on the Greendale Unit, out of three controlled substance books reviewed.Specifically, for the Greendale Unit, the facility failed to maintain a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation in the Controlled Substance Book (Narcotic Book). Findings include:Review of nurse in-service titled How to do a Narcotic Count, undated, included:-As soon as the count is completed, both nurses should sign as count done. At this point the narcotic keys are transferred to oncoming nurse Review of nurse in-service titled Controlled Substance Book Documentation, undated, included:-The narcotic count should not be signed off in advance-Count should be performed at the beginning and end of your work shift-This count requires both nurses to be present at the med (medication) cart with the narcotic book opened to the index page and the narcotic drawer opened-At the end of the narcotic count, both nurses are then to sign the signature entries. Document the date, time and answer if count was correct On 4/27/26 at 9:45 A.M., the surveyor and Nurse #4 reviewed the Controlled Substance Book for the Greendale Unit. Review of the signature log in the back of the book failed to provide evidence of two licensed nurses signing to verify the accuracy and reconciliation of the controlled medication count at the change of each shift on the following dates and times:-4/26/26 at 7:00 A.M.-4/26/26 at 3:00 P.M.-4/26/26 at 11:00 P.M.-4/27/26 at 7:00 A.M. During an interview on 4/27/26 at 9:58 A.M., Nurse #4 said she did conduct the controlled medication count at 7:00 A.M. on 4/27/26 for the Greendale medication cart with the off-going Nurse. Nurse #4 said the controlled medication count was accurate, but she must have forgotten to sign her name in the log at the back of the Narcotic Book as required. During an interview on 4/27/26 at 10:57 A.M., Nurse #3 said she had worked a double shift on the Greendale Unit on 4/26/26 from 7:00 A.M. until 11:00 P.M. and had possession of the medication cart keys during that time. Nurse #3 said she did conduct a count of the controlled medication with the off-going licensed Nurse on 4/26/26 at 7:00 A.M. and then again on 4/26/26 at 11:00 P.M. with the oncoming licensed Nurse. Nurse #3 said the controlled medication count was accurate during both counts, but she must have forgotten to sign her name in the log at the back of the Narcotic book as required. During an interview on 4/27/26 at 11:00 A.M., the Director of Nursing (DON) said there was an expectation that the count of all controlled medications stored in the medication cart would occur at the change of each shift, by the licensed Nurse coming on duty with the licensed Nurse going off duty. The surveyor and the DON reviewed the back of the Controlled Substance Book on the Greendale medication cart and the DON said that there were no signatures indicating that a count of the controlled medications stored in the Greendale medication cart was conducted by two Nurses on the following dates and times:-4/26/26 at 7:00 A.M.-4/26/26 at 3:00 P.M.-4/26/26 at 11:00 P.M.-4/27/26 at 7:00 A.M.The DON said the licensed Nurses should have conducted the controlled medication count and then signed the back of the Controlled Medication Book together as required, but they had not done so.

Based on observation and interviews, the facility failed to keep confidential information contained in the resident's record secure, in accordance with accepted professional standards and practice for one (Greendale Unit) medication cart computer screen, out of three medication cart computer screens reviewed.Specifically, for the Greendale Unit medication cart computer screen, the facility failed to properly secure the computer screen containing confidential resident specific medication administration information when the computer screen was left unlocked and unattended, leaving the information readily viewed by unauthorized persons. Findings include:Review of the facility policy titled Information Technology Policy, dated 2/9/24, included:>Examples of Confidential Data-Medical and healthcare information>Storage-Confidential information must be removed from desks, computer screens, and common areas unless it is currently in use. Confidential information should be stored under lock and key (or keycard/keypad), with the key, keycard, or code secured. On 4/27/26 at 9:45 A.M., the surveyor observed an unlocked and unattended medication cart in the Greendale Unit hallway. The surveyor further observed that the computer screen on the medication cart was unlocked and confidential resident information was clearly visible. The surveyor remained at the medication cart until Nurse #4 returned. During an interview at the time, Nurse #4 said she had not noticed the surveyor standing by her medication cart. The surveyor and Nurse #4 reviewed the medication cart and observed that the medication computer screen was left open displaying confidential resident information. Nurse #4 said she left the medication cart and went into an adjacent room to give a resident their medication. Nurse #4 said she forgot to secure the computer resident information screen before she stepped away from the medication cart, but she usually does lock the computer information screen. Nurse #4 said that the correct thing to do when she steps away from the medication cart was to lock the cart, and to hide the computer information screen but she had not done so. During an interview on 4/29/26 at 12:30 P.M., the Director of Nursing (DON) said the expectation would be that computer screens containing confidential resident information were hidden, before the assigned licensed Nurse leaves the medication cart unattended, to preserve the residents' privacy. The DON said Nurse #4 should have hidden the computer information screen before walking away from the medication cart.

Based on observations, interviews, and record review, the facility failed to implement infection control practices to prevent transmission of infections for one Residents (#136) out of a total sample of 29 residents. Specifically, for Resident #136, the facility failed to ensure that staff implemented Enhanced Barrier Precautions (EBP- the use of protective equipment such as gowns and gloves to prevent the spread infection from one person to another) during high contact care activities for the Resident, placing the Resident, other residents, and staff at risk for the spread of infection. Findings include: Review of the facility policy titled Enhanced Barrier Precautions Policy, undated, included but was not limited to the following: -It is the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug -resistant organisms (MRDOs-bacteria or microorganisms that are difficult to treat, easily spread, and resistant to one or more antimicrobial agents [antibiotics]). -MRDOs may include >Methicillin Resistant Enterococcus (MRSA- a specific type of staphylococcus bacteria that has developed resistance to many common antibiotics) -EBPs require the use of gown and gloves for certain residents during specific high contact care activities. High contact resident care activities include bathing, providing hygiene, dressing, transferring, linen changes, toileting, device care and wound care. Resident #136 was admitted to the facility in April 2019 with diagnoses including obstructive and reflux uropathy, history of MRSA, and immunodeficiency. Review of Resident #136's April 2026 Physician orders indicated: -Foley Catheter 14 French/10 milliliter balloon (a specific type of soft, flexible tube that is inserted into one's bladder to drain urine). -EBP related to Foley, History (Hx) of MRSA, every shift, effective 3/21/25 Review of Resident #136's person-centered care plan indicated the following: -Infection with a Resistant Micro-Organism history of MRSA, revised 8/10/25. >Interventions: Precautions as ordered. On 4/26/26 at 7:45 A.M., the surveyor observed Resident #136's doorway to have the following signage posted: -STOP Enhanced Barrier Precautions STOP -EVERYONE MUST: >Clean their hands, including before and after entering and when leaving the room. -PROVIDERS AND STAFF MUST ALSO: >Wear gloves and a gown for the following high contact Resident Care Activities: --Dressing, Bathing --Transferring --Changing Linens --Providing Hygiene --Device care or use: urinary catheter, feeding tube, central line, tracheostomy --Wound Care On 4/26/26 at 9:12 A.M., the surveyor observed Nurse #1 sitting on Resident #136's bed and assisting him/her to eat oatmeal. The surveyor observed Nurse #1's left leg and shoe making direct contact with Resident 136's Foley catheter tubing and drainage bag. Nurse #1 was observed not wearing a gown or gloves at the time. Nurse #1 then exited the Resident's room and said she thought the EBP signage in the Resident's doorway was old and that nobody living in the room had wounds. Nurse #1 further said she would double check why the signage for EBP was posted. On 4/26/26 at 3:31 P.M., the surveyor observed Certified Nurse Aide (CNA) #1 changing the bed linens on Resident #136's bed. CNA #1 was observed to be wearing gloves but not a gown while changing the Resident's linens. The surveyor then observed CNA #1 exit the Resident's room. During an interview at the time, CNA #1 said Resident #136 was on EBP and that she should have worn gown and gloves when changing the Resident's linens. CNA #1 said a gown and gloves should be used to protect the Resident from getting an infection. During a follow-up interview on 4/26/26 at 3:54 P.M., Nurse #1 said Resident #136 had a history of MRSA in the urine and had a Foley catheter. Nurse #1 said that she should have been wearing a gown and gloves when sitting on the Resident's bed linens because she could have spread infection to the Resident or from the Resident to other residents on the unit. During an interview on 4/26/26 at 4:30 P.M., the infection Preventionist (IP) said Resident #136 required EBP because the Resident had a history of MRSA in his/her urine but was contained in the Foley catheter and not an active infection, and EBP would protect the staff from transmitting the MRSA to themselves and the other residents in the facility. The IP said Resident #136 also needed EBP to protect the Resident from getting infections because the Resident's Foley catheter device made it easier for the Resident to get infections. The IP said CNA #1 should have worn both gown and gloves while changing the Resident's linens and Nurse #1 should not have been sitting on the Resident's bed without having a gown and gloves on nor made contact with the Resident's Foley catheter. The IP said the Resident was at higher risk to contract and spread infection when the staff did not wear a gown and gloves.

Based on record review, and interview, the facility failed to provide written notification of a hospital transfer to the Resident's Responsible Party for one Resident (#2) out three closed records sampled. Specifically, for Resident #2, the facility failed to provide written notice of transfer to the Resident's Responsible Party when the Resident was emergently transferred to the hospital for respiratory distress. Findings include: Review of the facility policy titled Emergency Transfers to Acute Care Hospitals and Psychiatric Hospitals, undated, included but was not limited to the following: -Emergency transfers to acute care hospital .and the facility has developed the following procedures to comply with this requirement. >A notice of immediate emergency transfer to a hospital must be completed and sent with the resident. >A copy must also be sent to the resident's responsible party. Resident #2 was admitted to the facility in November 2025 with diagnoses including Acute and Chronic Respiratory Failure and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #2's medical record included the following: -A Nursing Progress Note dated 2/5/26, which indicated Resident #2 had stated he/she could not breathe, had a pulse oximetry (measure of the oxygen saturation level in the blood) reading of 70% (normal level 95 - 100%), and was ordered to be transferred to the hospital by the Nurse Practitioner (NP). -A Less than 30-Day Notice of Intent to Transfer Resident Form dated 2/5/26, addressed to the Resident and signed by Social Worker (SW) #1. -No evidence that the Resident's Responsible Party was notified, in writing, relative to the Resident's hospital transfer on 2/5/26. During an interview on 4/29/26 at 8:52 A.M., SW #1 said Resident #2's Responsible Party had not been notified of the Resident's hospital transfer on 2/5/26. SW #1 said Resident #2's Responsible Party should have been notified of Resident's transfer to the hospital. During an interview on 4/29/26 at 9:03 A.M., Nurse #1 said she had called 911 to transfer Resident #2 to the hospital because the Resident could not breathe, had a low pulse oximetry reading, and the Resident's condition was emergent. Nurse #1 said she did not contact the Resident's Responsible Party at the time of hospital transfer because the Social Worker was responsible for notifying the Resident's Responsible Party. During an interview on 4/29/26 at 11:52 A.M., the Administrator said it was the responsibility of the transferring Nurse to notify the Resident's Responsible Party when Resident #2 was transferred to the hospital.

Based on records reviewed and interviews, for three of four sampled residents (Resident #1, Resident #2, and Resident #4), the Facility failed to ensure that prior to the time of their discharge from the facility, that the Residents were provided with a Notice of Intent to Discharge which included the necessary information to appeal, and that a copy of the Notice of Intent to Discharge was sent to the Office of the State Long-Term Care Ombudsman.Findings include:Review of the Facility Policy, titled Discharge Planning Policy and Procedure, dated 08/2018 indicated the following:-Residents who are admitted for short term rehabilitation and request/indicated their desire to return home will work with social service staff, as a member of the interdisciplinary team, to formulate a viable discharge plan.-Social Service will verify the request to be discharged with the resident and/or responsible party.-Social Service will ensure systems are implemented to provide written notification to the resident and/or responsible party to transfer/discharge in accordance with Massachusetts Department of Public Health.-The Intent to Discharge Notice will be provided and include:-The reason and effective date of discharge/transfer.-The location to which the resident is to be transferred/discharged -An explanation of the right to appeal-The name, address and telephone number of the ombudsman and other parties/agencies required by the state.-The name, address and telephone number of protection and advocacy agencies for individuals with developmental disabilities or mental illness-A statement as to how the resident will be prepared/oriented to move.1. Resident #1 was admitted to the Facility in April 2025, diagnoses included acute and subacute infective endocarditis, depression, and bacteremia.Review of Resident #1's admission Minimum Data Set (MDS) assessment, dated 04/17/25, indicated he/she was alert, oriented and scored 15 on the Brief Interview for Mental Status (BIMS) assessment, (a score of 13-15 suggests no cognitive impairment, a score of 8-12 suggests moderate cognitive impairment, and a score of 0-7 suggests severe cognitive impairment).Review of Resident #1's Social Service Progress Note, dated 05/09/25, indicated the Director of Social Services informed Resident #1 that he/she would be medically cleared for discharge some time the following week, and Resident #1 requested a discharge date of 05/16/25.Review of Resident #1's Nursing Progress Note, dated 05/16/25, indicated Resident #1 was informed his/her new discharge date of 05/19/25.Review of Resident #1's medical record indicated there was no documentation to support that:-Resident #1 was issued a Notice of Intent to Discharge prior to the planned discharges on 05/16/25 or 05/19/25.-A copy of Resident #1's Notices of Intent to Discharge was sent to the Office of the State Long-Term Care Ombudsman.2. Resident #2 was admitted to the Facility in March 2025, diagnoses included chronic kidney disease and low back pain.Review of Resident #2's admission MDS assessment, dated 03/25/25, indicated he/she was alert, oriented and scored a 15 on the BIMS assessment.Review of Resident #2's Nursing Progress Note, dated 07/24/25, indicated Resident #2 was discharged to a local shelter with his/her medications and assistive medical devices.Review of Resident #2's medical record indicated there was no documentation to support that:-Resident #2 was issued a Notice of Intent to Discharge.-A copy of Resident #2's Notice of Intent to Discharge was sent to the Office of the State Long-Term Care Ombudsman.3. Resident #4 was admitted to the Facility in July 2025, diagnoses included acute and subacute infective endocarditis and pneumonia. Review of Resident #4's admission MDS assessment, dated 07/14/25, indicated he/she was alert, oriented and scored a 15 on the BIMS assessment. Review of Resident #4's Nursing Progress Note, dated 07/30/25, indicated Resident #4 was discharged to his/her family's home. Review of Resident #4's medical record indicated there was no documentation to support that: -Resident #4 was issued a Notice of Intent to Discharge. -A copy of Resident #4's Notice of Intent to Discharge was sent to the Office of the State Long-Term Care Ombudsman. During an interview on 08/19/25 at 1:39 P.M., the Director of Social Services said that she had not been issuing the Notices of Intent to Discharge to the short term stay residents and she had not been notifying the Office of the State Long-Term Care Ombudsman of the short term stay resident discharges. During an interview on 08/19/25 at 4:10 P.M., the Administrator said they were unaware they were required to issue Notices of Intent to Discharge to short term stay residents or notify the Office of the State Long-Term Care Ombudsman.

Based on records reviewed and interviews, for three of three sampled residents (Resident #1, #2, and #3), as well as interviews with several non-sampled residents, the Facility failed to ensure the residents were treated in a dignified and respectful manner by a staff member, when all of the residents reported that Certified Nurse Aide (CNA) #1's behavior toward them was rude and aggressive, that CNA #1 yelled at and could be mean to them, and had stopped asking CNA #1 for assistance in order to avoid having any interaction with her. Findings include: Review of the Facility Policy titled Resident Rights, dated as revised July 2015, indicated that residents have the right to be treated with consideration, respect, and full recognition of their dignity and individuality. Review of the Report submitted Facility via the Health Care Facility Reporting System (HCFRS) on 02/20/25, indicated that during a resident council meeting on 02/13/25, residents expressed concerns about CNA #1's customer service. Review of the Facility's Internal Investigation Report, dated 03/07/25, indicated that following a resident council meeting held on 02/13/25, during which multiple residents raised concerns about a CNA (later identified as CNA #1), an internal investigation was conducted. The Report indicated that the Facility determined CNA #1's actions were inconsistent with the Facility's standards for care and professionalism, and that CNA #1 had been terminated. Review of the Resident Council Meeting minutes, dated 02/13/25, indicated that residents had voiced complaints about CNAs on the 3:00 P.M.-11:00 P.M. shift on the [NAME] Unit and said that they were not attentive to residents' needs and answering call lights. During an interview on 04/01/25 at 10:54 A.M., the Activities Director said during a Resident Council Meeting on 02/13/25, residents voiced general concerns about CNAs on the [NAME] Unit specifically on the 3:00-11:00 P.M. shift. The Activities Director said she notified administration, and that it was initially considered a customer service issue based on what residents reported. Resident #1 was admitted to the Facility in November 2023, diagnoses included chronic obstructive pulmonary disease, major depressive disorder, post-traumatic stress disorder, and generalized anxiety disorder. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 02/10/25 indicated he/she was cognitively intact and dependent on staff for care. During an interview on 04/01/25 at 11:58 A.M. (which included a review of his/her Written Interview documented by Director of Social Services (SS), dated 02/19/25), Resident #1 said CNA #1 was rude and treated residents as less than. Resident #1 said CNA #1 was aggressive when she threw sugar packets onto his/her bedside table and slammed his/her cup of milk down onto his/her bedside table hard enough that it spilled. Resident #1 said he/she just stopped talking to CNA #1 and avoided her. Resident #2 was admitted to the Facility in October 2023, diagnoses included non-traumatic intracerebral hemorrhage (brain bleed) and seizures. Review of Resident #2's Quarterly MDS Assessment, dated 01/16/25, indicated he/she was cognitively intact and required supervision from staff for all care. During an interview on 04/01/25 at 12:03 P.M. (which included a review of his/her Written Interview documented by Director of SS, dated 02/19/25), Resident #2 said CNA #1 yelled at him/her when he/she asked her for more milk. Resident #2 said CNA #1 also slammed his/her cup down onto his/her bedside table hard enough that liquid spilled onto his/her computer, and she (CNA #1) would not help him/her clean it up. Resident #2 said CNA #1 was mean and very short with him/her so he/she would ask other CNAs for help in order to avoid her. Resident #3 was admitted to the Facility in January 2023, diagnoses included anoxic brain injury (due to lack of oxygen) and anxiety disorder. Review of Resident #3's Quarterly MDS Assessment, dated 01/16/25, indicated he/she was cognitively intact and dependent on staff for all care. During an interview on 04/01/25 at 12:11 P.M. (which included a review of his/her Written Interview documented by Director of SS, dated 02/19/25), Resident #3 said CNA #1 yelled a lot and was rude to residents. Resident #3 said CNA #1 was a bitch and made him/her wait for care. During an interview on 04/01/25 at 12:57 P.M. (which included a review of his/her Written Interview documented by Director of SS, dated 02/19/25, Resident #4 said he/she didn't like the way CNA #1 treated him/her, and that she was disrespectful and angry all of the time and did not want to help him/her. During an interview on 04/01/25 at 1:11 P.M. (which included a review of his/her Written Interview documented by Director of SS, dated 02/19/25), Resident #5 said CNA #1 is like a Pitbull, she is very unfriendly and has a bad attitude. Resident #5 said he/she stopped asking CNA #1 for help because she was so rude and demeaning. During an interview on 04/01/25 at 1:26 P.M. (which included a review of his/her Written Interview documented by Director of SS, dated 02/19/25), Resident #6 said CNA #1 yelled at him/her every time he/she had to go to the bathroom and yelled that she did not give out bedpans. Resident #6 said CNA #1 was mean and angry, so he/she was afraid to ask her for help sometimes During an interview on 04/01/25 at 2:29 P.M. (which included a review of his/her Written Interview documented by Director of SS, dated 02/19/25), Resident #7 said CNA #1 was moody, grumpy, and yelled that he/she (Resident #7) could not have a snack because it was not time yet. Resident #7 said he/she did not want to ask CNA #1 for anything, so he/she would avoid her at all cost. Review of Resident #8's Written Interview (documented by the Director of SS, dated 02/19/25), indicated that Resident #8 said CNA #1 had a very negative attitude and if he/she asked her to push his/her wheelchair, she (CNA #1) would tell him/her (Resident #8) No! Resident #8 was not available to be interviewed by the Surveyor. During an interview on 04/01/25 at 12:57 P.M., Resident #9 said he/she was the Resident Council President and during the Resident Council Meeting held on 02/13/25, several residents voiced concerns about the CNAs on the [NAME] Unit that worked the 3:00-11:00 P.M. shift. Resident #9 said the residents said one of the CNAs (later identified as CNA #1) was mean, rude, complained about the residents, and would not provide care when asked. During an interview on 04/01/25 at 11:37 A.M., the Director of SS said that the Administrator asked her to interview residents on the [NAME] Unit about their interactions with CNA #1. The Director of SS said she received several complaints about CNA #1 and brought the interviews back to the Administrator. During an interview on 04/01/25 at 3:35 P.M., CNA #4 said CNA #1 was rough, abrupt, and yelled for residents to stop ringing their call lights. During a telephone interview on 04/04/25 at 2:27 P.M., Nurse #2 said CNA #1 spoke rudely to residents and that she (Nurse #1) had redirected her (CNA #1) several times. Nurse #2 said CNA #1 raised her voice, was abrasive, and did not want to do what residents asked her to do. During an interview on 04/01/25 at 1:49 P.M., the Assistant Director of Nurses (ADON) said that when the Activities Director brought the Resident Council's concerns to administration, it was considered a customer service concern but then determined to be a reportable incident after the Director of SS conducted individual resident interviews specific to CNA #1's behavior. During an interview on 04/01/25 at 3:43 P.M., the Administrator said that the Activities Director told her that during a Resident Council meeting residents complained that 3:00 P.M.-11:00 P.M. CNAs on the [NAME] Unit were being rude. The Administrator said the complaints involving the CNAs were initially determined to be customer service related, but later identified CNA #1 specifically as a concern, so she had the Director of SS interview [NAME] residents specific to CNA #1's behavior. The Administrator said based on the results of the resident interviews, she determined that this was an abuse allegation. The Administrator said that based on the Facility's investigation, and CNA #1's abusive behavior, she terminated CNA #1's employment at the Facility.

Based on interview, and record review, the facility failed to ensure that recommendations made by the Consultant Pharmacist during a monthly Medication Regimen Review (MRR) were implemented as required for three Residents (#116, #122, and #49), out of a total sample of 29 residents. Specifically, the facility failed to: 1. For Resident #116, act upon the Consultant Pharmacist recommendations dated 10/19/24 and 11/23/24, to discontinue a Multivitamin and Calcium tablets to reduce polypharmacy (use of multiple medications at once, often exceeding what's clinically necessary) when the recommendations were reviewed and agreed upon by the Physician. 2. For Resident #122, act upon the Consultant Pharmacist recommendations dated 10/19/24 and 1/16/25, to update the Physician's order for Vitamin D3 50,000 IU (international units) monthly, when the recommendations were reviewed and agreed upon by the Physician. 3. For Resident #49, act upon the Consultant Pharmacist recommendations to obtain orders and complete a Thyroid Stimulating Hormone (TSH) level and ensure Physician review of the recommendations. Findings include: Review of the facility policy titled Policy and Procedure: Consultant Services, initiated April 2015, indicated: -A note should be recorded on the consultant form by any health care consultant who sees the resident/patient at the request of the MD (medical doctor) or the family. The consultant should document findings and recommendations on this form. -The charge nurse will then notify the attending physician of findings, and he/she can then order the specific treatment as outlined by the consultant. 1. Resident #116 was admitted to the facility in January 2023, with diagnoses including Gastrostomy Status, Dysphagia Oropharyngeal Phase, and Mild Protein Calorie Malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #116 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of a total possible score of 15. Review of the Consultant Pharmacist Recommendation to Prescriber Forms dated 10/19/24 and 11/23/24, indicated: -In an effort to reduce polypharmacy: Evaluate the continued use of these vitamins/supplements and consider discontinuing multivitamin and Calcium. -The Pharmacist recommendation had been reviewed and agreed to by the Physician. Review of Resident #116's March 2025 Physician Orders indicated the following: -Multivitamin Tablet, give 1 tablet via G-tube in the morning for preventative maintenance, initiated 11/26/23. -Calcium Carbonate Tablet, give 500 mg via G-tube in the morning for preventative maintenance, initiated 11/26/23. Review of Resident #116's Medication Administration Record (MAR) from 10/1/24 to 3/20/25, indicated that the Resident was administered multivitamin and Calcium daily. Review of Resident #116's Clinical Record failed to indicate that the Consultant Pharmacist Recommendations which had been agreed to by the Physician, had been implemented prior to the survey start. Further review of Resident #116's March 2025 MAR indicated the Physician's orders for Calcium Carbonate tablet 500 mcg via G-Tube and multivitamin tablet, 1 tablet via G-Tube were discontinued on 3/21/25 (153 days after the initial Consultant Pharmacist recommendation on 10/19/24). 2. Resident #122 was admitted to the facility in November 2023, with diagnoses including Alcohol Abuse, Hyperlipidemia, and Chronic Viral Hep C (Hepatitis C). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #122 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible score of 15. Review of the Consultant Pharmacist Recommendation to Prescriber Forms dated 10/19/24 and 1/6/25, indicated: -Resident is receiving Vitamin D3 1000 IU daily. In order to save nursing med pass time and enhance Resident convenience, consider change to the following: monthly administration. If no change is indicated, note medical necessity of current therapy in progress note. -The Pharmacist recommendation had been reviewed and agreed to by the Physician. Review of Resident #122's March 2025 Physician's orders indicated: -Vitamin D3 Oral Tablet (Cholecalciferol), give 25 mcg (micrograms) by mouth in the morning for supplement, initiated 3/6/24. Review of Resident #122's Medication Administration Record (MAR) from 11/1/24 to 3/20/25, indicated that the Resident was administered Vitamin D3 Oral tablet 25 mcg daily. Review of Resident #122's Clinical Record failed to indicate that the Consultant Pharmacist Recommendations which had been agreed to by the Physician, had been implemented prior to the survey start. Further review of Resident #122's March 2025 MAR indicated a Physician's order for Vitamin D3 50,000 IU, to be administered monthly, was initiated 3/20/25 (152 days after the initial Pharmacist Recommendation had been made on 10/19/24). During an interview on 3/21/25 at 12:54 P.M., the Director of Nursing (DON) said that the Pharmacy Recommendations for Resident's #116 and #122 were signed by the Physician and should have been implemented, but the pharmacy recommendations had not been implemented. During a follow-up interview on 3/25/25 at 7:30 A.M., the DON said that she is responsible for sorting all the Pharmacy Recommendations for Residents. The DON said she puts all the Pharmacy Recommendations in an envelope for the Charge Nurses on the units. The DON said the Charge Nurses are responsible for ensuring that the Pharmacist Recommendations were given to the Physicians for review, and for updating the Resident records. 50320 3. The Food and Drug Administration (FDA) Highlights of Prescribing Levothyroxine Tablets for Oral Use, dated December 2017, indicated: -In adult patients with primary hypothyroidism, monitor serum TSH (Thyroid Stimulating Hormone) levels after an interval of 6 to 8 weeks after any change in dose. -In patients on a stable and appropriate replacement dose, evaluate clinical and biochemical response every 6 to 12 months and whenever there is a change in the patient's clinical status. Resident #49 was admitted to the Facility in August 2023 with diagnoses including Human Immunodeficiency Virus, Chronic Viral Hepatitis, and Opioid Dependence with Unspecified Opioid Induced Disorder. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #49: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 points. Review of Resident #49's clinical record indicated the Resident had a Physician's order for Levothyroxine Sodium (medication used to treat hypothyroidism [condition where the thyroid gland does not produce enough thyroid hormone]), oral tablet 150 micrograms (mcg), give one tablet by mouth in the morning for preventative maintenance, effective 8/25/23. Review of Resident #49's Medication Administration Records (MAR) for December 2024 and January 2025 through March 2025, indicated the Resident was administered the Levothyroxine medication as ordered by the Physician. Review of Resident #49's Medication Regimen Review completed by the Consultant Pharmacist on 12/18/24, indicated: -laboratory test for TSH to help assess the efficacy and potential side effects of continued use of Levothyroxine. Further review of the medical record failed to provide evidence that the TSH lab test was obtained or that the recommendation was reviewed with Resident #49's Physician. During an interview on 3/24/25 at 1:56 P.M. the DON said the Pharmacy Recommendation was reviewed in December 2024, but the TSH level had not been completed as recommended. The DON said the laboratory test for the TSH level should have been completed.

Based on observation, and interview, the facility failed to adhere to infection control standards of practice, increasing the risk of contamination and the spread of infection to other residents within the facility. Specifically, the facility failed to ensure that housekeeping staff on the Greendale Unit adhered to appropriate Personal Protective Equipment (PPE) use and hand hygiene when cleaning resident rooms. Findings include: Review of the Facility policy titled Hand Hygiene, dated April 2015, indicated: >Alcohol hand sanitizer should be used: -after removing gloves -before entering the residents' rooms -before exiting the residents' rooms Review of the facility clinical competency for putting on (donning) and removing (doffing) PPE indicated: >sequence for removal of PPE: -Remove PPE at the doorway of the room. -after all PPE has been removed, perform hand hygiene. -perform hand hygiene between steps if hands become contaminated and immediately after removing all PPE. On 3/24/25 at 9:18 A.M. through 9:22 A.M, the surveyor observed the following on the Greendale Unit: -Housekeeper #1 walked down the unit hallway with gloved hands, carrying two clear trash bags with refuse in both bags. -Housekeeper #1 opened the soiled utility room by entering the code on the locked door with the same gloves in place. -Housekeeper #1 disposed of the two trash bags in the soiled utility room, exited the soiled utility room and remained wearing the same gloves. -Housekeeper #1 walked back down the hallway to her utility cart located outside of a resident room, removed a broom from the cart and entered the resident's room without removing the used gloves. -Housekeeper #1 exited the resident's room with gloved hands, carrying a trash bag in the hallway to the soiled utility room. -Housekeeper #1 handed the trash bag to another staff member standing in the doorway of the soiled utility room and returned to her utility cart, removed her dirty gloves and disposed of the dirty gloves in the trash bag on the cart. -Housekeeper #1 re-entered the same resident room without performing hand hygiene. During an interview at the time, Housekeeper #1 said she should have removed her gloves before she left the resident's room and should not be wearing the gloves in the hallway. Housekeeper #1 said she did not remove her gloves because the trash bag was wet. Housekeeper #1 said she should not have gloves on leaving a resident room and she should wash her hands before entering and exiting a resident room. During an interview on 3/25/25 at 8:18 A.M., the Infection Preventionist (IP) said Housekeeper #1 should not be walking in the hallway with gloves on. The IP further said Housekeeper #1 should not be going from room to room with the same gloves on, and not performing hand hygiene upon entering and exiting a resident's room. The IP said all the staff are educated on proper PPE use annually and given a competency exam. The IP said Housekeeper #1 should have known the right procedure for hand hygiene and proper use of PPE. The IP said Housekeeper #1 was not completing PPE or hand hygiene the proper way, based on the training provided by the facility.

Based on observation, and interview, the facility failed to implement an effective pest control program on three Units (Tatnuck, Greendale, and [NAME]) out of five units observed, and impacting nine Residents (#42, #97, #144, #53, #21, #85, #49, #119 and #63) on the three Units. Specifically, the facility failed to implement effective pest control measures when: -live mice were observed in Resident's rooms by the survey team for the duration of the survey. -Exterminator services were suspended when bi-weekly Exterminator visits were indicated in the facility's pest control plan and the pest control issues related to mice in the facility was not resolved. -Residents in Resident Council meetings reported ongoing mice activity. Findings include: During an interview and observation by surveyor #1 on 3/19/25 at 9:14 A.M., on the Greendale Unit, Resident #42 said that he/she saw mice nightly, in the halls and in his/her room. Surveyor #1 observed no sticky pads or mouse traps in the Resident's room. During an interview and observation by surveyor #4 on 3/19/25 at 9:19 A.M., on the Tatnuck Unit, Resident #97 said that he/she saw mice all day, everyday and he/she had to store any food in his/her room in locking plastic bins. At the same time, surveyor #4 observed a mouse crawling under the Resident's bed along the wall, behind a nightstand in the corner of the room and returned back in the same direction a moment later. Surveyor #4 did not observe any mouse traps in the Resident's room. During an interview by surveyor #2 on 3/19/25 at 9:20 A.M., on the [NAME] Unit, Resident #144 said that there were mice in the facility. During an interview by surveyor #2 on 3/19/25 9:34 A.M., on the [NAME] Unit, Resident #53 said that there were mice in the facility. During an interview by surveyor #1 on 3/19/25 at 9:47 A.M., on the Greendale Unit, Resident #21 said that he/she sees one or two mice a night when things quiet down. Resident #21 further said the building has not had sticky traps in more than a month and usually three to four mice would be caught with the sticky traps. During an interview and observation by surveyor #2 on 3/19/25 at 9:56 A.M., on the [NAME] Unit, Resident #85 said that there were mice in the facility and surveyor #2 observed a silver mouse trap in the Resident's room. During an interview and observation by surveyor #3 on 3/19/25 at 10:08 A.M. on the Tatnuck Unit, Resident #49 said that he/she sees mice and mice droppings in his/her room all the time. Surveyor #3 observed three black pieces of debris that looked like rodent droppings against the wall outside of the bathroom door in the Resident's room. Surveyor #3 did not observe any mouse traps in the Resident's room. During an interview by surveyor #1 on 3/19/25 at 10:08 A.M., on the Greendale Unit, Resident #119 said that he/she saw mice two to three times a week. During an interview on 3/19/25 at 9:48 A.M., the Regional Maintenance Director (RMD) said that he assessed Resident #97's room and that there is usually a mouse trap in the Resident's room. During an interview on 3/20/25 at 7:43 A.M., the RMD said that the facility is contracted with an Exterminator Company for visits every other week. The RMD said that he has a specific communication process with the Exterminator, and he utilizes a request log book which is located at the facility front desk and accessible for all staff or residents to note any observations of rodents or pests. The RMD said that there is a maintenance request log book on all of the units and he and his maintenance staff round daily to review any requests in the log books and that he is available by phone as well for any immediate issues. The RMD further said that he conducts additional rounds weekly to check for room cleanliness and that the facility has discussed concerns with clutter in resident rooms, resident food storage, and increased food and spills in the evenings when housekeeping were not available. During an interview on 3/20/25 at 8:21 A.M., the Exterminator said that he had not been in the facility since his last contracted visit in December 2024 and he was unsure if another staff from his agency had serviced the facility. The Exterminator said that he primarily uses Tin Cats as mouse trap boxes and those traps are in each resident room in addition to other traps around the perimeter of the facility. During an interview on 3/20/25 at 8:33 A.M., the front desk Receptionist said that she recognizes the Exterminator as he will review the Exterminator communication book at the front desk for any requests. The Receptionist said that she had not seen the Exterminator since December, until today. During an interview on 3/20/25 at 9:05 A.M., the RMD provided the Maintenance Weekly Rounding Logs for the Greendale, Tatnuck, and [NAME] Units, which failed to indicate any logged concerns relative to rodents or pests from December 2024 to current day for Resident's #42, #97, #53, #85, #49, and #119 rooms. The RMD said if there were observed issues or pest sightings reported by staff or residents during the weekly rounding, he would notify the Director of Nursing (DON) and the Administrator. During an interview on 3/20/25 at 9:28 A.M., the Exterminator said he had completed the consulting visit and that he usually has a total of roughly 156 tin cat traps in the facility, typically one per each resident room, and that there were about three dozen traps missing from his count. The Exterminator said the missing tin can traps would be replaced with bait stations and glue boards. During an interview and observation on the Tatnuck Unit on 3/20/25 at 10:07 A.M., Resident #63 asked if surveyor #4 wanted to see a mouse and said there was a mouse in his/her room. Surveyor #4 observed a sticky trap placed next to Resident #63's bed and nightstand with one live mouse caught in the trap. Resident #63 said that staff had just put the sticky trap in place that day. Review of the Work Order Summary for General Pest Control, dated 12/27/24 indicated: >Service Frequency: Biweekly. >Service type: Regular. >14 dead mice were found at Nurses Station. >8 dead mice found in patient rooms. >20 rodent glue traps were replaced in the facility. Review of the Work Order Summary for General Pest Control, dated 3/20/25 indicated: >Service Frequency: Biweekly. >Service type: Regular. >10 dead mice were found in patient rooms. >Recommend replacing tin cats . >60 rodent glue traps were replaced in the facility. Review of the Resident Council Meeting Minutes dated 1/9/25, indicated the following: -Despite the efforts of the housekeeping staff, mice continue to be an issue in resident rooms. -Clutter, opened containers, food not put away in plastic totes, food/spills on the floor from the evening before etc . -Rounds are done weekly on all the units . -Maintenance has a contract with the Exterminator. He comes every other week and as needed. Review of the Resident Council Meeting Minutes dated 2/13/25, indicated the following: -Despite the efforts of the housekeeping staff, mice continue to be an issue in resident rooms. -This topic was discussed again. It appears some rooms are seeing more mice than others. -Maintenance has a contract with the Exterminator. He comes every other week and as needed. -This too was re-discussed with the residents. They were encouraged to report mice sightings to staff. During an interview on 3/20/25 at 9:00 A.M., the RMD said that he was not aware of any concerns about mice or pests from Resident Council meetings in January 2025 or February 2025. During an interview on 3/20/25 at 9:02 A.M., the Activities Director (AD) said that she did not initiate any Resident Council response for Maintenance about mice from the January 2025 or February 2025 Resident Council meetings, because the conversation was to minimize concerns with resident's food storage and to communicate that the facility was aware of the issues with mice. During the Resident Council Meeting on 3/20/25 at 1:00 P.M., 8 Residents from the Greendale and [NAME] units attended and indicated the following: -8 out of 8 Residents were concerned about mice in the facility. -Maintenance puts mouse traps in rooms and an Exterminator comes to the facility, but they are not sure how often. -The facility staff provided locked plastic bins to the Residents for storing food in their rooms and educated the Residents on appropriate food storage. -Residents felt the issues with mice are ongoing. During an interview on 3/20/25 at 10:39 A.M., the Administrator said that the facility had a Quality Improvement plan relative to pest control and were working to establish a new contract with a different Extermination company. The Administrator said that services with the current Extermination company were suspended for January 2025 and February 2025, and the services were re-instated on 3/19/25 at 4:00 P.M. Review of the Quality Improvement Plan titled Food and Hoarding, initiated 1/1/22 and last revised 2/1/25, indicated: -Goal was to eliminate Pests and Congestion in Rooms -Action Steps were: >To have extra treatments done by pest company as needed. >Maintenance has also bought and set traps to rid pests from resident rooms. >To keep monitoring rooms on a weekly basis for food and hoarding. >To fill any holes created by pests. September 2024: >Exterminator is still coming [every other week] and checking stations that they supply for building and inside and outside. October 2024: >Exterminator is still on an [every other week] basis and will do any extra service needed. November 2024: >Exterminator to check all areas for any pests and Maintenance to do any work that is needed. >Exterminator is still on an [every other week] basis and on call as needed. >Exterminator has added an extra additive with traps to kill the pests faster. -January 2025: >Maintenance has continued to audit all residents rooms weekly and report . to DON. >Maintenance is still checking all units weekly and filling any holes. >Housekeeping was cleaning all rooms on all units. They will continue to monitor and report any problems to Maintenance. -February 2025: >Maintenance is still doing weekly audits of rooms on every unit. >The Administrator has walked around the building to check and we have seen zero mice running around or in traps. >We will continue to keep Exterminator on an [every other week] basis. Review of the January 2025 Quality Improvement Plan (QAPI) Meeting Minutes provided by the facility, indicated: -Maintenance reported an increase in things being chewed through by mice. -[12/27/24] Exterminator added into the traps a new additive. -Maintenance is doing check for holes and/or mouse droppings. -Exterminator pulled out 8 mice the last time he was here, is improvement, added extra bait traps, will put in problems rooms, filling holes to keep mice out, cleaning rooms, and keeping food out as much as we can. Review of the QAPI Meeting Minutes, dated 2/20/25, provided by the facility, indicated: >Administrator continues to work on eradicating pests in the building. >Administrator walking around the building, no mice found in traps. >Exterminator every other week. >Problem rooms identified with housekeeping and maintenance. During an interview on 3/20/25 at 2:26 P.M., the RMD said when the Exterminator did not come to the facility for the anticipated January 2025 visit, the RMD contacted the Extermination company and was informed that services were suspended due to non-payment of past invoices. The RMD further said Exterminator services were re-instated yesterday 3/19/25 to allow for a visit today.

Based on observation, record review, and interview, the facility failed to provide respiratory care and services consistent with professional standards of practice for one Resident (#91), out of a total sample of 29 residents. Specifically, for Resident #91, the facility failed to ensure that the oxygen concentrator was set at 2 liters per minute (LPM) as ordered by the Physician, when the Resident was observed with the oxygen concentrator set at 1.5 LPM. Findings include: Review of the AARC (American Association for Respiratory Care) Clinical Practice Guideline, updated 2014: https://www.aarc.org/wp-content/uploads/2014/08/08.07.1063.pdf indicates: -All oxygen must be prescribed and dispensed in accordance with federal, state, and local laws and regulations. -Oxygen is a medical gas and should only be dispensed in accordance with all federal, state, and local laws and regulations. -Undesirable results or events may result from noncompliance with Physicians' orders or inadequate instruction for oxygen therapy. -There is a potential in some spontaneously breathing hypoxemic patients with hypercapnia [high carbon dioxide levels in the blood) and chronic obstructive pulmonary disease (COPD) that oxygen administration may lead to an increase in PaCO2. -Equipment maintenance and supervision: >All oxygen delivery equipment should be checked at least once daily . >Facets to be assessed include proper function of the equipment, prescribed flowrates, remaining liquid or compressed gas content, and backup supply. Review of the facility policy titled Oxygen Concentrators, undated, indicated the following: -Verify the Physician's order and review the patient's chart. -Adjust the liter flow in accordance with the Physician's order by rotating the flow selector knob on the flow meter located on the front panel of the unit. Resident #91 was admitted to the facility in April 2024 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and chronic respiratory failure. Review of Resident #91's most recent Minimum Data Set (MDS) Assessment, dated 1/13/25, indicated: -Resident #91 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15 possible points. -Resident #91 received oxygen therapy. Review of Resident #91's COPD Care Plan, last revised 2/10/25, indicated: -give oxygen 2 liters (via) nasal cannula continuously as the Resident has shortness of breath when lying flat, per Resident interview. Review of Resident #91's March 2025 Physician orders indicated the following: -oxygen continuously via nasal cannula at 2 liters a minute. -every shift check pulse ox (SpO2 - measure of oxygen in the blood as a percentage of the maximum oxygen the blood could carry) and Liters Per Minute (LPM), start date 11/11/24. On 3/19/25 at 12:39 P.M., the surveyor observed that Resident #91 was receiving oxygen via nasal cannula while lying in bed and the oxygen concentrator attached to the nasal cannula was set at 1.5 LPM. During an interview at the time, Resident #91 said that the oxygen concentrator should be set to 2 LPM. On 3/20/25 at 7:47 A.M., the surveyor observed Resident #91 lying in bed and receiving oxygen via nasal cannula with the oxygen concentrator set at 1.5 LPM. On 3/24/25 at 7:54 A.M., the surveyor observed Resident #91 receiving oxygen via nasal cannula while lying in bed and the oxygen concentrator was set to 1.5 LPM. During an interview on 3/24/25 at 9:44 A.M., Nurse #3 said that Resident #91 should have been receiving oxygen via nasal cannula at 2 LPM per the Physician's orders. The surveyor and Nurse #3 went into Resident #91's room and observed the oxygen concentrator was set at 1.5 LPM. Nurse #3 was observed to adjust the oxygen concentrator to 2 LPM and exit the Resident's room. During an interview on 3/24/25 at 12:43 P.M., the Director of Nursing (DON) said the oxygen that Resident #91 had been receiving via nasal cannula should reflect the liters per minute as prescribed by the Physician.

Based on record review, and interview, the facility failed to provide care and services consistent with professional standards of practice related to renal dialysis (procedure to remove waste products and excess fluid from the body when the kidneys stop functioning properly) for two Residents (#93 and #147), out of a total sample of 29 residents. Specifically, the facility failed to communicate and maintain ongoing documentation with the dialysis center to ensure that the dialysis center and the facility received the most current information pertaining to Resident's #93 and #147. Findings include: Review of the facility policy titled Hemodialysis, dated April 2015, included but was not limited to: -Communication between the facility and the hemodialysis center will occur using a communication book/sheet that consists of: >vital signs >Copy of MAR (Medication Administration Record) >any change of condition from last hemodialysis treatment -Documentation will be completed prior to dialysis treatment. -The communication book/sheet will be reviewed upon return from dialysis. 1. Resident #93 was admitted to the facility in February 2023, with diagnoses including Chronic Kidney Disease Stage 4, Hypertensive Emergency, and Anemia in Chronic Kidney Disease. Review of Resident #93's Care Plan for Hemodialysis, initiated 2/20/23, indicated: -Goal: To tolerate dialysis without complications, revised 12/9/24. -Intervention: Complete Hemodialysis Communication form in Hemodialysis Communication book. Include vital signs and anything noteworthy since last appointment, initiated 7/26/23. Review of the most recent Minimum Data Set (MDS) Assessment, dated 2/14/25, indicated Resident #93: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15 possible points. -received Dialysis treatment. Review of Resident #93's March 2025 Physician's orders indicated: -Dialysis Days: Tuesday, Thursday, and Saturdays, at 10:30 A.M., initiated 12/15/23. -Hemodialysis pick up 9:30 A.M., with pick up scheduled Tuesday, Thursday, and Saturdays, initiated 1/23/25. Review of Resident #93's Dialysis Communication Book failed to provide evidence of any communication sent to the Dialysis Center from the facility for any dialysis days in January 2025, February 2025, or March 2025. Review of the Resident #93's clinical record failed to provide any evidence of ongoing communication by the facility with the dialysis center. During an interview on 3/19/25 at 9: 21 A.M., Resident #93 said that he/she went to the dialysis center three times a week on Tuesday, Thursday, and Saturday and had not missed any dialysis treatments. Resident #93 said that dialysis treatments were going well. On 3/20/25 at 8:50 A.M., the surveyor observed Resident #93's dialysis communication book/binder at the nurses station which contained copies of blank facility daily dialysis communication forms. The dialysis communication form required the Resident's face sheet, pre-weight, labs, medications administered, vital signs, allergies, and if the Resident had eaten a meal prior to leaving for dialysis treatment to be completed for dialysis center communication. The surveyor failed to find any evidence in Resident #93's dialysis communication book/binder that the dialysis communication forms were completed as required by the facility. Further review of Resident #93's clinical record failed to indicate that dialysis communication forms were completed for January 2025, February 2025, and March 2025. During an interview on 3/20/25 at 9:02 A.M., the Unit Manager (UM) #2 said that Resident #93 has dialysis treatments three times a week on Tuesday, Thursday, and Saturday. UM #2 said that there is no daily dialysis communication from the facility to the dialysis center when Resident #93 goes for dialysis. UM #2 said that the dialysis communication binder for Resident #93 contains dialysis communication from the dialysis center to the facility after treatment is completed. The surveyor and UM #2 reviewed the dialysis communication binder, and UM #2 said that nursing staff only complete the dialysis communication form if there was an issue before the Resident goes for dialysis treatments. During an interview on 3/20/25 at 11:22 A.M., the Assistant Director of Nurses (ADON) said that the Nurses should be communicating vital signs and weights prior to each dialysis appointment, and they have not been providing this information. 45429 2. Resident #147 was admitted to the facility in January 2025 with diagnoses including End Stage Renal Disease (ESRD) and Adult Failure to Thrive. Review of Resident #147's Care Plan for Hemodialysis, initiated 2/6/25, indicated the following: -Goal: to tolerate dialysis without signs of complications. -Intervention: monitor intake and output. -If Resident has decreased urinary output, increased confusion, fever, changes in usual mental status, poor skin turgor, Resident may be dehydrated. Review of Resident #147's most recent Minimum Data Set (MDS) Assessment, dated 2/25/25, indicated: -staff assessment for mental status had been completed as the Resident had been transferred out to the hospital. -short-term memory was okay. -cognitive skills for daily decision making coded as modified independence with some difficulty only in new situations. -receiving dialysis treatment. During an interview on 3/19/25 at 9:36 A.M., Resident #147 said that he/she went to the dialysis center three times a week on Monday, Wednesday, and Friday. Review of Resident #147's March 2025 Physician's orders indicated: -Dialysis days Monday, Wednesday, Friday at 4:00 P.M., pick up time 3:15 P.M. -Check dialysis book after treatment for any new recommendations or issues, update Physician or Nurse Practitioner(NP) if needed. -Ongoing assessment of Resident prior to dialysis. Review of Resident #147's dialysis communication book failed to provide evidence of any communication sent to the dialysis center from the facility for any dialysis days in January 2025, February 2025, or March 2025, except for 1/29/25 and 2/14/25. Review of Resident #147's clinical record failed to provide any evidence of ongoing dialysis communication between the facility and the dialysis center. During an interview on 3/20/25 at 9:02 A.M., UM #2 said that there was no dialysis communication on dialysis days from the facility to the dialysis center. UM #2 also said that the dialysis communication book for the Resident contains information from the dialysis center. UM #2 said the facility only complete a hemodialysis communication sheet for the Resident if there is an issue prior to the Resident leaving for dialysis. During an interview on 3/20/25 11:22 A.M., the ADON said that the Nurses should have been communicating Resident #147's vital signs and weights prior to each dialysis appointment, and they had not been communicating the information.

Based on observation, and interview, the facility failed to provide a safe and homelike environment for one Resident (#3) out of a total sample of 29 residents, and for residents on one Unit (Burncoat) out of five Units. Specifically, the facility failed to: -repair a hole located in the wall behind the headboard of Resident #3's bed. -enclose exposed pipes (from a water fountain removal) protruding from a wall in a hallway on the Burncoat unit, placing residents at potential risk of injury. Findings include: Resident #3 was admitted to the facility in December 2019, with diagnoses including Dementia and Schizophrenia. Review of a Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 was severely cognitively impaired as evidenced by a Brief Interview of Mental Status (BIMS) score of three out of a total possible score of 15. On 3/19/25 at 9:34 A.M., the surveyor observed Resident #3 sitting on the edge of his/her bed eating breakfast. The surveyor also observed a large hole in the wall behind the headboard of Resident #3's bed. During an interview on 3/20/25 at 10:08 A.M., Nurse #2 said that Resident #3 was moved into his/her present room a few weeks ago. Nurse #2 said that the hole in the wall behind the headboard in Resident #3's room was made by the resident who was previously in the room. Nurse #2 also said that she was unaware whether maintenance had been notified of the hole in the wall in Resident #3's room. Nurse #2 said when staff have maintenance concerns they enter the concern into the maintenance log book at the nurses station or call down to the Maintenance staff and leave a voice message. Nurse #2 said she was unsure if the maintenance staff were aware of the hole in the wall behind Resident #3's bed. On 3/20/25 at 10:10 A.M., the surveyor observed exposed pipes protruding from a wall in the hallway of the Burncoat Unit. The surveyor further observed a resident standing in the hallway grab onto the exposed pipes and Nurse #2 had to redirect the resident away from the exposed pipes. During an interview at the time Nurse #2 said that maintenance staff had removed a drinking fountain from the hallway leaving the exposed pipes protruding from the wall. Nurse #2 said the exposed pipes protruding from the wall were not safe and she was afraid a resident might fall onto the exposed pipes and get hurt.

Based on observation, interview, and record review, the facility failed to provide necessary care and services relative to enteral feeding (also known as tube feeding, is the delivery of nutrients directly into the stomach), for one Resident (#116), out of a total sample of 29 residents. Specifically, for Resident #116, the facility failed to label and date enteral feeds and fluids being administered to the Resident via Gastrostomy Tube (G-tube - tube placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) as required, to ensure the enteral nutrition administration was consistent with Physician orders and that the product had not exceeded the expiration date. Findings include: Review of the facility policy titled Nursing Policy & Procedure Manual: Enteral Feeding, dated 4/15, indicated the following: -Label formula and administration set with: >Date >Time >Resident's name >Nurse initials Resident #116 was admitted to the facility in January 2023, with diagnoses including Gastrostomy Status, Dysphagia Oropharyngeal Phase, and Mild Protein Calorie Malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #116: -cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points. -received nutrition via a feeding tube. -received over 51 percent (%) of their calories via tube feed. -received fluid intake via a feeding tube and received over 501cc (cubic centimeters) of fluid for hydration per day. Review of Resident #116's March 2025 Physician's orders indicated: -Enteral Feed order: At bedtime, Jevity 1.5 @100 ml/hr (milliliters per hour) up [start] at 10:00 P.M. down [end] at 11:00 A.M., initiated 1/14/25. -Administer 220 ml of H20 (water) every 6 hours via G-Tube every 6 hours, initiated 1/14/25. -Flush feeding tube with 60 ml of water before and after Tube Feed cycle, two times a day, initiated 10/7/24. -Flush G-Tube with 30 ml of H20 before and after medication administration every shift, initiated 11/26/23. On 3/19/25 at 12:19 P.M., the surveyor observed Resident #116 lying in bed and an enteral feeding pump on a pole positioned next to the bed. The surveyor also observed two graduated clear bags hanging on the pole above the enteral feeding pump. One clear bag contained approximately 50 ml beige colored liquid, and the second bag contained approximately 500 ml clear liquid. The enteral feeding pump was observed connected to the Resident and set to infuse at 100 ml/hr. The surveyor did not observe a label, date, or content identifiers on the two bags hanging on the enteral feeding pump pole and being administered to the Resident. On 3/20/25 at 8:32 A.M., the surveyor observed Resident #116 lying in bed and watching television. The surveyor observed that the enteral feeding pump was set to infuse at 100 ml/hr. The surveyor observed two graduated clear bags hanging on the feeding pump pole, one bag contained a beige liquid, and the second bag contained a clear liquid. The two bags did not have a label, a date, or the time they were hung. During an interview at the time, Resident #116 said that the 11:00 P.M. -7:00 A.M.(night) shift Nurses set up his/her enteral feeding, and that the time works best for him/her. On 3/21/25 8:01 A.M., the surveyor and Nurse #1 observed Resident #116 lying in bed with the enteral feeding pump running. During an interview at the time, Nurse #1 said that she works the 7:00 A.M. to 3:00 P.M.(Day) shift and Resident #116's enteral feed is hung by the 11:00 P.M. to 7:00 A.M. shift. Nurse #1 said she takes the enteral feeding down around 11:00 A.M. when the total amount of feeding is completed. Nurse #1 said that the rate of enteral feeds and water flushes are programmed by a Nurse into the enteral feeding pump and Resident #116 received Jevity 1.5 at 100 ml/hr with automatic water flushes set at 220 ml every 6 hours. The surveyor and Nurse #1 observed approximately 300 ml of beige liquid remaining in one of the graduated plastic bags, which Nurse #1 identified as Jevity 1.5 calorie product, and the bag of clear liquid was identified as water for water flushes. The surveyor observed the screen on the feeding pump machine indicated 696 ml of the beige liquid had been administered to Resident #116. Nurse #1 said that the water bag and Jevity bag were not labeled or dated and should have been. Nurse #1 said that typically when an enteral feeding bag and the water flush are administered, both bags should be labeled with the Resident name, date, time, formula administration set and the initial of the Nurse who hung the enteral feed and the water flushes bags. During an interview on 3/21/25 at 11:12 A.M., the Director of Nursing (DON) said that the expectation for the Resident's enteral feeds, is that the nursing staff should have used a sticker which is provided to label the enteral feed and the water flushes with the Resident's name, date, time, formula administration set by the Physician and the initials of the Nurse who hung the enteral feed bags.

Based on record review, and interview, the facility failed to coordinate vision care services for one Resident (#129) out of a total sample of 29 residents. Specifically, for Resident #129, the facility failed to schedule vision care appointments and ensure that the Resident was seen and received appropriate treatment to maintain vision abilities, when the Resident consented to and requested vision care services. Findings include: Review of the facility policy titled Consultant Services, dated April 2015, included: -identify and facilitate consultant services to meet the resident's needs, to ensure optimum care for each resident/patient through consultant services. -once the consultant is identified by the MD (medical doctor) and after the family has been notified and given the permission for the consult, the staff will call the consultant to notify him/her of the request and document response in medical record. Resident #129 was admitted to the facility in April 2024 with diagnoses including Complete Traumatic Amputation at level between Knee and Ankle Left Lower Leg and Adjustment Disorder with Anxiety. Review of Resident #129's current March 2025 Physician's orders included an order dated 4/8/24 for Consults: -Ophthalmic care as needed. Review of the Resident's clinical record included a Request for Service for Eye Care Services signed by the Resident, and dated 4/30/24. Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15 possible points. During an interview on 3/19/25 at 10:18 A.M., Resident #129 said that he/she was still waiting to see the eye doctor. Resident #129 said that he/she needed glasses for distance and reading. Resident #129 further said that he/she has worn glasses his/her whole life, but none since coming to the facility. During an interview on 3/24/25 at 1:06 P.M., the Director of Nursing (DON) said that she was unaware that Resident #129 had signed a consent for Visual Consultant Services on 4/30/24. During an interview on 3/24/25 at 2:45 P.M., the Assistant Director of Nurses (ADON) said that Resident #129 had not been seen by the Vision Consultants over the last year, but should have been. The ADON showed the surveyor a list of eight dates over the past year that the Vision Consultants had been in the facility since the Resident signed the consent for vision services but he/she had not been seen by the Vision Consultants.

Based on record review, and interview, the facility failed to ensure that residents and/or their representatives were informed and given necessary information to make health care decisions including the risks and benefits of psychotropic (any drug that affects behavior, mood, thoughts, or perception) medications prior to their use for one Resident (#205) out of a total sample of 29 residents. Specifically, for Resident #205, the facility failed to obtain informed consent from the Resident with notification of the risks and benefits for the use of Clonidine (antihypertensive medication that can also be prescribed for anxiety) prior to administering the medication to the Resident. Findings include: Review of the facility policy titled Psychotropic Medication Informed Consent - Massachusetts Only, dated February 2016, included: -Informed written consent shall include the following information: the purpose for administering the psychotropic medication, the prescribed dosage and, any known effect or side effect of the psychotropic medication. -Documentation of informed consent for prescribing psychotropic medication including but not limited to, drugs that treat Depression, anxiety disorders, or attention deficit/hyperactivity disorder. Resident #205 was admitted to the facility in March 2025 with diagnoses including Major Depressive Disorder and Anxiety Disorder. Review of Resident #205's March 2025 Physician's orders included: -Clonidine HCI Oral Tablet 0.1 mg (milligram), Give 1 tablet at bedtime for anxiety. Ordered 3/10/25, started 3/11/25. Review of Resident #205's March 2025 Medication Administration Record (MAR) indicated that the Clonidine medication was administered as ordered. Review of Resident #205's Minimum Data Set (MDS) Assessment, dated 3/14/25, indicated Resident #205: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points. -was receiving antianxiety medication. Further review of Resident #205's clinical record failed to indicate any evidence that the purpose, dosage, risks, or benefits of the medication were discussed with the Resident prior to the administration of Clonidine for anxiety. During an interview on 3/20/25 at 12:15 P.M., the Assistant Director of Nurses (ADON) and Unit Manager (UM) #1 said that they were unable to locate an Informed Consent for Psychotropic Medication for the administration of Clonidine for anxiety in the Resident's record, but there should be one. During an interview on 3/20/25 at 2:11 P.M., the Director of Nursing (DON) said that an Informed Consent for Psychotropic Medication administration should have been completed for the Clonidine prescribed for anxiety for Resident #205, but the Informed Consent had not been done.

Based on records reviewed, interviews, and review of Facility video/audio surveillance camera footage for one of three sampled residents (Resident #1), who was dependent on a wheelchair for mobility, was homeless without a community support system in place, was undergoing antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . - On 02/16/22, Resident #1, who was approximately five hours late returning from a social Leave of Absence (LOA) in the community, was informed that because he/she was late and had not notified the Facility that he/she was going to be late, that per Administration, he/she was considered discharged Against Medical Advice (AMA). - Resident #1 could be seen and heard on facility video camera surveillance footage becoming emotionally upset and distressed, when he/she was made to wait outside of the Facility for almost two hours in 37 degree (per weather.com) Fahrenheit weather, while staff charged his/her cell phone and gathered some of his/her personal belongings. - Resident #1 left the Facility (as instructed by the Nurse Supervisor) to go to the Hospital Emergency Department to get medically cleared, in order to be readmitted . - Facility Staff failed to provide Resident #1 with a safe discharge plan, a notice of discharge, and failed to assist in making arrangements for care or services in an appropriate and safe setting. Findings include: Review of the Facility's Policy titled, Discharge Against Medical Advice (AMA), dated April 2015, indicated that the Facility would not detain a resident against his/her wishes unless he/she was unable to make his/her own heath care decisions. The Policy indicated that the nurse would try to ascertain if it was the resident's wish to be discharged . The Policy also indicated, in the event an alert and coherent resident did not wish to leave, the resident's wishes would be honored. Review of Facility's Policy titled, Discharge Planning, dated August 2018, indicated that resident discharge planning would be addressed upon admission and throughout the resident's stay. The Policy indicated that interdisciplinary discharge plans would be developed to provide sufficient preparation, orientation, and education to residents to ensure safe and orderly discharge to home or a lesser level of care. The Facility's Policy titled Intoxication Protocol, dated December 2018, indicated that all residents with suspected illicit drug use at the Facility would be sent out to acute care for further assessment. Resident #1 was admitted to the Facility in June 2021, medical history included Cerebral Infraction (stroke), left sided [CONDITION(S)] (paralysis on one side of the body), Unsteadiness on Feet, Hypertension, and a history of falls. Review of Resident #1's Plan of Care (POC) related to Discharge Planning, dated 06/15/21, indicated Resident #1 had history of chronic homelessness, previously residing in shelters, until he/she required more care and assistance. The POC indicated Resident #1 expressed interest in returning to the community and they would continue to explore possible referrals to discharge him/her to an appropriate setting with appropriate services. Review of Resident #1's Plan of Care (POC) related to Activities of Daily Living (ADL), dated as revised 10/04/21, indicated he/she had self-care deficits related to a prior [CONDITION(S)] (stroke) with a left sided [CONDITION(S)] (paralysis). The POC indicated Resident #1 required extensive assistance from one staff member for dressing, toilet use, and grooming. Review of Resident #1's POC related to incontinence care, dated as revised 10/04/21, indicated he/she wore adult briefs due to occasional bowel/bladder incontinence and required staff assistance with personal hygiene after an incontinent episode. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was cognitively intact (able to make his/her own health care decisions) and was able to clearly communicate his/her needs with others. The MDS indicated Resident #1 required extensive assistance from one-to-two staff members with dressing, personal hygiene, and toilet use. During an interview on 04/13/22 at 2:10 P.M., the Director of Addiction Services said she had attended Resident #1's Care Plan Meetings in the past, and said Resident #1 expressed a desire to return to the community, but due to limited options, his/her plan was to remain as a long-term care resident at the Facility. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Situation, Background, Assessment, and Recommendation (SBAR) Communication Note, dated 02/11/22, indicated Resident #1 needed more assistance with ADLs (compared to his/her baseline) due to an abscess and back pain. Review of Resident #1's Physician's Progress Note, dated 02/13/22, indicated that Resident #1 was taking antibiotics for an abscess on his/her left buttocks, and he/she would be referred to be seen by the Wound Physician. Review of the MAR, dated February 2022, indicated that on 02/15/22, Resident #1 began taking [MEDICATION(S)] (combination of two antibiotics) Tablet 800-160 mg, twice a day, for ten days to treat his/her wound. Review of the Release from Responsibility for Leave of Absence (LOA) Log, dated 2/16 (later identified as 02/16/22), indicated Resident #1 signed out of the Facility to go to two stores in the community from 11:00 A.M., with an anticipated return time of 3:00 P.M. The Form included a pre-populated agreement which indicated that I [the Resident] would inform the Facility if I would not be returning at the anticipated time. However, further review of the LOA Form indicated there was no documentation to support that Resident #1 would be considered discharge AMA if he/she did not comply with the terms and conditions outlined within the LOA Form. Review of the Nurse Supervisor's Progress Note, dated 02/16/22, at 9:23 P.M., indicated that Resident #1 signed out for a LOA and he/she refused to return to the Facility at the scheduled time. The Note indicated Resident #1 did not call the Facility to report he/she would be late. The Note indicated that the Administrator and the Director of Nursing were informed of the incident, and they gave an order that Resident #1 could not return to the Facility due to a violation of the Facility's LOA Policy. The Note indicated Resident #1 was given some of his/her belongings (winter jacket, tablet, cell phone, and device charger) and Resident #1 asked the Facility to keep the remainder of his/her belongings so he/she could arrange retrieving the items later. The Note indicated Resident #1 said he/she would go to the Hospital and check him/herself in. The Note indicated the Physician was notified. During an interview on 05/03/22 at 12:05 P.M., the Physician said the Nurse Supervisor called during the evening of 02/16/22, after Resident #1 was discharged AMA from the Facility. Review of Resident #1's medical record indicated there was no documentation to support that the Physician was notified prior to Resident #1 being discharged AMA by the facility. Furthermore, the facility was unable to provide the surveyor with documentation to support they had obtained a telephone order from the Physician to discharge Resident #1 AMA. During an interview on 04/12/22 at 11:31 A.M., the Nurse Supervisor said that on 02/16/22, he arrived to work for the evening shift (3:00 P.M. to 11:00 P.M.) at the Facility, and said the Administrator and Director of Nursing informed him that Resident #1 was out late on an LOA, and therefore, could not return to the Facility, and said that he/she was considered discharged Against Medical Advice. The Nurse Supervisor said Resident #1 returned to the Facility sometime around 8:30 P.M., and said he told Resident #1 that he/she was unable to return to the Facility, per the Administrators orders. The Nurse Supervisor said Resident #1 told him that his/her phone was dead, so he charged Resident #1's phone while he gathered some of Resident #1's personal belongings. The Nurse Supervisor said he gave Resident #1 the Administrator's phone number so he/she could speak directly with the Administrator about returning late from the LOA and possibly returning to the Facility even though he/she was later than expected. The Nurse Supervisor said Resident #1 did not want to call the Administrator. The Nurse Supervisor said he offered to call a ride for Resident #1 to get to the Hospital, but Resident #1 said he/she did not have a medical reason to go to the Hospital and he/she would find his/her own way there. The Nurse Supervisor said he provided Resident #1 with a phone number to call for transportation to the Hospital. Review of Nurse #1's Progress Note, dated 02/16/22 at 11:56 P.M., indicated that Resident #1 left that day, and the Director of Nursing and the Administrator were informed when Resident #1 returned. The Note indicated staff advised Resident #1 to report to the Hospital ED (Emergency Department) before coming back to the Facility. The Note indicated some of Resident #1's belongings were given to him/her, and the bulk of his/her belongings were kept in the staff room to be collected later. Review of Resident #1's Medical Record indicated there was no documentation to support that Resident #1 was provided with discharge paperwork for his/her care needs or that community services had been set-up. During an interview on 4/12/22 at 8:00 A.M., and throughout the Survey, the Director of Nursing (DON) said that on 02/16/22, she received a call from the Nurse Supervisor once Resident #1 returned (five hours later than anticipated) from his/her LOA. The DON said the Facility considered Resident #1 discharged AMA since he/she did not contact the Facility to report he/she would be returning late, as indicated on the LOA Log Agreement Form. The DON said she asked the Nurse Supervisor to call the Administrator regarding the situation with Resident #1. During an interview on 04/12/22 at 10:15 A.M., and throughout the Survey, the Administrator said the Facility has a LOA Policy, but said each LOA was specific for each resident and situation. The Administrator said that before Resident #1 left the Facility for an LOA on 02/16/22, she spoke with him/her about the Facility LOA Policy and the expectations. The Administrator said Resident #1 did not return at the expected time from the LOA, so she said she told the evening Nurse Supervisor and Nurse #1 about the need for Resident #1 to go to the Hospital, if he/she returned and appeared intoxicated. The Administrator said Resident #1 returned late from another LOA back in November 2021 and said she educated Resident #1 about the LOA Policy. The Administrator said there was no documentation of this incident in November with Resident #1 violating the LOA Policy and/or requiring re-education about the Policy. Review of the Release from Responsibility for Leave of Absence (LOA) Log, dated 11/15/21, indicated Resident #1 signed out to go to the store at 11:09 A.M., with an anticipated return time of 12:30 P.M., however, the time in column was left blank, so therefore there was no way to validate if he/she returned on time or was late, and had violated the agreement. On 12/23/21, there was also an entry on the LOA Form that indicated Resident #1 was going to the ATM, the time out written on the form was 1:15 P.M., however the Form was incomplete, there was no anticipated time of return indicated, Resident #1's signature was missing, and the time in was also blank. Review of Resident #1's Medical Record indicated there was no documentation to support he/she was re-educated by facility staff, including Administration, on the LOA Policy, the expectations, or that his/her non-compliance with the Policy and/or non-adherence to the LOA Agreement would result in him/her being considered discharged AMA. The Administrator said that around 9:00 P.M., she received a call from the Nurse Supervisor, who said Resident #1 looked shaky like he/she was drinking. The Administrator said she was unaware if the Nurse Supervisor asked Resident #1 if he/she consumed any substances during the LOA. The Administrator said she was unaware if the Nurse Supervisor completed any clinical assessments of Resident #1, but said the Nurse Supervisor asked Resident #1 to go to the Hospital for an evaluation. However, the Nurse Supervisor said he did not perform any type of assessments on Resident #1 when he/she returned to the Facility, because the Administrator told him the Resident #1 was discharged AMA, and said he thought it would not have been appropriate to assess Resident #1 because he/she was no longer a resident of the Facility. The Nurse Supervisor said he was unable to tell if Resident #1 had used any drugs or was under the influence of any substances because he did not assess Resident #1. The Administrator said the Nurse Supervisor asked Resident #1 to call her but Resident #1 refused. The Administrator said the Facility considered Resident #1 discharged AMA after Resident #1 declined to go to the Hospital and then he/she left Facility property. The Administrator said the Nurse Supervisor was trying to encourage Resident #1 to go to the Hospital, and said the Nurse Supervisor did not discuss the discharge AMA process and/or paperwork with Resident #1. Review of the Facility video camera surveillance footage which included audio recording, date stamped 02/16/22, from 20:08:14 (8:08 P.M.) to 21:43:28 (9:43 P.M.), depicted the outside patio area near the front door of the Facility. In the video Resident #1 can be heard expressing emotional upset and distress that the Facility staff would not allow him/her back into the Facility after he/she returned late from an LOA. Resident #1 remained outside of the Facility for almost two hours waiting for his/her cell phone to be charged by staff, which was ample time for the Nurse Supervisor to provide Resident #1 with the appropriate discharge paperwork. The Administrator said the next morning, on 02/17/22, she received a call from the Facility's receptionist because Resident #1 was outside of the Facility with emergency medical services (EMS). The Administrator said she went to speak with EMS because the Facility was not contacted by the Hospital about Resident #1 returning and said that the Facility had not reviewed any paperwork from the Hospital. The Administrator said she asked EMS to bring Resident #1 back to the Hospital. The Administrator said Resident #1 did not return to the Facility. During an interview on 04/12/22 at 11:00 A.M. the Director of Social Services said she did not assist with Resident #1's discharge process. During an interview on 04/13/22 at 2:10 P.M., the Director of Addiction Services said she did not assist with Resident #1's discharge process. Review of Resident #1's Medical Record indicated there was no documentation to support the Facility completed any form of discharge planning or education with Resident #1, including providing documentation of his/her discharge needs and/or ensure services were put in to place.

Based on records reviewed, interviews, and review of Facility video/audio surveillance camera footage for one of three sampled residents (Resident #1), who was dependent on a wheelchair for mobility, was homeless without a community support system in place, was undergoing antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . - On [DATE], Resident #1, who signed him/herself out to the Facility for a social Leave of Absence (LOA), and had indicated he/she anticipated being LOA from 11:00 A.M. to 3:00 P.M., returned to the Facility approximately five hours later than anticipated, was denied retry, and became emotionally distressed and upset when he/she was informed by staff that since he/she failed to notify the Facility that he/she was going to be late, that he/she considered discharged Against Medical Advice (AMA). - At the time of Resident #1's return that night (approximately 8:00 P.M.), the temperature was 37 degrees (per weather.com) Fahrenheit, he/she was wearing a sweatshirt, not a winter jacket, and it was very dark outside. Resident #1 told staff that his/her cell phone had died and that he/she could not make or receive calls. Although staff gave Resident #1 his/her winter coat to wear, he/she was not allowed to enter the Facility lobby to warm up and was made to stay outside while he/she waited two hours for his/her cell phone to charge. - Resident #1 was informed by staff that Administration said he/she was considered discharged AMA, and that he/she would have to go to the Hospital Emergency Department (on his/her own) to get medically cleared first and then could return to the Facility to be readmitted . - Resident #1 was brought back to the facility on [DATE], by Emergency Medical Services (EMS) after he/she was medically cleared at the Hospital, and without reaching out to the Hospital, the Facility denied re-admission to Resident #1 and informed EMS they needed to take Resident #1 back to the Hospital. Findings include: Review of the Facility's Policy titled, Discharge Against Medical Advice (AMA), dated [DATE], indicated that the Facility would not detain a resident against his/her wishes unless he/she was unable to make his/her own heath care decisions. The Policy indicated that the nurse would try to ascertain if it was the resident's wish to be discharged . The Policy also indicated, in the event an alert and coherent resident did not wish to leave, the resident's wishes would be honored. Review of the Facility's Policy titled, Leave of Absence (LOA), dated [DATE], indicated that staff would obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Policy indicated that when a resident leaves the Facility, attempts would be made to have the resident complete the LOA log accepting his/her responsibility for his/her well-being when on LOA. Further review of the Facility's LOA Policy, indicated there was no documentation related to what was considered a violation of the policy, what would happen should resident violate the policy, and/or in the event of repeated non-compliance with the policy, what actions could or would be taken with the resident by the facility. Review of Facility's Policy titled, Discharge Planning, dated [DATE], indicated that resident discharge planning would be addressed upon admission and throughout the resident's stay. The Policy indicated that interdisciplinary discharge plans would be developed to provide sufficient preparation, orientation, and education to residents to ensure safe and orderly discharge to home or a lesser level of care. Review of the Facility video camera surveillance footage which included audio recording, date stamped [DATE], from 20:08:14 (8:08 P.M.) to 21:43:28 (9:43 P.M.), depicted the outside patio area near the front door of the Facility. In the video Resident #1 can be heard expressing emotional upset and distress that the Facility staff would not allow him/her back into the Facility after he/she returned late from an LOA. The video camera surveillance footage depicted the following: - 20:09:23 (8:09 P.M.) - 20:19:20 (8:19 P.M.): Resident #1, who was sitting in a wheelchair, approached the Facility's front door. A staff member opened the door, walked outside, and Resident #1 asked Could you do me a favor and put my left foot up on the pedal, my left foot? The staff member assisted Resident #1 and then the staff member entered the Facility. Resident #1 remained outside. - 20:22:06 (8:22 P.M.) - 20:32:03 (8:32 P.M.): Resident #1 was outside in the patio area near the front door, when an Unidentified Staff Member (later identified as the Nurse Supervisor), walked outside. The Nurse Supervisor said to Resident #1 They said you're on your own now, we can't let you back in the building because you [unintelligible words], so they don't want to let you back in. Resident #1 said Well I can't go to the ER (emergency room ), I don't have anything medically wrong with me. Nurse Supervisor said Well I know but that's what they asked to be said. Resident #1 said Then I want all my[OBSCENITY] I want to be transferred to another [OBSCENITY] ing facility. Nurse Supervisor said You want your belongings? Resident #1 said Yes. Nurse Supervisor said Alright, I will bring them to you. The Nurse Supervisor walked back inside the Facility. Resident #1 remained outside. Unidentified Staff Member (not in view of the camera), said to Resident #1 They just said you can't come in and you have to go to the ER to get readmitted . Resident #1 said How am I supposed to get to the ER if I don't have a phone and can't call for an ambulance? Unidentified Staff Member (not in view of the camera), said I'll go ask them if they will call for you. Resident #1 said, Ask him if he'll allow someone else to call for me. Unidentified Staff Member (not in view of the camera) walked back inside the Facility. Resident #1 remained outside. The Nurse Supervisor walked back outside and said to Resident #1 let me charge your phone for you for a while so you can use it. Resident #1 said Alright, thank you. It should work at about 20 percent. The Nurse Supervisor walked back inside the Facility. Resident #1 remained outside. - 20:32:17 (8:32 P.M.) - 20:39:27 (8:39 P.M.): Resident #1 said (with no one else in view of the camera), [OBSCENITY] ing great, I hate this [OBSCENITY] ing place. Unidentified Staff Member-C walked to the Facility's front door and said to Resident #1 Are you coming in? Resident #1 said No, they're not letting me back in. Unidentified Staff Member-C said Huh? Resident #1 said No, they aren't going to let me back in because I'm late coming back from an LOA. Unidentified Staff Member-C said So you're going to stay in the cold? Resident #1 said Yeah. Unidentified Staff Member-C said All night? Resident #1 said No, they want me to go to a Hospital and get admitted , and head back. I don't know why. I can't go to the ER, I don't have any medical issues to report. The Nurse Supervisor walked back outside and handed Resident #1 a winter jacket and said Your coat. Resident #1 said Let me stand up, it's easier and he/she lifted his/her left leg off of the wheelchair leg rest and said This is ridiculous. Nurse Supervisor said It's your own fault, I don't make the rules, you know that. When I can help you, I help you. Resident #1 said I understand that, and I understand why they are doing it now. I thought of it, for coming back late from my LOA, it means I'm AMA. Nurse Supervisor said Yes, you discharged yourself. Resident #1 said Right. Resident #1 stood up from his/her wheelchair and the Nurse Supervisor assisted him/her with putting on his/her winter jacket. Resident #1 said My left side is the weak side. Nurse Supervisor said What did you smoke, your eyes are very red. Resident #1 said Ah, I haven't slept in like 24 hours. They didn't do this to me before when I came back late. Nurse Supervisor said That was because that was your first time you did it, and now you know the rules and you're still doing it. Resident #1 said They didn't tell me this would happen the next time. I wasn't aware. Nurse Supervisor said Yeah, ok, well, I don't want to lose my job. Resident #1 said Can you take this bag of stuff back to the room? Nurse Supervisor said We're bringing everything. Resident #1 said Why? What am I going to do with it all? How am I going to carry it? Nurse Supervisor said You want us to keep it in the room? Resident #1 said Yeah, and I'll have someone send for it. Nurse Supervisor said Let me get your phone. Resident #1 said Alright thank you. The Nurse Supervisor walked back inside the Facility. Resident #1 remained outside. - 21:01:00 (9:01 P.M.) - 21:01:29 (9:01 P.M.): Resident #1 said I'm done with their bull[OBSCENITY]policies. Unidentified Staff Member-C said Yeah, you know how it is living under someone else's roof. Resident #1 said Yeah, unfortunately. They won't even let me in the lobby to stay warm. Unidentified Staff Member-C said Oh my goodness, they won't even let you in the lobby? Resident #1 said Nope. Unidentified Staff Member-C said Oh that's some bull[OBSCENITY] Then what are you doing sitting out here? Resident #1 said Yup. Waiting for them to bring me one of the wall chargers for my phone. Resident #1 remained outside. - 21:10:00 (9:10 P.M.) - 21:19:58 (9:19 P.M.): Resident #1 said (with no one else in view of the camera), Will it get me admitted if I piss myself? What do I do? I've had a day from hell and it keeps getting worse. Resident #1 remained outside. - 21:31:25 (9:31 P.M.) - 21:40:14 (9:40 P.M.): Unidentified Staff Member-D asked Resident #1 Did you call an ambulance to take you to the Hospital? Resident #1 said Not yet, I don't have my phone. Unidentified Staff Member-D said Damn [Resident #1's name], I don't like this. Resident #1 said They said I signed out from ,d+[DATE] but I was trying to write five, but I came back at like 8. Unidentified Staff Member-D said When you were late, did you call them when you were coming in? Resident #1 said My phone was dead. I had to have them charge it up. He was going to be bringing all my stuff out to me and I said how the [OBSCENITY] am I going to carry all that. Unidentified Staff Member-D said Yo, that[OBSCENITY]s [OBSCENITY] ed up. Resident #1 said With a wheelchair. Unidentified Staff Member-D said That[OBSCENITY]s [OBSCENITY] ed up. Oh, my heart is breaking right now. Resident #1 said I mean, as good as I am to everyone around here. Unidentified Staff Member-D walked back inside the Facility. Resident #1 remained outside. The Nurse Supervisor walked back outside and said to Resident #1, I didn't know you were waiting for [unintelligible words] and handed Resident #1 something. Nurse Supervisor said Why won't you call the Administrator and beg her and say Administrator, say I'm sorry or call the Administrator and beg her. Resident #1 said I'm not going to [OBSCENITY] with [unintelligible words]. Nurse Supervisor said, Well, then what are you going to do? Resident #1 said I'll go to the Hospital and see what they can do. The Nurse Supervisor walked back inside the Facility. Resident #1 remained outside. Resident #1 said to Unidentified Staff Member-E, I haven't had anything to eat since breakfast either. They won't even let me in the lobby to stay warm. - 21:40:42 (9:40 P.M.)- 21:43:28 (9:43 P.M.): Resident #1 said to Unidentified Staff Member-E, Thank you. I'll take the bus down to the Hospital or whatever, and tell them to waste their time. Unidentified Staff Member-E said What about maybe calling an ambulance for a ride? Resident #1 said They're not going to send down an ambulance just because I need to be admitted . Unidentified Staff Member-E said But I worry, how are you going to get a bus? When? Resident #1 said [unintelligible words] on the side of the road. Unidentified Staff Member-E said What happened? Resident #1 said I signed out from 11 to what I thought was 5, but looked like [unintelligible words] and they said because I came back late from LOA, that means I'm AMA, and I can't get brought back in unless I get discharged from a Hospital. After all the things I've done for people around here. Resident #1 left the Facility's property by him/herself in his/her wheelchair. Resident #1 was admitted to the Facility in [DATE], medical history included Cerebral Infraction (stroke), left sided [CONDITION(S)] (paralysis on one side of the body), Unsteadiness on Feet, Hypertension, and a history of falls. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Plan of Care (POC) related to Discharge Planning, dated [DATE], indicated Resident #1 had history of chronic homelessness, previously residing in shelters, until he/she required more care and assistance. The POC indicated Resident #1 expressed interest in returning to the community and they would continue to explore possible referrals to discharge him/her to an appropriate setting with appropriate services. Review of Resident #1's Plan of Care (POC) related to activities of daily living (ADL), dated as revised [DATE], indicated he/she had self-care deficits related to a prior [CONDITION(S)] (stroke) with a left sided [CONDITION(S)] (paralysis). The POC indicated Resident #1 required extensive assistance from one staff member for dressing, toilet use, and grooming. Review of the Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was cognitively intact (able to make his/her own health care decisions) and was able to clearly communicate his/her needs with others. During an interview on [DATE] at 2:10 P.M., the Director of Addiction Services said she had attended Resident #1's Care Plan Meetings in the past, and said Resident #1 expressed a desire to return to the community, but said due to limited options, his/her plan was to remain as a long-term care resident at the Facility. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Situation, Background, Assessment, and Recommendation (SBAR) Communication Note, dated [DATE], indicated Resident #1 needed more assistance with ADLs (compared to his/her baseline) due to an abscess (swollen area within body tissue, containing an accumulation of pus) and back pain. Review of the Resident #1's Physician's Progress Note, dated [DATE], indicated he/she was taking antibiotics for an abscess on his/her left buttocks, and would need to be referred to the Wound Physician to be seen. Further review of Resident #1's MAR, indicated that on [DATE], Resident #1's had a new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurse Supervisor's Progress Note, dated [DATE], at 9:23 P.M., indicated that Resident #1 signed out for a LOA and he/she refused to return to the Facility at the scheduled time. The Note indicated Resident #1 did not call the Facility to report he/she would be late. The Note indicated that the Administrator and the Director of Nursing were informed of the incident, and they gave an order that Resident #1 could not return to the Facility due to a violation of the Facility's LOA Policy. The Note indicated Resident #1 was given some of his/her belongings (winter jacket, tablet, cell phone, and device charger) and Resident #1 asked the Facility to keep the remainder of his/her belongings so he/she could arrange retrieving the items later. The Note indicated Resident #1 said he/she would go to the Hospital and check him/herself in. The Note indicated the Physician was notified. During an interview on [DATE] at 12:05 P.M., the Physician said the Nurse Supervisor called during the evening of [DATE], after Resident #1 was discharged AMA from the Facility. The Physician said the Nurse Supervisor said Resident #1 returned several hours late from an LOA, so he (Nurse Supervisor) asked Resident #1 to go to the Hospital ED for an evaluation. The Physician said he was unaware what assessments, if any, were completed by the Nurse Supervisor or what specific concerns staff had about Resident #1 which required a transfer to the Hospital. The Physician said that if there are concerns of a resident returning from an LOA and appearing under the influence, then staff should call an ambulance to transport the resident to the Hospital. During an interview on [DATE] at 11:31 A.M., the Nurse Supervisor said that on [DATE], he arrived to work for the evening shift (3:00 P.M. to 11:00 P.M.) at the Facility, and said the Administrator and Director of Nursing informed him that Resident #1 was out late on an LOA, and therefore, could not return to the Facility, said that he/she was considered discharged Against Medical Advice. The Nurse Supervisor said Resident #1 returned to the Facility sometime around 8:30 P.M., and said he told Resident #1 that he/she was unable to return to the Facility, per the Administrator's orders. The Nurse Supervisor said Resident #1 told him that his/her cell phone was dead, so he charged Resident #1's cell phone while he gathered some of Resident #1's personal belongings. The Nurse Supervisor said he gave Resident #1 the Administrator's phone number so he/she could speak directly with the Administrator about returning late from the LOA and possibly returning to the Facility even though he/she was later than expected. The Nurse Supervisor said Resident #1 did not want to call the Administrator. The Nurse Supervisor said he offered to call a ride for Resident #1 to get to the Hospital, but Resident #1 said he/she did not have a medical reason to go to the Hospital and he/she would find his/her own way there. The Nurse Supervisor said he provided Resident #1 with a phone number to call for transportation to the Hospital. Review of Nurse #1's Progress Note, dated [DATE] at 11:56 P.M., indicated that Resident #1 left that day, and the Director of Nursing and the Administrator were informed when Resident #1 returned. The Note indicated staff advised Resident #1 to report to the Hospital ED before coming back to the Facility. The Note indicated some of Resident #1's belongings were given to him/her, and that the bulk of his/her belongings were kept in the staff room to be collected later. During an interview on [DATE] at 11:59 A.M., Certified Nurse Aide (CNA) #2 said that on [DATE], around 9:00 P.M. or 9:30 P.M., she saw Resident #1 sitting outside, and said that Resident #1 told her he/she was waiting his/her cell phone to charge. CNA #2 said Resident #1 said he/she was unable to go back inside the Facility because he/she was supposed to come back at a certain time, but he/she was late. CNA #2 said Resident #1 said he/she wanted to go back into the Facility. CNA #2 said Resident #1 seemed sad because he/she could not go inside. CNA #2 said Resident #1 said he/she was going to take a bus to the Hospital. CNA #2 said she stayed with Resident #1 until he/she left the Facility's property. Review of the Hospital Emergency Department (ED) Record, dated [DATE] at 11:57 P.M., indicated Resident #1 reported falling from his/her wheelchair, but he/she did not want to be evaluated. The Record indicated Resident #1 requested a note saying he/she was medically cleared to return to the Facility where he/she lived. The Record indicated Resident #1 said he/she left the Facility to go shopping, but because he/she was out too late, he/she was considered discharged AMA, and said the Facility would not allow him/her to return tonight until he/she had a note of medical clearance. During an interview on [DATE] at 8:00 A.M., and throughout the Survey, the Director of Nursing (DON) said that on [DATE], she received a call from the Nurse Supervisor once Resident #1 returned (five hours later than anticipated) from his/her LOA. The DON said the Facility considered Resident #1 to be discharged AMA since he/she did not contact the Facility to report he/she would be returning late, as requested in the LOA Log Agreement Form. The DON said she asked the Nurse Supervisor to call the Administrator regarding the situation with Resident #1. During an interview on [DATE] at 10:15 A.M., and throughout the Survey, the Administrator said the Facility has a LOA Policy, but said each LOA was specific for each resident and situation. The Administrator said that before Resident #1 left the Facility for an LOA on [DATE], she spoke with him/her about the Facility LOA Policy and the expectations. The Administrator said Resident #1 did not return at the expected time from the LOA, so she said she told the evening Nurse Supervisor and Nurse #1 about the need for Resident #1 to go to the Hospital, if he/she returned and appeared intoxicated. The Administrator said Resident #1 returned late from another LOA in [DATE] and said she educated Resident #1 about the LOA Policy. The Administrator said there was no documentation of this incident in [DATE] with Resident #1 violating the LOA Policy and/or requiring re-education about the Policy. The Administrator said that around 9:00 P.M., she received a call from the Nurse Supervisor, who said Resident #1 looked shaky like he/she was drinking. The Administrator said she was unaware if the Nurse Supervisor asked Resident #1 if he/she consumed any substances during the LOA. The Administrator said she was unaware if the Nurse Supervisor completed any clinical assessments of Resident #1, but said the Nurse Supervisor asked Resident #1 to go to the Hospital for an evaluation. The Administrator said that the Nurse Supervisor did not call an ambulance for Resident #1 after he/she appeared to be shaky because he/she was alert and oriented and declined ambulance transfer to the Hospital. The Administrator said that Resident #1 left the Facility of his/her own will and said the Facility was unable to accept Resident #1 to return to the Facility due to concerns of him/her shaking. The Administrator said Resident #1 could have consumed something (alcohol or drugs) during the LOA and said he/she needed to be cleared by a Hospital for safety before Resident #1 could return to the Facility. The Administrator said she was unaware why Resident #1 returned late from the LOA, and said she was unaware why Resident #1 did not notify the Facility when he/she would be returning late from his/her LOA. The Administrator said the Nurse Supervisor asked Resident #1 to call her but Resident #1 refused. The Administrator said the Facility considered Resident #1 discharged AMA after Resident #1 declined to go to the Hospital and left Facility property. The Administrator said the Nurse Supervisor was trying to encourage Resident #1 to go to the Hospital, and said the Nurse Supervisor did not discuss the discharge AMA process and/or paperwork with Resident #1. Review of the Facility's Investigation and Resident #1's Medical Record indicated there was no documentation to support the Facility asked Resident #1 why he/she returned late from his/her LOA and why he/she did not notify the Facility about being late or that the Facility tried to contact Resident #1 when he/she was late from returning from his/her LOA. The Administrator said the next morning, on [DATE], she received a call from the Facility's receptionist because Resident #1 was outside of the Facility with Emergency Medical Services (EMS). The Administrator said she went to speak with EMS because the Facility was not contacted by a hospital about Resident #1 returning and the Facility had not reviewed any paperwork from the Hospital. The Administrator said she informed EMS that they needed to bring Resident #1 back to the Hospital. The Administration said Resident #1 did not return to the Facility. There was no documentation to support the Facility reached out to the Hospital to obtain Resident #1's discharge paperwork to re-admit Resident #1 to the facility on [DATE]. There was no documentation to support that Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on records reviewed, interviews, and review of Facility video/audio surveillance camera footage for one of three sampled residents (Resident #1), who was dependent on a wheelchair for mobility, was homeless without a community support system in place, was undergoing antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . - On [DATE], Resident #1, who signed him/herself out of the Facility for a social LOA, indicated he/she anticipated to be LOA from 11:00 A.M. to 3:00 P.M., however, he/she returned to the Facility approximately five hours later than anticipated, was denied retry, he/she became distressed and emotionally upset when he/she was informed by staff that since he/she failed to notify the Facility that he/she was going to be late, that he/she was considered discharged Against Medical Advice (AMA). - At the time of his/her return that night (approximately 8:00 P.M.), Resident #1's outerwear consisted of a sweatshirt (not a winter jacket), the temperature (per weather.com) was 37 degrees Fahrenheit, and it was very dark outside. - Resident #1 told staff that his/her cell phone had died and that he/she could not make or receive calls. Resident #1 was informed by staff that Administration said he/she was considered discharged AMA, and that he/she would have to go to the Hospital Emergency Department (ED), on his/her own, to get medically cleared first and then could return to the Facility to be readmitted . - Despite Resident #1 telling staff he/she did not want to leave and wanted to go back into the Facility, Resident #1 was still denied entry to the Facility, and was told that because he/she did not come back on time, he/she was considered discharged AMA per Administration. - Resident #1 was never assessed by nursing that night, and although there was a report that staff said that night he/she looked shaky, based on the time of night, the temperature, and how he/she was dressed (sweatshirt, not a winter jacket), the shaking could have been simply a sign that Resident #1 was cold from being outside for so long. Resident #1 told staff that night that there was nothing medically wrong with him/her and that he/she did not need to go to the Hospital. - Although staff retrieved and gave Resident #1 his/her winter jacket to wear, he/she was not allowed to enter the Facility lobby to warm up and was made to stay outside for almost two hours while his/her cell phone was being charged. - Resident #1's Physician was contacted by staff only after Resident #1 left the Facility that night (approximately 10:00 P.M.) and was told Resident #1 had decided to leave AMA. Findings include: Review of the Facility's Policy titled, Discharge Against Medical Advice (AMA), dated [DATE], indicated that the Facility would not detain a resident against his/her wishes unless he/she was unable to make his/her own heath care decisions. The Policy indicated that the nurse would try to ascertain if it was the resident's wish to be discharged . The Policy also indicated, in the event an alert and coherent resident did not wish to leave, the resident's wishes would be honored. Review of the Facility's Policy titled, Leave of Absence (LOA), dated [DATE], indicated that staff would obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Policy indicated that when a resident leaves the Facility, attempts would be made to have the resident complete the LOA log accepting his/her responsibility for his/her well-being when on LOA. Further review of the Facility's LOA Policy, indicated there was no documentation related to what was considered a violation of the policy, what would happen should resident violate the policy, and/or in the event of repeated non-compliance with the policy, what actions could or would be taken with the resident by the facility. Review of Facility's Policy titled, Discharge Planning, dated [DATE], indicated that resident discharge planning would be addressed upon admission and throughout the resident's stay. The Policy indicated that interdisciplinary discharge plans would be developed to provide sufficient preparation, orientation, and education to residents to ensure safe and orderly discharge to home or a lesser level of care. Review of the Facility's Policy titled, Abuse Prohibition Policy, dated [DATE], indicated that the Facility had the responsibility to ensure that each resident had the right to be free from neglect. The Policy defined neglect as the failure of the Facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The Facility's Policy titled Intoxication Protocol, dated [DATE], indicated that all residents with suspected illicit drug use at the Facility would be sent out to acute care for further assessment. Review of the Facility video camera surveillance footage which included audio recording, date stamped [DATE], from 20:08:14 (8:08 P.M.) to 21:43:28 (9:43 P.M.), depicted the outside patio area near the front door of the Facility. In the video Resident #1 can be heard becoming emotionally upset and distressed that the Facility staff would not allow him/her back into the Facility after he/she returned late from an LOA. The video camera surveillance footage depicted the following: - 20:09:23 (8:09 P.M.) - 20:19:20 (8:19 P.M.): Resident #1, who was sitting in a wheelchair, approached the Facility's front door. A staff member opened the door, walked outside, and Resident #1 asked Could you do me a favor and put my left foot up on the pedal, my left foot? The staff member assisted Resident #1 and then the staff member entered the Facility. Resident #1 remained outside. - 20:22:06 (8:22 P.M.) - 20:32:03 (8:32 P.M.): Resident #1 was outside in the patio area near the front door, when an Unidentified Staff Member (later identified as the Nurse Supervisor), walked outside. The Nurse Supervisor said to Resident #1 They said you're on your own now, we can't let you back in the building because you [unintelligible words], so they don't want to let you back in. Resident #1 said Well I can't go to the ER (emergency room ), I don't have anything medically wrong with me. Nurse Supervisor said Well I know but that's what they asked to be said. Resident #1 said Then I want all my[OBSCENITY] I want to be transferred to another [OBSCENITY] ing facility. Nurse Supervisor said You want your belongings? Resident #1 said Yes. Nurse Supervisor said Alright, I will bring them to you. The Nurse Supervisor walked back inside the Facility. Resident #1 remained outside. Unidentified Staff Member (not in view of the camera), said to Resident #1 They just said you can't come in and you have to go to the ER to get readmitted . Resident #1 said How am I supposed to get to the ER if I don't have a phone and can't call for an ambulance? Unidentified Staff Member (not in view of the camera), said I'll go ask them if they will call for you. Resident #1 said, Ask him if he'll allow someone else to call for me. Unidentified Staff Member (not in view of the camera) walked back inside the Facility. Resident #1 remained outside. The Nurse Supervisor walked back outside and said to Resident #1 let me charge your phone for you for a while so you can use it. Resident #1 said Alright, thank you. It should work at about 20 percent. The Nurse Supervisor walked back inside the Facility. Resident #1 remained outside. - 20:32:17 (8:32 P.M.) - 20:39:27 (8:39 P.M.): Resident #1 said (with no one else in view of the camera), [OBSCENITY] ing great, I hate this [OBSCENITY] ing place. Unidentified Staff Member-C walked to the Facility's front door and said to Resident #1 Are you coming in? Resident #1 said No, they're not letting me back in. Unidentified Staff Member-C said Huh? Resident #1 said No, they aren't going to let me back in because I'm late coming back from an LOA. Unidentified Staff Member-C said So you're going to stay in the cold? Resident #1 said Yeah. Unidentified Staff Member-C said All night? Resident #1 said No, they want me to go to a Hospital and get admitted , and head back. I don't know why. I can't go to the ER, I don't have any medical issues to report. The Nurse Supervisor walked back outside and handed Resident #1 a winter jacket and said Your coat. Resident #1 said Let me stand up, it's easier and he/she lifted his/her left leg off of the wheelchair leg rest and said This is ridiculous. Nurse Supervisor said It's your own fault, I don't make the rules, you know that. When I can help you, I help you. Resident #1 said I understand that, and I understand why they are doing it now. I thought of it, for coming back late from my LOA, it means I'm AMA. Nurse Supervisor said Yes, you discharged yourself. Resident #1 said Right. Resident #1 stood up from his/her wheelchair and the Nurse Supervisor assisted him/her with putting on his/her winter jacket. Resident #1 said My left side is the weak side. Nurse Supervisor said What did you smoke, your eyes are very red. Resident #1 said Ah, I haven't slept in like 24 hours. They didn't do this to me before when I came back late. Nurse Supervisor said That was because that was your first time you did it, and now you know the rules and you're still doing it. Resident #1 said They didn't tell me this would happen the next time. I wasn't aware. Nurse Supervisor said Yeah, ok, well, I don't want to lose my job. Resident #1 said Can you take this bag of stuff back to the room? Nurse Supervisor said We're bringing everything. Resident #1 said Why? What am I going to do with it all? How am I going to carry it? Nurse Supervisor said You want us to keep it in the room? Resident #1 said Yeah, and I'll have someone send for it. Nurse Supervisor said Let me get your phone. Resident #1 said Alright thank you. The Nurse Supervisor walked back inside the Facility. Resident #1 remained outside. - 21:01:00 (9:01 P.M.) - 21:01:29 (9:01 P.M.): Resident #1 said I'm done with their bull[OBSCENITY]policies. Unidentified Staff Member-C said Yeah, you know how it is living under someone else's roof. Resident #1 said Yeah, unfortunately. They won't even let me in the lobby to stay warm. Unidentified Staff Member-C said Oh my goodness, they won't even let you in the lobby? Resident #1 said Nope. Unidentified Staff Member-C said Oh that's some bull[OBSCENITY] Then what are you doing sitting out here? Resident #1 said Yup. Waiting for them to bring me one of the wall chargers for my phone. Resident #1 remained outside. - 21:10:00 (9:10 P.M.) - 21:19:58 (9:19 P.M.): Resident #1 said (with no one else in view of the camera), Will it get me admitted if I piss myself? What do I do? I've had a day from hell and it keeps getting worse. Resident #1 remained outside. - 21:31:25 (9:31 P.M.) - 21:40:14 (9:40 P.M.): Unidentified Staff Member-D asked Resident #1 Did you call an ambulance to take you to the Hospital? Resident #1 said Not yet, I don't have my phone. Unidentified Staff Member-D said Damn [Resident #1's name], I don't like this. Resident #1 said They said I signed out from ,d+[DATE] but I was trying to write five, but I came back at like 8. Unidentified Staff Member-D said When you were late, did you call them when you were coming in? Resident #1 said My phone was dead. I had to have them charge it up. He was going to be bringing all my stuff out to me and I said how the [OBSCENITY] am I going to carry all that. Unidentified Staff Member-D said Yo, that[OBSCENITY]s [OBSCENITY] ed up. Resident #1 said With a wheelchair. Unidentified Staff Member-D said That[OBSCENITY]s [OBSCENITY] ed up. Oh, my heart is breaking right now. Resident #1 said I mean, as good as I am to everyone around here. Unidentified Staff Member-D walked back inside the Facility. Resident #1 remained outside. The Nurse Supervisor walked back outside and said to Resident #1, I didn't know you were waiting for [unintelligible words] and handed Resident #1 something. Nurse Supervisor said Why won't you call the Administrator and beg her and say Administrator, say I'm sorry or call the Administrator and beg her. Resident #1 said I'm not going to [OBSCENITY] with [unintelligible words]. Nurse Supervisor said, Well, then what are you going to do? Resident #1 said I'll go to the Hospital and see what they can do. The Nurse Supervisor walked back inside the Facility. Resident #1 remained outside. Resident #1 said to Unidentified Staff Member-E, I haven't had anything to eat since breakfast either. They won't even let me in the lobby to stay warm. - 21:40:42 (9:40 P.M.)- 21:43:28 (9:43 P.M.): Resident #1 said to Unidentified Staff Member-E, Thank you. I'll take the bus down to the Hospital or whatever, and tell them to waste their time. Unidentified Staff Member-E said What about maybe calling an ambulance for a ride? Resident #1 said They're not going to send down an ambulance just because I need to be admitted . Unidentified Staff Member-E said But I worry, how are you going to get a bus? When? Resident #1 said [unintelligible words] on the side of the road. Unidentified Staff Member-E said What happened? Resident #1 said I signed out from 11 to what I thought was 5, but looked like [unintelligible words] and they said because I came back late from LOA, that means I'm AMA, and I can't get brought back in unless I get discharged from a Hospital. After all the things I've done for people around here. Resident #1 left the Facility's property by him/herself in his/her wheelchair. Resident #1 was admitted to the Facility in [DATE], medical history included Cerebral Infraction (stroke), left sided [CONDITION(S)] (paralysis on one side of the body), Unsteadiness on Feet, Hypertension, and a history of falls. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Plan of Care (POC) related to Discharge Planning, dated [DATE], indicated Resident #1 had history of chronic homelessness, previously residing in shelters, until he/she required more care and assistance. The POC indicated Resident #1 expressed interest in returning to the community and they would continue to explore possible referrals to discharge him/her to an appropriate setting with appropriate services. Review of Resident #1's Plan of Care (POC) related to Activities of Daily Living (ADL), dated as revised [DATE], indicated he/she had self care deficits related to a prior [CONDITION(S)] (stroke) with a left sided [CONDITION(S)] (paralysis). The POC indicated Resident #1 required extensive assistance from one staff member for dressing, toilet use, and grooming. Review of Resident #1's POC related to incontinence care, dated as revised [DATE], indicated he/she wore adult briefs due to occasional bowel/bladder incontinence and required staff assistance with personal hygiene after an incontinent episode. Review of the Resident #1's Certified Nurse Aide (CNA) Care Card, dated [DATE], indicated he/she required assistance from one staff member for dressing, bathing, and incontinence care. Review of the Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was cognitively intact (able to make his/her own health care decisions) and was able to clearly communicate his/her needs with others. The MDS indicated Resident #1 required extensive assistance from one to two staff members with dressing, personal hygiene, and toilet use. During an interview on [DATE] at 2:10 P.M., the Director of Addiction Services said she had attended Resident #1's Care Plan Meetings in the past, and said Resident #1 expressed a desire to return to the community, but due to limited options, his/her plan was to remain as a long-term care resident at the Facility. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Situation, Background, Assessment, and Recommendation (SBAR) Communication Note, dated [DATE], indicated Resident #1 needed more assistance with ADLs (compared to his/her baseline) due to an abscess (swollen area within body tissue, containing an accumulation of pus) and back pain. Review of Resident #1's Physician's Progress Note, dated [DATE], indicated he/she was taking antibiotics for an abscess on his/her left buttocks, and would need to be referred to the Wound Physician to be seen. Further review of Resident #1's MAR, indicated that on [DATE], Resident #1's had a new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Release from Responsibility for Leave of Absence (LOA) Log, dated ,d+[DATE] (verified by Facility staff as [DATE]), indicated Resident #1 signed out of the Facility to go to two stores in the community from 11:00 A.M., with an anticipated return time of 3:00 P.M. Further review of the Form indicated a pre-populated statement of agreement which indicated that I [the Resident] would inform the Facility if I would not be returning at the anticipated time. However, further review of the LOA Form indicated there was no documentation to support that Resident #1 would be considered discharge AMA if he/she did not comply with the terms and conditions outlined within the LOA Form. Review of the Nurse Supervisor's Progress Note, dated [DATE], at 9:23 P.M., indicated that Resident #1 signed out for a LOA and he/she refused to return to the Facility at the scheduled time. The Note indicated Resident #1 did not call the Facility to report he/she would be late. The Note indicated that the Administrator and the Director of Nursing were informed of the incident, and they gave an order that Resident #1 could not return to the Facility due to a violation of the Facility's LOA Policy. The Note indicated Resident #1 was given some of his/her belongings (winter jacket, tablet, cell phone, and device charger) and Resident #1 asked the Facility to keep the remainder of his/her belongings so he/she could arrange retrieving the items later. The Note indicated Resident #1 said he/she would go to the Hospital and check him/herself in. The Note indicated the Physician was notified. During an interview on [DATE] at 11:31 A.M., the Nurse Supervisor said that on [DATE], he arrived to work for the evening shift (3:00 P.M. to 11:00 P.M.) at the Facility, and said the Administrator and Director of Nursing informed him that Resident #1 was out late on an LOA, and therefore, could not return to the Facility, that he/she was considered discharged Against Medical Advice. The Nurse Supervisor said Resident #1 returned to the Facility sometime around 8:30 P.M., and said he told Resident #1 that he/she was unable to return to the Facility, per the Administrators orders. The Nurse Supervisor said Resident #1 told him that his/her phone was dead, so he charged Resident #1's phone while he gathered some of Resident #1's personal belongings. The Nurse Supervisor said he gave Resident #1 the Administrator's phone number so he/she could speak directly with the Administrator about returning late from the LOA and possibly returning to the Facility even though he/she was later than expected. The Nurse Supervisor said Resident #1 did not want to call the Administrator. The Nurse Supervisor said he did not perform any type of assessments on Resident #1 when he/she returned to the Facility, because the Administrator told him the resident was discharged AMA, and said he thought it would not have been appropriate to assess Resident #1 because he was no longer a resident of the Facility. The Nurse Supervisor said he was unable to tell if Resident #1 had used any drugs or was under the influence of any substances because he did not assess Resident #1. The Nurse Supervisor said he offered to call a ride for Resident #1 to get to the Hospital, but Resident #1 said he/she did not have a medical reason to go to the Hospital and he/she would find his/her own way there. The Nurse Supervisor said he provided Resident #1 with a phone number to call for transportation to the Hospital. There was no documentation in Resident #1's record that the Nurse Supervisor assessed Resident #1 upon return to the facility on [DATE]. Review of the Facility's Investigation and Resident #1's Medical Record indicated there was no documentation to support the Facility asked Resident #1 why he/she returned late from his/her LOA and why he/she did not notify the Facility about being late or that the Facility tried to contact Resident #1 when he/she was late from returning from his/her LOA. Review of Nurse #1's Progress Note, dated [DATE] at 11:56 P.M., indicated that Resident #1 left that day, and the Director of Nursing and the Administrator were informed when Resident #1 returned. The Note indicated staff advised Resident #1 to report to the Hospital ED (Emergency Department) before coming back to the Facility. The Note indicated some of Resident #1's belongings were given to him/her, and that the bulk of his/her belongings were kept in the staff room to be collected later. During an interview on [DATE] at 11:59 A.M., Certified Nurse Aide (CNA) #2 said that on [DATE], around 9:00 P.M. or 9:30 P.M. she saw Resident #1, sitting outside, and said that Resident #1 told her he/she was waiting for his/her phone to charge. CNA #2 said Resident #1 said he/she was unable to go back inside the Facility because he/she was supposed to come back at a certain time, but he/she was late. CNA #2 said Resident #1 said he/she wanted to go back into the Facility. CNA #2 said Resident #1 seemed sad because he/she could not go inside. CNA #2 said Resident #1 said he/she was going to take a bus to the Hospital. CNA #2 said she stayed with Resident #1 until he/she left the Facility's property. Review of the Hospital Emergency Department (ED) Record, dated [DATE] at 11:57 P.M., indicated Resident #1 reported falling from his/her wheelchair, but he/she did not want to be evaluated. The Record indicated Resident #1 requested a note saying he/she was medically cleared to return to the Facility where he/she lived. The Record indicated Resident #1 said he/she left the Facility to go shopping, but because he/she was out too late, he/she was considered discharged AMA, and said the Facility would not allow him/her to return tonight until he/she had a note of medical clearance. During an interview on [DATE] at 8:00 A.M., and throughout the Survey, the Director of Nursing (DON) said that on [DATE], she received a call from the Nurse Supervisor once Resident #1 returned five hours later than anticipated from his/her LOA. The DON said the Facility considered Resident #1 to be discharged AMA since he/she did not contact the Facility to report he/she would be returning late, as requested on the LOA Log Agreement Form. The DON said she asked the Nurse Supervisor to call the Administrator regarding the situation with Resident #1. During an interview on [DATE] at 10:15 A.M., and throughout the Survey, the Administrator said the Facility has a LOA Policy, but said each LOA was specific for each resident and situation. The Administrator said that before Resident #1 left the Facility for an LOA on [DATE], said she spoke with him/her about the Facility LOA Policy and the expectations. The Administrator said Resident #1 did not return at the expected time from the LOA, so she said she told the evening Nurse Supervisor and Nurse #1 about the need for Resident #1 to go to the Hospital, if he/she returned and appeared intoxicated. The Administrator said Resident #1 returned late from another LOA in [DATE] and said she educated Resident #1 about the LOA Policy. The Administrator said there was no documentation of the incident back in [DATE] regarding Resident #1 violating the LOA Policy and/or requiring re-education about the Policy. Review of the Release from Responsibility for Leave of Absence (LOA) Log, dated [DATE], indicated Resident #1 signed out to go to the store at 11:09 A.M., with an anticipated return time of 12:30 P.M., however, the time in column was left blank, so therefore there was no way to validate if he/she returned on time or was late, and had violated the agreement. On [DATE], there was also an entry on the LOA form that indicated Resident #1 was going to the ATM, the time out written on the form was 1:15 P.M., however the form was incomplete, there was no anticipated time of return indicated, Resident #1's signature was missing, and the time in was also blank. Review of Resident #1's Medical Record indicated there was no documentation to support he/she was re-educated by facility staff, including Administration, on the LOA Policy, the expectations, or that his/her non-compliance with the Policy and/or non-adherence to the LOA Agreement would result in him/her being considered discharged AMA. The Administrator said that around 9:00 P.M., she received a call from the Nurse Supervisor, who said Resident #1 looked shaky like he was drinking. The Administrator said she was unaware if the Nurse Supervisor asked Resident #1 if he/she consumed any substances during the LOA. The Administrator said she was unaware if the Nurse Supervisor completed any clinical assessments of Resident #1, but said the Nurse Supervisor did tell Resident #1 he/she needed to go to the Hospital for an evaluation. The Administrator said that the Nurse Supervisor did not call an ambulance for Resident #1 after he/she appeared to be shaky because he/she was alert and oriented and declined an ambulance transfer to the Hospital. The Administrator said that Resident #1 left the Facility by his/her own will and said the Facility was unable to accept Resident #1 to return to the Facility due to concerns of him/her shaking. The Administrator said Resident #1 could have consumed something (alcohol or drugs) during the LOA and he/she needed to be cleared by a Hospital for safety before Resident #1 could return to the Facility. The Administrator said she was unaware why Resident #1 returned late from the LOA, and said she was unaware why Resident #1 did not notify the Facility that he/she would be returning late from his/her LOA. The Administrator said the Nurse Supervisor asked Resident #1 to call her but Resident #1 refused. The Administrator said the Facility considered Resident #1 discharged AMA after Resident #1 declined to go to the Hospital and then he/she left the Facility property. The Administrator said the Nurse Supervisor was trying to encourage Resident #1 to go to the Hospital, said the Nurse Supervisor did not discuss the discharge AMA process and/or paperwork with Resident #1. The Administrator said the next morning, on [DATE], she received a call from the Facility's receptionist because Resident #1 was outside of the Facility with emergency medical services (EMS). The Administrator said she went to speak with EMS because the Facility was not contacted by the Hospital about Resident #1 returning and said the Facility had not reviewed any paperwork from the Hospital. The Administrator said she asked EMS to bring Resident #1 back to the Hospital. The Administrator said Resident #1 did not return to the Facility after that. There was no documentation to support the Facility reached out to the Hospital to obtain Resident #1's discharge paperwork to re-admit Resident #1 to the facility on [DATE]. During an interview on [DATE] at 12:05 P.M., the Physician said the Nurse Supervisor called during the evening of [DATE], after Resident #1 was discharged AMA from the Facility. The Physician said the Nurse Supervisor said Resident #1 returned several hours late from an LOA, so he asked Resident #1 to go to the Hospital ED for an evaluation. The Physician said he was unaware what assessments, if any, were completed by the Nurse Supervisor or what specific concerns staff had about Resident #1 which required a transfer to the Hospital. The Physician said that if there are concerns of a resident returning from an LOA and appearing under the influence, then staff should call an ambulance to transport the resident to the Hospital. There was no documentation to support that Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations, record reviews and interviews, the facility staff failed to ensure the environment remained free of accident hazards for 7 sampled residents (#25, #79, #85, #111, #116, #133 and #349) in a total sample of 38 residents. Findings include: 1. For Resident #79, the facility staff failed to ensure adequate interventions were implemented for 10 of 15 falls the resident sustained [REDACTED]. Resident #79 was admitted to facility in 2/2016, and then readmitted ,[DATE] with [DIAGNOSES REDACTED]. Review of the facility's Fall Management Policy, dated 4/2015, indicated the following; the facility will utilize all resident/patient related information made available upon admission and ongoing to determine residents/patients at risk for fall status. Review of the clinical record indicated the resident had multiple discharges to the hospital and readmissions back into the facility. Review of the Fall Care Plan, date initiated 7/8/16, indicated the following interventions; -Use fall risk screen to identify risk factors. -Call light within reach. -Remind resident and reinforce safety awareness: When rising from lying position, sit on side of the bed for a few minutes before transferring/standing, educate/remind resident to request assistance prior to ambulation, appropriate footwear. -Invite, encourage, remind, escort to activity programs consistent with resident's interests to enhance physical strengthening needs. -Referral to Physical Therapy (PT), Occupational Therapy (OT) and Mental Health for screen and treatment as needed. -Provide resident/family teaching to include; safety measures to reduce fall risk and what to do if fall occurs. Review of the Functional Mobility Care Plan, date initiated 7/8/16, indicated the following interventions: -Transfers with continual supervision -Ambulation/Mobility with continued supervision to get to destinations. Review of the Significant Change in Status Minimum Data Set (MDS) Assessment, dated 2/16/17, indicated the resident had cognitive severe impairment as evidenced by a score of 7 on the Brief Interview for Mental Status (BIMS) exam, was independent with bed mobility, required supervision with transfers and walking, required extensive assistance with dressing and toileting, was dependent with hygiene and bathing, and had 2 falls with no injuries and one fall with major injury. Review of the a Fall/Incident Report and Investigation, dated 2/24/17, indicated the resident had a witnessed fall in the hallway at 11:15 A.M., and sustained a [MEDICAL CONDITION] requiring 4 staples. Review of the Fall Risk Evaluation, dated 2/24/17, indicated a score of 21. A score of 10 or greater indicated a resident is a high fall risk. Review of the a Fall/Incident Report and Investigation, dated 2/25/17, indicated the resident had a second witnessed fall in the bedroom at 11:00 A.M., and sustained a [MEDICAL CONDITION] again that required 6 staples. Review of the Fall Care Plan indicated the following interventions were added; -2/25/17: wheelchair with self releasing seat belt, a bed alarm, and PT evaluation. -3/3/17: Helmet to be worn to prevent head injuries from falls. -3/9/17: Monitor behaviors daily (history of increased behaviors with urinary infection), notify provider for a urinalysis culture and sensitivity test, and put resident on antibiotics to help lessen the potential of falls. During an interview on 04/12/18 at 11:05 A.M., the following staff members met with the surveyors relative to Resident #79 and the multiple falls he/she sustained; the Administrator, Director of Nurses (DON), Assistant DON (ADON), Rehabilitation Director, a primary care Certified Nursing Assistant (CNA) and Unit Manager (UM) #4. The following were stated relative to the above falls: The Administrator said after the first fall, the resident was given a big white helmet to wear, but it was not added to the Fall Care Plan. The Rehabilitation Director said he had been seen by therapy, but he/she was unable to be taught new things because of his/her past medical and mental history. The DON said a wheel chair with a self releasing seat belt was added as a safety intervention and the Administrator said the resident discontinued this intervention. The DON further said the self release seat belt was an intervention only used for a short time, and the facility got the resident a newer helmet that was a better fit than the first one. The DON said she was unsure if the other helmet was on at the time of the fall. The team was unsure why the Fall Care Plan indicated the helmet was not initiated until 3/3/17 because it had already been implemented after the fall of 2/24/17. Review of the a Fall/Incident Report and Investigation, dated 4/1/17, indicated the resident had a witnessed fall in the bedroom at 1:30 P.M. and was uninjured. The report indicated the resident got out of bed and fell backwards. The report did not indicate whether or not the resident had the helmet on. The report indicated the alarm was not sounding, and it had been found on the floor (he/she threw it on the floor). Review of the a Fall/Incident Report and Investigation, dated 4/11/17, indicated the resident had a witnessed fall in the bedroom at 12:45 P.M. and was uninjured. The report indicated the resident was sitting in a wheel chair prior to the fall. The report did not indicate any interventions were put in place to prevent further falls, and there were no new interventions added to the Fall Care Plan. Review of the Fall Risk Assessment, dated 4/11/17, indicated the resident remained a high fall risk as evidenced by a score of 21. Review of the a Fall/Incident Report and Investigation, dated 4/25/17, indicated the resident had a witnessed fall in the bedroom at 11:00 A.M. and was uninjured. The report indicated the resident had been in bed prior to the fall. The report indicated there was not an alarm in place at the time of the fall, and did not indicate if the resident had on the helmet. The report and the Fall Care Plan did not indicate what new interventions were added to prevent further falls. During the group staff interview with the surveyors, the following were stated relative to the 3 falls in 4/2018: The CNA said when the resident had the bed alarm he/she knew how to shut it off and could remove his/her helmet at will. The staff was unsure if the helmet was on at the time of the falls on 4/1/17 and 4/25/17, and the reports did not indicate it was. The DON said the staff should have indicated on the reports whether or not the helmet was on at the time of the falls. The ADON said the alarm was probably not on his/her bed at the time of the fall, and may have been discontinued. She was unsure why it had not been removed from the Fall Care Plan. During the group interview with the surveyors, the staff could not indicate what interventions had been added after the falls, as the some of the reports had no interventions documented on them. Review of the a Fall/Incident Report and Investigation, dated 5/15/17, indicated the resident had an unwitnessed fall in the bedroom at 11:15 A.M. and was uninjured. The report indicated he/she had been in bed prior to the fall, and indicated no alarm was on. The report did not indicate if he/she was wearing the helmet at the time of the fall. Review of a Fall Risk Assessment, dated 5/16/17, indicated the resident remained at a high fall risk as evidenced by a score of 22. Review of the a Fall/Incident Report and Investigation, dated 5/26/17, indicated the resident had an unwitnessed fall in the bedroom at 12:30 P.M. and was uninjured. The report indicated the resident was in bed prior to the fall. The report indicated his/her helmet was on, but did not indicate if a bed alarm was on. The report and the fall care plan did not indicate if new interventions were added to prevent further falls. Review of the Quarterly MDS Assessment, dated 5/27/17, indicated the resident had mild cognitive impairment as evidenced by a score of 10 on the BIMS, was independent for bed mobility, required supervision for transfers and walking, required extensive assistance with dressing and toileting, was dependent for bathing and hygiene, and 1 fall with no injuries. During the group interview with the staff and the surveyors, the following were stated relative to the 2 falls in 5/2018; The staff were unable to answer if the resident had on his/her helmet at the time of the fall on 5/11/17, and said there were no new interventions documented on the 5/27/17 fall report. Review of the a Fall/Incident Report and Investigation, dated 6/25/17, indicated the resident had a witnessed fall in the hallway at 1:30 P.M. and sustained a laceration to the right eye brow that was closed with steri strips. Review of the a Fall/Incident Report and Investigation, dated 6/26/17, indicated the resident had a witnessed fall in the hallway at 2:30 P.M. and was uninjured. The report did not indicate if the resident had on his/her helmet at the time of the fall. The report and the fall care plan did not indicate what interventions were added to prevent further falls. Review of the Fall Risk Assessment, dated 6/26/17, indicated the resident remained a high fall risk as evidenced by a score of 16. During the group interview with staff and the surveyors, the following were stated relative to the falls in 6/2017; The Director of Rehabilitation said the resident had no carryover, so all staff that knew him/her and would have to constantly reinforce for him/her to slow down the pace of walking. The staff said they were unclear if his/her helmet was on at the time of the fall on 6/26/17, and the fall report did not indicate it was. The DON said an intervention was to have the resident sit and eat a snack, however it was not added to the care plan. Review of the a Fall/Incident Report and Investigation, dated 8/16/17, indicated the resident had an unwitnessed fall in the bedroom at 1:00 P.M. and sustained a fracture to his/her left index finger. The report indicated the resident was in bed prior to the fall. The report indicated there was no alarm on, and did not indicate if the resident was wearing the helmet at the time of the fall. The new interventions included: to splint the finger, administer Tylenol for pain, and to monitor orthostatic blood pressures twice daily for 3 days. Review of the a Fall/Incident Report and Investigation, dated 8/31/17, indicated the resident had an unwitnessed fall in the doorway of the bedroom at 1:00 P.M. and was uninjured. The report indicated the resident was in bed prior to the fall, and no alarm was in place at the time of the fall. The report did not indicate if the helmet was on at the time of the fall. The new intervention added was for shoes to always be on. During the group interview with the staff and the surveyors, the following were stated relative to the fall in 8/2017; The staff could not indicate if the helmet was on at the time of either fall, and the fall reports did indicate it was. The staff said his/her finger was x-rayed, determined to be fractured and the staff splinted it. Review of the Fall Risk Assessment, dated 8/31/17 and 10/19/17 indicated the resident remained a high fall risk as evidenced by scores of 16 and 12. Review of the Fall/Incident Report and Investigation, dated 10/22/17, indicated the resident had a witnessed fall in the hallway at 3:00 P.M. and was uninjured. The report did not indicate if the helmet was on at the time of the fall. Review of the Fall Risk Assessment, dated 10/22/17, indicated the resident remained a high fall risk as evidenced by a score of 15. Review of an Admission MDS Assessment, dated 10/26/17, indicated the resident had impaired long and short term memory, had severely impaired decision making skills, required extensive assistance with bed mobility, toileting, dressing and hygiene, was a total assist for bathing, required supervision for transfers and ambulation and had 1 fall with no injury. Review of the a Fall/Incident Report and Investigation, dated 11/4/17, indicated the resident had a witnessed fall in the hallway at 1:00 P.M. and was uninjured. The report indicated that prior to the fall, the resident was lying down in bed. The report indicated no alarm was in place, and did not indicate if the helmet was on at the time of the fall. The report and the fall care plan did not indicate new interventions were added to prevent further falls. Review of the Fall Risk Assessment, dated 11/8/17, indicated the resident remained a high fall risk as evidenced by a score of 16. Review of the a Fall/Incident Report and Investigation, dated 11/25/17, indicated the resident had an unwitnessed fall in the hallway and was uninjured. During the group interview with the staff and the surveyors, the following were stated relative to the 1 fall in 10/2017 and the 2 investigated falls of 11/2017; They said the reports did not document if the helmet was on at the time of the 3 falls. The DON said there were no new interventions documented for the falls in 11/2017. She also said the fall report of 11/25/17 was incomplete. Review of a Nursing Progress note, dated 11/29/17, indicated the resident had a witnessed fall at 11:00 A.M. and was uninjured. The note indicated the resident fell to his/her knees and then into another persons wheelchair. An Accident/Incident Report and Investigation was not available for this fall. The resident was observed on 4/3/17 at 9:00 A.M., ambulating independently in the hallway. He/she appeared agitated and was yelling at staff who were trying to redirect him/her. The resident was observed multiples through out the day on 4/6/17, ambulating independently on the unit walking and was wearing non skid socks. The resident was observed yelling and screaming out at staff and other residents. During the interview with the staff, the following was also stated relative to the resident's falls; The DON said there was not an investigation for the 11/29/17 fall, and there should have been. The staff did not know of any new interventions that may have been added after this fall. The DON and the ADON both acknowledged there were a lot of questions unanswered in their investigative reports, and questions of whether the fall interventions in place were effective. The staff could not say when the bed alarm was discontinued. The staff said multiple interventions were verbally discussed however not trialed. The DON said there was no documentation of those discussed interventions. The staff said the fall care plan should have reflected the current interventions to prevent further fall. The DON said all the fall reports should have documented interventions to prevent further falls. 2. For Resident #116, the facility failed to ensure effective interventions were in place for 5 of 6 falls the resident sustained [REDACTED].>Resident #116 was admitted to the facility in 11/2015 with [DIAGNOSES REDACTED]. Review of the Resident Care Card, date initiated 5/25/16 (and last updated 1/18/18) included the following interventions: -Transfer assistance with one staff and rolling walker. -Bed mobility assistance with one staff. -Ambulation assistance with one staff and rolling walker. -Wheelchair with continued supervision. Review of the Fall Care Plan, date initiated 6/9/16, indicated the following interventions; -Provide call bell within reach. -Provide use of adaptive devices; wheel chair, walker/cane. -Remind resident and reinforce safety awareness: lock brakes on bed, chair, etc before transferring, educate/remind resident to request assistance prior to ambulation, appropriate footwear. -Provide resident/family teaching to include: safety measures to reduce fall risk and what to do if a fall occurs. Review of the Quarterly MDS Assessment, dated 2/9/17 indicated the resident had moderate cognitive impairment as evidenced by a score of 9 on the BIMS, required limited assistance with bed mobility, transfers, walking, dressing and hygiene, required extensive assistance with toileting and bathing and had no falls. Review of a Fall Risk Evaluation, dated 2/11/17, indicated a score of 16. A score of 10 or greater indicated the resident was a high fall risk. Review of an Accident/Incident Report and Investigation, dated 2/11/17, indicated the resident had an unwitnessed fall in the bedroom at 8:45 A.M. and sustained a hematoma (bruise) to the left forehead. The report indicated that prior to the fall, the resident was sitting in the wheel chair. The resident reached over to pick up something from the floor, and fell from the wheel chair. The new intervention added was to encourage him/her to ask for help when something is on the floor. Review of the Quarterly MDS Assessment, dated 5/11/17, indicated the resident had cognitive severe impairment as evidenced by a score of 7 on the BIMS, was independent with bed mobility and transfers, require limited assistance with walking and hygiene, required extensive assistance with toileting and bathing and had one fall with no injuries. Review of the Fall Risk Evaluation, dated 7/1/17, indicated the resident remained a high fall risk by evidence of a score of 12. Review of an Accident/Incident Report and Investigation, dated 7/16/17, indicated the resident had an unwitnessed fall in the bedroom at 7:00 P.M. and was uninjured. The report indicated the resident was in the wheel chair prior to the fall. The resident attempted to self transfer to the bathroom and slid out of the chair to the floor. The report did not indicate if the wheel chair brakes were locked. The new intervention was to educate the resident to call for help before getting out of the chair to go to the bathroom. Review of the Quarterly MDS Assessment, dated 8/8/17 indicated the resident had cognitive severe impairment as evidenced by a score of 7 on the BIMS, was independent with bed mobility, required limited assistance with walking and hygiene, required extensive assistance with transfers, walking, dressing, toileting, hygiene and bathing and had no falls. Review of an Accident/Incident Report and Investigation, dated 8/29/17, indicated the resident had a witnessed fall in the shower room at 12:20 P.M. Review of the Fall Risk Evaluation, dated 11/3/17, indicated the resident remained a high fall risk by evidence of a score of 14. Review of an Accident/Incident Report and Investigation, dated 11/9/17, indicated the resident had an unwitnessed fall in the bedroom at 9:15 A.M. and complained of left hip pain. The resident was transferred to the hospital for an evaluation and later returned. The report indicated that the resident was in bed prior to the fall. The resident self transferred out of bed, ambulated to the bathroom and fell . The new intervention add was to re-educate the resident to request assistance and on safe ambulation. Review of the Significant Change in Status MDS Assessment, dated 11/19/17, indicated the resident had moderate cognitive impairment as evidenced by a score of 8 on the BIMS, required extensive assistance with bed mobility, transfers, ambulation, dressing, toileting and hygiene, was totally dependent for bathing and had 1 fall with injury (not major). Review of the Fall Risk Assessment, dated 12/20/17, indicated the resident was a high fall risk as evidenced by a score of 22. Review of an Accident/Incident Report and Investigation, dated 12/20/17, indicated the resident had an unwitnessed fall in the bedroom at 3:00 A.M. and was uninjured. The report indicated the resident was in the wheel chair watching television prior to the fall. The resident fell from the wheel chair. The report did not indicate if the wheel chair brakes were locked. The new intervention added was to educate the resident to call for help. Review of the Fall Risk Evaluation, dated 1/16/18, indicated the resident remained a high fall risk by evidence of a score of 17. Review of an Accident/Incident Report and Investigation, dated 1/24/18, indicated the resident had an unwitnessed fall in the bedroom at 2:00 A.M. and was uninjured. The report indicated the resident was sitting in the wheel chair. The resident self transferred from the chair, ambulated to the bathroom and fell . The report did not indicate if the wheel chair brakes were locked. The new interventions added were to remind the resident to call for help and toilet every 2 hours, and as needed. During an observation on 4/03/18 at 9:53 A.M., the resident was in a low bed, with half side rails up on either side of the bed. The resident appeared to be sleeping. During an observation on 4/10/18 at 9:54 A.M., the resident was lying in bed, wearing oxygen via nasal cannula. The bed was in a low position, the side rails were up, and the resident appeared to be sleeping. During an interview on 4/10/18 at 1:30 P.M, UM #4 said the resident makes her own choices and moves freely around the unit in her wheel chair when he/she is out of bed. During an interview on 4/10/18 at 1:43 P.M., UM #4 she said there could have been more effective fall intervention besides just educating the resident to call for help after each of his/her falls. She said the resident continued to fall after being educated. 3. For Resident #111 the facility staff failed to provide continual supervision to ensure smoking safety. Resident #111 was admitted to the facility in 4/2016 with [DIAGNOSES REDACTED]. Review of the facility Smoking policy, dated 12/2016, indicated the following: -the facility to provide a healthy and safe environment for residents .by limiting the use of tobacco smoking materials -residents who smoke will be evaluated for their ability to smoke safely upon admission, quarterly and as dictated by any significant change in condition, to ensure that they continue to be capable of smoking and use smoking materials without presenting a danger to themselves or others. -smoking will take place under the supervision of a staff member Review of the Smoking Evaluation and Safety Screen, dated 2/14/18, indicated Resident #111 was able to hold a cigarette and dispose of ashes and cigarette into an ash tray. The evaluation indicated the resident was to have routine supervision during scheduled smoking activities. Review of the Annual MDS Assessment, dated 2/20/18, indicated Resident #111 had severe cognitive impairment as indicated by staff interview. Review of the Smoking care plan, revised 3/25/18, indicated the resident was to have continual supervision when smoking. The interventions included: monitor the resident's safety during smoking. During an interview and observation on 4/3/18 at 11:05 A.M., Resident #111 was lying in bed, was dressed, and had sneakers on both his/her feet. The surveyor observed a circular hole on the top of the resident's right sneaker. Resident #111 said he/she thinks the hole is from a cigarette. Resident #111 said he/she goes out for scheduled smoke breaks. He/she further said that he/she is able to smoke independently and that facility staff mostly supervise the breaks but sometimes they don't. The surveyor observed the resident's left hand to be shaking during the interview. On 4/03/18 at 3:48 P.M.- 3:58 P.M., the surveyor observed CNA #17 lighting the resident cigarettes while on the patio outside of the dining room on the Tatnuck unit during a scheduled smoking time. The surveyor observed the door to the outside patio was open, and that four residents who are not smoking were present in dining room. The surveyor observed and smelled smoke inside the dining room during this time. After lighting the resident cigarettes, CNA #17 was observed to re-enter the dining room, while several residents, including Resident #111 were still outside smoking. CNA #17 was observed to converse with another resident who was ambulating in the dining room area. There were no other facility staff members outside supervising the smoking time at the time of this observation. On 4/06/18 at 9:36 A.M., the surveyor observed Resident # 111 on the patio off the Tatnuck dining room, smoking with other residents. The surveyor observed Resident #111 seated in a wheel chair near the door way to the dining room. A facility staff member was observed to give Resident #111 a cigarette, and lit the cigarette. The surveyor observed the facility staff member remained outside during the smoke break while Resident #111 was smoking. The surveyor observed Resident #111 discard cigarette ashes in front of his/her wheel chair near his/her shoes which were positioned in front of him/her. During this observation, the surveyor observed Resident #111 discard ashes onto his/her pants and then brushed them off onto the ground. The surveyor observed there was one cigarette ash dispenser which was not within reach of Resident #111. On 4/06/18 at 10:07 A.M., CNA # 6 said all resident that smoke are supervised on the patio. She said the facility staff are supposed to stay on the patio with the residents, and are they are not supposed to be in the dining room. CNA #6 said the role of the smoking CNA is to light the resident's cigarettes and monitor the residents safety and behaviors with other residents during smoking. CNA #6 said if staff notice the residents are not holding the cigarettes well, for example if they are shaking, or if they are coughing while smoking, they would let the nurse know. She said if burn holes were noted in the clothing or shoes, they would notify the nursing staff. On 4/06/18 at 10:12 A.M. UM #1 said smoking evaluation are completed every three months unless there is a significant change in the resident's status. She said that all residents are considered supervised smokers as long as they feel sensation in their hands, can hold cigarettes without tremors or [MEDICAL CONDITION] in their hands. She said if a concern with safety is identified, interventions will be added. UM #1 said if staff see that there are burn holes in the resident's clothes and/or shoes, the facility will investigate. She said facility staff are supposed to be outside with the residents during the smoking breaks to observe/monitor the resident's safety during the smoking time. She said the staff observe residents with any difficulties while smoking, and if they did observe a concern, they would report this concern to nursing to further evaluate the resident's safety. She said that the staff are to remain outside on the patio while residents are smoking, and are not to be in the Tatnuck dining area. During a follow up interview on 04/06/18 at 11:01 A.M., UM #1 said the facility had two ash receptacles on the patio outside of Tatnuck, but one was removed. She said the current smoking evaluation is not accurate regarding the disposing of ashes into the ash tray since there is only one receptacle. She said she thought that the ashes would blow away from the residents while smoking outside since not all of the residents are close to the ash receptacle to use it. She said if she saw the resident putting ash on his/her lap while smoking, she would be concerned about his/her safety while smoking. 4. For Resident #133, the facility staff failed to ensure the safety during transport via a wheel chair. Resident #133 was admitted to the facility in 4/2016 with [DIAGNOSES REDACTED]. Review of the Significant Change in Status MDS Assessment, dated 3/1/18, indicated Resident #133 exhibited severe cognitive as per staff assessment, required extensive assistance of 1 staff for locomotion on the unit, and utilized a wheelchair. Review of a nurse's progress note, dated 3/6/18, indicated at 4:50 P.M., Resident #133 requested for his/her roommate to bring him/her to the dining room for dinner. The progress indicated that while being assisted by the roommate, Resident #133's foot hit the floor resulting in a fall out of the wheel chair, landing on his/her face. Resident #133 had a bloody nose which lasted approximately 10-15 minutes, an ecchymotic (reddened area) above the bridge of his/her nose, and a hematoma ( a collection of blood) on his/her forehead. The Physician was updated, and the resident was sent to the hospital for evaluation. Review of the facility investigation, dated 3/6/18, indicated Nurse #5 observed both residents pass by him/her going towards the dining room. Nurse #5 indicated on the investigation statement that he/she reminded the roommate not to push Resident #133 in the wheel chair. Nurse #5 indicated in the statement that about 10 minutes later, a loud sound was heard and he/she saw Resident #133 on the floor on his/her stomach. Further review of the investigation included a behavior care plan, updated 2/2018, for the roommate, which indicated he/she pushes other residents in their wheel chairs. The interventions included for staff to intervene as needed to protect the rights and safety of others, and to remove from the situation and take to another location as needed. The intervention added at this time included to educate both residents to ask staff for assistance and not have other residents assist with wheel chair transport. On 4/03/18 at 11:49 A.M., the surveyor observed Resident # 133 seated in a wheel chair in the doorway to his/her room. The resident was dressed, had on non-skid socks and shoes in place. During an interview on 4/06/18 at 11:11 A.M., Unit Manager (UM) #1 said Resident #133's roommate will push him/her in the wheel chair and requires constant re-direction and re-education from staff to not push other residents in their wheel chairs. UM #1 said when staff see this occurring, they are to stop the residents, re-direct and supervise the residents to ensure they get to their destination safely. UM #1 said facility staff did not supervise Resident #133 to make sure that he/she reached the dining room safely. She further said it's the facility policy to not push a resident in a wheelchair without leg rests on. 5. For Resident #349, the facility staff failed to provide assistance of two staff with transfers, resulting in a fall. Resident #349 was admitted to the facility in 3/2018 with [DIAGNOSES REDACTED]. Review of the Resident Care Card, dated 3/12/18, indicated the resident required assistance of two staff with transfers using a slide board (a piece of equipment used for transferring). Review of the Impaired Functional Mobility care plan, revised 3/23/18, indicated Resident #349 required physical assist of two staff members for transfers. Review of the nurse progress note, dated 3/25/18, indicated Resident #349 was lowered to the ground during a transfer from the bed to the wheel chair using the slide board and with staff assistance. Review of the facility investigation, dated 3/25/18, indicated the resident experienced a fall at 1:00 P.M. with no injury. The report indicated the fall was witnessed by CNA #16. The interventions added at the time of the fall included: staff re-training. On 04/11/18 at 8:20 A.M., the surveyor observed Resident # 349 self propelling in his/her electric wheel chair down the hallway. The resident was dressed and said good morning to this surveyor upon passing in the hallway. During an interview on 4/11/18 at 11:00 A.M., CNA #11 said Resident #349 required at least two staff with transfers. During an interview on 4/11/18 at 1:30 P.M., UM #5 said during the fall on 3/25/18 the resident was not assisted by two staff during the transfer as he/she should have been. She further said that one staff member assisted R (TRUNCATED)

Based on observations, interviews and record reviews, the facility staff failed to ensure Physician prescribed nutrition interventions were implemented for 2 sampled residents (#114 and #64), in a total of 38 sampled residents. Findings include: 1. For Resident #114, the facility staff failed to ensure a Physician's prescribed nutritional supplements were administered as ordered, resulting in continued unplanned weight decline. Review of the facility Food First Nutrition policy, dated 8/2015, indicated the following: - facility staff will identify residents at risk for weight loss and provide appropriate interventions - monitoring and evaluation by administrative staff to ensure positive outcomes - all residents with a significant weight loss are reviewed by the Interdisciplinary team interventions implemented as appropriate and are monitored weekly - supplements, when recommended by the Dietitian and ordered by the Physician are documented by the licensed nurse on the Medication Administration Record (MAR) Resident #114 was admitted to the facility in 3/2012 with [DIAGNOSES REDACTED]. a. Review of the Nurse's Progress Note, dated 1/26/18 at 12:26 A.M., indicated Resident #114 was admitted back to the facility after a hospitalization for septic shock secondary to hospital acquired pneumonia. Review of the Nutrition care plan, revised on 1/26/18, indicated the resident was at risk for nutritional decline related to difficulty swallowing, restrictive or mechanically altered diet, variable intake of food/beverages, and recent hospitalization with a noted decline. The goals identified included: weight at 164 pounds (plus or minus 4 pounds), and average of 75% of food/beverages taken at meals. The interventions included the following: monitor intake, monitor weight changes, and provide meals as ordered by the physician. Review of the Monthly Weight Report, dated 1/2018, indicated Resident #114 weighed 167.6 pounds. Review of the Dietitian Progress Note, dated 1/31/18, indicated Resident #114 had variable intake of food/fluids, and experienced a diet downgrade since readmitted from the hospital. The note indicated that the resident required total assistance with meals, and that his/her weight had been stable in the past month. The plan indicated in the progress note was to continue with the current plan of care, monitor weights, and intake. Review of the Significant Change in Status Minimum Data Set (MDS) Assessment, dated 2/8/18, indicated Resident #114 exhibited moderate cognitive impairment (with a score of 11 out of 15 on the BIMS = Brief Interview of Mental Status exam), required extensive assistance of one staff with eating, had a significant weight loss of 5% or more in the last month or 10% or more in the last 6 months and was not on a physician prescribed weight loss regimen, was on a mechanically and therapeutically altered diet, and received Speech Language Pathology services during the assessment period. Review of Monthly Weight Report, dated 2/2018, indicated Resident #114 weighed 150.4 pounds (>10% weight decline in a period of one month). Review of the Dietitian Progress Note, dated 2/9/18, indicated Resident #114 continued with variable intake with meals, and required extensive assistance with meals. The note indicated the resident experienced a significant weight loss of 10.5% in the past month which was attributed to the hospitalization . The plan indicated in the progress note was to continue with the current plan of care, monitor weights, lab work and intake. Review of the Physician's Telephone Order, dated 2/23/18, indicate an order for [REDACTED]. Review of the Medication Administration Record (MAR), dated 2/2018, indicated a handwritten order dated 2/23/18 to administer Magic Cup twice daily, and Mighty Shakes at lunch. Further review of the MAR indicated the Magic Cup was administered 8 out of 10 times, and the Mighty Shake was administered 4 out of the 5 times. Review of the Dietitian Progress Note, dated 2/27/17, indicated Resident #114 was consuming 25-75% of meals, and required extensive assistance with meals. The plan indicated in the progress note was to continue with the plan of care, monitor weights, lab work and intake. Review of the MAR, dated 3/2018, did not indicate an order to administer Magic Cup or Mighty shakes. Review of the Monthly Weight Report, dated 3/2018, indicated Resident #114 was 143.0 pounds (>10% weight loss in two months). Review of the Dietitian Progress Note, dated 3/23/18, indicated Resident #114 continued with variable meal intakes, and frequently was not receiving the Magic Cups and the Mighty Shakes as ordered. The Dietitian indicated in the progress note that the issue was now resolved. The note further indicated that the resident's weight continues to decline significantly. The plan includes to monitor the resident's weights, intake, lab work, and to continue with Magic Cups and Mighty Shakes. Review of the Physician's Telephone Orders, dated 4/10/18 at 10:00 A.M., indicated to administer Med Pass 4 ounces by mouth three times daily. Review of the MAR, dated 4/2018, indicated Med Pass was administered 1 of 5 times since the order was obtained. Further review of the MAR, did not indicate orders to administer Magic Cup or Mighty Shakes. Review of the Monthly Weight Report, dated 4/2018, indicated Resident #114 weighed 142.5 pounds (>10% weight loss in three months). On 4/12/18 at 9:01 A.M., the surveyor observed Resident # 114 seated in a stationary chair in the dining room for breakfast. Certified Nurse Aide (CNA) #15 prepared resident's breakfast tray and brought it to the resident. The surveyor observed the breakfast tray did not contain a Magic Cup supplement. During an interview on 4/12/18 at 10:26 A.M., Nurse #4 said Resident #114 was just put on a nutritional supplement called Med Pass on 4/11/18. She said nursing provides nutritional supplements like Boost, Ensure and Med Pass, while the kitchen provides the Mighty Shakes and nutritional ice creams (Magic Cups). During an interview on 4/12/18 at 10:32 A.M., Dietary Staff #1 said that special items like Mighty Shakes and Magic Cups are printed on the resident meal tickets. Review of Resident #114 meal tickets for 4/13/18 breakfast, lunch and dinner, with Dietary Aide #2, did not indicate Magic Cup or Mighty Shake nutritional supplements were to be given. She said special items like these would printed on the resident meal tickets. During an interview on 4/12/18 at 12:09 P.M., Unit Manager (UM) #4 said the current Physician's order does not include the interventions (Mighty Shakes and Magic Cup) that the dietitian had recommended. She said that those interventions should be on the current Physician's Orders and given as ordered. She further said those nutritional supplements would come with the resident meal trays from the kitchen, but they have not been. 2. For Resident #64, the facility staff failed to ensure a therapeutic diet was administered as originally ordered by the Physician and as recommended by the Dietitian. Review of the facility Fluid Restriction policy, dated 4/2015, indicated the following: -restricted fluid intake will be maintained for an individual resident, as ordered by the physician -there must be a physician order specifying the amount of the restriction per 24 hours -the fluid restriction breakdown should be documented on the Medication Administration Record, as well as the dietary or tray card -maintain accurate intake and output -communicate to relevant staff members, the resident, as appropriate and family/visitors about the restricted fluids intake. -document .the resident's compliance with the fluid restriction and notify the physician if any issues Review of the Physician's Orders, dated 7/2017, indicated to administer the following diet order: regular, regular texture with thin liquids, oatmeal with breakfast daily, mashed potatoes with lunch/dinner, all meals in the dining room, cue and encourage resident to eat meats especially the protein (meat) portion of the meal (initiated 11/23/16). The order also included a 1500 milliliter (ml)/ day Fluid Restriction, with 360 ml given at breakfast, 240 ml given at lunch and dinner. Review of the Nutrition at Risk care plan, reviewed 12/11/17, indicated Resident #64 was on a restrictive or mechanically altered diet, and a F.R. (fluid restriction). The interventions included in the plan of care at this time included: provide meals as per the Physician's diet order. encourage/provide intake of fluids throughout the day and monitor/evaluate energy intake via meal intake records and observation. Review of the [MEDICAL TREATMENT]/[MEDICAL CONDITION] care plan, reviewed 1/30/18, included the following interventions: 1500 ml Fluid Restriction, and monitor intake and output. Review of the Physician's Orders, dated 1/2018 and signed by the Physician on 1/30/18, did not indicate a diet order for Resident #64. Further review of the Physician's Orders did not indicate Resident #64 was on a fluid restriction. Review of the Resident Care Card, revised 1/30/18, indicated Resident #64 was on a Renal, NCS (No Concentrated Sweets) Diabetic diet, regular consistency with moist ground meat sandwiches, 1/2 teaspoon bites, thin liquids and 1500 ml Fluid Restriction/24 hours. Review of the Physician's Orders, dated 2/2018, did not indicate a diet order for Resident #64, and did not indicate an order to administer a fluid restriction. Review of the MAR, dated 2/2018, indicated the nursing staff signed off the blank diet order was administered from 2/01/18 through 2/27/18. Review of the Physician's Orders, dated 3/2018, did not indicate a diet order for Resident #64, and did not indicate an order to administer a fluid restriction. Review of the MAR, dated 3/2018, indicated the diet was left blank. Further review of the MAR was blank under the administration of the diet. Review of the Physician's Orders, dated 4/2018, did not indicate a diet order for Resident #64, and did not indicate an order to administer a fluid restriction. Review of the MAR, dated 4/2018, indicated the nursing staff signed off the blank diet order as administered from 4/01/18 through 4/10/18. Review of the lunch meal ticket, dated 4/10/18, indicated the following diet order: Regular House, Nectar thick liquids, with one puree item on every meal tray. There was no indication Resident #64 was on a modified/restricted diet. Further review of the lunch ticket indicated the resident was to be given 4 oz nectar thick milk, 8 oz whole milk and 8 oz coffee (indicating a total of 600 ml of fluid.) During an interview on 4/10/18 at 12:08 P.M., UM #1 said Resident #64 is on a diabetic diet with a 1500 ml fluid restriction because he/she is on [MEDICAL TREATMENT]. She said he/she eats a regular texture diet and thin liquids. UM #1 said the nursing staff sign off in the MAR for the percentage of the meal taken, and that Resident #64 only receives a certain amount on his/her meal trays because of the fluid restriction. UM #1 further said that Resident #64 is allowed two cups of ice daily and sips of liquids with medications, and that she is not sure if resident is currently on intake and output monitoring. UM #1 said the resident only receives liquids with meal trays and can have two cups of ice daily. During an interview on 4/10/18 at 12:21 P.M., Nurse #2 said Resident #64 is on a [MEDICAL TREATMENT] diet which is low potassium. She said Resident #64 is also on a 1200 ml fluid restriction daily. Nurse #2 said Resident #64 does not really take much fluids with his/her medications, but when he/she requests water- he/she is given water. Nurse #2 said she gives Resident #64 half of a 7 oz cup of fluids with his/her medications, and that the MAR indicates how much Resident #64 is supposed to have daily for fluids. During an interview on 4/10/18 at 12:34 P.M., CNA #6 said she set up lunch for Resident #64 today. She said the resident is on a regular diet with thickened liquids. Surveyor reviewed the resident tray ticket with CNA #6, which indicated a regular house diet with nectar thick liquids, and puree items with each meal. CNA #6 did not indicate Resident #64 was on a restricted diet of any kind. On 4/11/18 at 8:48 A.M., the surveyor observed Resident # 64 seated in the day room with his/her breakfast tray. Upon review of the resident's breakfast ticket, the surveyor observed the diet indicated the resident was on a regular house diet with puree items on each tray and nectar thick liquids. There was no indication on tray ticket that Resident #64 was on a fluid restriction. Resident #64 was observed to have 8 oz nectar thick milk, cup of coffee, and a cup of orange juice on his/her meal tray. During an interview on 4/11/18 at 11:55 A.M., UM #1 said that she updated the Physician about Resident #64's diet order and fluid restriction. She said there was no monitoring of the fluid restriction at this time, and that she met with the Food Service Director and the Dietitian today regarding the resident's diet. UM #1 said the resident's diet should be Diabetic, Renal, Regular consistency with thin liquids and 1500 ml fluid restriction daily. During an interview on 4/11/18 at 12:10 P.M., the Dietitian said she was made aware of diet order issues today. She said Resident #64 should be on a 1500 ml fluid restriction/day, diabetic, renal diet. The dietitian said a communication slip never came down to the kitchen to notify the kitchen of a diet order change. She was unable to tell the surveyor how long the resident has been receiving the incorrect diet order. Please refer to F 698

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #2), the facility failed to notify Resident #2's Physician and Invoked Health Care Proxy when Resident #2 became agitated in the middle of the night, was handcuffed behind his/her back by Security Guard #1, when he/she was on the floor, on his/her stomach, and Nurse #2 administered IM (intramuscularly) [MEDICATION NAME] (a sedative), even though Resident #2 asked them to stop and told them they were not allowed to do this or words to that effect. Findings include: The Facility Policy titled Condition: Significant Change, dated April 2015, indicated the physician, resident/patient and/or responsible party will be notified by the nurse in the event of a change in condition. Resident #2's [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS), dated [DATE], indicated during a Brief Interview of Mental Status (BIMS) scored 12 (scale is 0-15), which indicated he/she had moderate cognitive impairment, and had an Invoked Health Care Proxy. The Medication Administration Record, [REDACTED].M. for increased agitation with positive effect. A Nurse's Progress Note, dated 9/12/16, indicated Resident #2 became agitated and threatened to hit Certified Nursing Assistant (CNA) #1 and break windows when CNA #1 did not give Resident #2 water without thickener (a substance used to increase the viscosity of a liquid) when he/she demanded. Resident #2, (who is a bilateral below the knee [MEDICAL CONDITION]), slid him/her self to the floor and proceeded to throw items from the storage container at CNA #1 and at the windows. Resident #2 asked to speak with Security Guard #1, then threatened Security Guard #1 when the conversation did not go his/her way. Nurse #2 documented in the Progress Note, that she could give Resident #2 IM [MEDICATION NAME] if she could get near him/her. Nurse #2 documented that Security Guard #1 placed Resident #2 in handcuffs and she administered the IM [MEDICATION NAME] to Resident #2. Resident #2 began to calm down after five minutes. There is no documentation to indicate Resident #2's Physician or Invoked Health Care Proxy was notified. Physician Order's, dated 12/4/14, indicated Residents #2 was on nectar thick liquids. The Surveyor interviewed the Director of Nurses (DNS) at 12:06 P.M. on 10/28/16 and at 10:28 A.M. on 11/4/16. The DNS said Nurse #2 said she did not notify the Physician and Invoked Health Care Proxy of the incident. The DNS said she notified the Physician on 9/12/16 at approximately 10:30 A.M. The Surveyor interviewed the Director of Social Services at 1:13 P.M. on 11/4/16. The Director of Social Services said she notified the Invoked Health Care Proxy of the incident on 9/13/16. The Accident/Incident Report, dated 9/12/16, indicated Resident #2 was restrained in order to administer the IM [MEDICATION NAME] order. The Physician and Responsible Party Time Notified were blank. The Facility Investigation Statement from Nurse #2, dated 9/12/16, indicated Resident #2's Physician and Invoked Health Care Proxy were not notified. The Medical Director was notified of the incident by the Director of Nurses on 9/12/16. The contracted Central Security President was notified of the incident by the Administrator on 9/12/16. Although Resident's cognitive and communication deficits limited his/her ability to understand and communicate the impact of having been administered medications while handcuffed, an unimpaired individual would experience mental anguish when administered medications while handcuffed.

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #2), the facility failed to prevent Resident #2 from being physically restrained, without a Physician's order and consent, in the middle of the night, when Security Guard #1 handcuffed Resident #2 behind his/her back, when he/she was on his/her stomach, on the floor. Findings include: The Facility Policy titled Restraint Management, dated July 2015, indicated no restraint may be applied unless there is a specific physician order and the resident, family member or legal representative will be notified and exercise the right to refuse or accept the restraint. Resident #2's [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS), dated [DATE], indicated during a Brief Interview of Mental Status (BIMS) scored 12 (scale is 0-15), which indicated he/she had moderate cognitive impairment, and had an Invoked Health Care Proxy. A Nurse's Progress Note, dated 9/12/16, indicated Resident #2 became agitated and threatened to hit Certified Nursing Assistant (CNA) #1 and break windows when CNA #1 did not give Resident #2 water without thickener (a substance used to increase the viscosity of a liquid) when he/she demanded. Nurse #2 documented in the Progress Note, she could give Resident #2 IM [MEDICATION NAME] if she could get near him/her. Nurse #2 documented that Security Guard #1 placed Resident #2 in handcuffs and she administered the IM [MEDICATION NAME] to Resident #2. The surveyor interviewed Nurse #2 at 11:50 A.M. on 10/31/16. Nurse #2 said Resident #2 became agitated when he/she could not have water without thickener. Resident #2 threatened to throw his television at the window. Resident #2 then put him/her self on the floor and proceeded to throw items out of his/her storage bins into the hallway and at the window. Nurse #2 said she told Security Guard #1 that she could give Resident #2 IM [MEDICATION NAME] if she could just get near him/her. Nurse #2 said Security Guard #1 placed Resident #2 in handcuffs and she administered Resident #2 IM [MEDICATION NAME]. Nurse #2 said she did not notify the Physician or Invoked Health Care Proxy. The surveyor interviewed Security Guard #1 at 3:14 P.M. on 11/10/16. Security Guard #1 said Nurse #2 asked him to restrain Resident #2 with his handcuffs so she could administer a sedative to Resident #2 because he/she was threatening and throwing items at staff. Security Guard #1 said, with the assistance of CNA #1, he rolled Resident #2 onto his/her stomach on the floor and handcuffed Resident #2 behind his/her back. Security Guard #1 said Nurse #2 then administered an injection to Resident #2. The Surveyor interviewed Social Worker #1 at 1:34 P.M. on 11/4/16. Social Worker #1 said she spoke with Resident #2 after the incident. Resident #2 said Nurse #2 came in to his/her room with Security Guard #1. Security Guard #1 placed Resident #2 in handcuffs behind his/her back while he/she was on his/her stomach on the floor. Social Worker #1 said Resident #2 said he/she was in pain from the handcuffs, and that he/she told Nurse #2 and Security Guard #1 to stop, that they were not allowed to do this, but they did not. Review of the clinical record indicated there was no Physician Order to physically restraint Resident #2. The Accident/Incident Report, dated 9/12/16, indicated Resident #2 was restrained in order to administer the IM [MEDICATION NAME] order. Central Security Incident Report, dated 9/12/16, indicated Nurse #2 asked Security Guard #1 to restrain Resident #2 with handcuffs so she could administer a sedative. Security Guard #1, with the assistance of CNA #1, rolled Resident #2 onto his/her stomach, while he/she was on the floor, and placed Resident #2 in handcuffs. Nurse #2 then administered the sedative. The Medical Director was notified of the incident by the Director of Nurses on 9/12/16. The contracted Central Security President was notified of the incident by the Administrator on 9/12/16. Although Resident's cognitive and communication deficits limited his/her ability to understand and communicate the impact of having been administered medications while handcuffed, an unimpaired individual would experience mental anguish when administered medications while handcuffed.

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #2), the facility failed to prevent Resident #2 from being chemically restrained in the middle of the night, when Security Guard #1 handcuffed Resident #2 behind his/her back, when he/she was on his/her stomach, on the floor, and Nurse #2 administered IM (intramuscularly) [MEDICATION NAME] (a sedative) to Resident #2, after Resident #2 had refused to take the PO (by mouth) [MEDICATION NAME] and asked them to stop and told them they were not allowed to do this. Findings include: The Facility Policy titled Restraint Management, dated July 2015, indicated no restraint may be applied unless there is a specific physician order [REDACTED]. Resident #2's [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS), dated [DATE], indicated during a Brief Interview of Mental Status (BIMS) scored 12 (scale is 0-15), which indicated he/she had moderate cognitive impairment, and had an Invoked Health Care Proxy. The Physician Orders, dated September 2016, indicated an order for [REDACTED]. The Medication Administration Record, [REDACTED].M. for increased agitation with positive effect. A Nurse's Progress Note, dated 9/12/16, indicated Resident #2 became agitated and threatened to hit Certified Nursing Assistant (CNA) #1 and break windows when CNA #1 did not give Resident #2 water without thickener (a substance used to increase the viscosity of a liquid) when he/she demanded. Nurse #2 documented in the Progress Note, she could give Resident #2 IM [MEDICATION NAME] if she could get near him/her. Nurse #2 documented that Security Guard #1 placed Resident #2 in handcuffs and she administered the IM [MEDICATION NAME] to Resident #2. Resident #2 began to calm down after five minutes. The surveyor interviewed Nurse #2 at 11:50 A.M. on 10/31/16. Nurse #2 said Resident #2 became agitated when he/she could not have water without thickener. Resident #2 threatened to throw his television at the window. Nurse #2 said she offered Resident #2 PO (by mouth) [MEDICATION NAME] but he/she refused. Resident #2 then put him/her self on the floor and proceeded to throw items out of his/her storage bins into the hallway and at the window. Nurse #2 said she told Security Guard #1 that she could give Resident #2 IM [MEDICATION NAME] if she could just get near him/her. Nurse #2 said Security Guard #1 placed Resident #2 in handcuffs and she administered Resident #2 IM [MEDICATION NAME]. Nurse #2 said she did not call the Physician or Invoked Health Care Proxy. The surveyor interviewed Security Guard #1 at 3:14 P.M. on 11/10/16. Security Guard #1 said Nurse #2 asked him to restrain Resident #2 with his handcuffs so she could administer a sedative to Resident #2 because he/she was threatening and throwing items at staff. Security Guard #1 said, with the assistance of CNA #1, he rolled Resident #2 onto his/her stomach on the floor and handcuffed Resident #2 behind his/her back. Security Guard #1 said Nurse #2 then administered an injection to Resident #2. The Surveyor interviewed Social Worker #1 at 1:34 P.M. on 11/4/16. Social Worker #1 said she spoke with Resident #2 after the incident. Resident #2 said Nurse #2 came in to his/her room with Security Guard #1 and he placed Resident #2 in handcuffs behind his/her back while on his/her stomach on the floor. Social Worker #1 said Resident #2 said he/she was in pain from the handcuffs and that he/she told Nurse #2 and Security Guard #1 to stop, that they were not allowed to do this, but they did not. The Accident/Incident Report, dated 9/12/16, indicated Resident #2 was restrained in order to administer the IM [MEDICATION NAME] order. Central Security Incident Report, dated 9/12/16, indicated Nurse #2 asked Security Guard #1 to restrain Resident #2 with handcuffs so she could administer a sedative. Security Guard #1, with the assistance of CNA #1, rolled Resident #2 onto his/her stomach, while he/she was on the floor, and placed Resident #2 in handcuffs. Nurse #2 then administered the sedative. The Medical Director was notified of the incident by the Director of Nurses on 9/12/16. The contracted Central Security President was notified of the incident by the Administrator on 9/12/16. Although Resident's cognitive and communication deficits limited his/her ability to understand and communicate the impact of having been administered medications while handcuffed, an unimpaired individual would experience mental anguish when administered medications while handcuffed.

Based on records reviewed, interviews, and observation the Facility failed for 7 of 8 residents, (Resident #3, Resident #5, Resident #7, Resident #8, Resident #9, Resident #10 and Resident #11), with substance abuse/use, issues to ensure each resident received a comprehensive medical and interdisciplinary evaluation to determine the severity of the issue, develop treatment priorities; failed to determine each resident's immediate psychiatric and/or substance abuse care needs, evaluate their risks, and strengths; identify all appropriate [DIAGNOSES REDACTED]. The facility failed to assess residents to determine those residents at risk for relapse, the level of supervision necessary, and failed to ensure they could provide the level of services necessary to provide the least restrictive but safe level of care to residents with substance abuse/use disorders or addiction prior to admitting residents with this need. The Facility failed to ensure they provided adequate numbers of qualified competent staff to ensure staff had knowledge and expertise in caring for residents with substance abuse/use or addiction. -On [DATE], Resident #3, who had a known history of intravenous drug use, was found using a [MEDICATION NAME] needle to inject an unknown substance into his/her vein; Resident #3 said it was [MEDICATION NAME] (opioid narcotic medication). The [MEDICATION NAME] needle was not a brand used by the Facility and upon further inspection, the nurse observed additional drug paraphernalia in Resident #3's room, which was later confiscated by the police department. Although Resident #3 was actively using intravenous drugs in the Facility, there was no effort by the Facility to evaluate Resident #3's drug use, risks to self, considered the Facility's abilities or inabilities to provide Resident #3 with the safest setting to meet his/her health care needs, including active substance abuse/use or addiction. There was no indication a comprehensive medical evaluation by a qualified addiction specialist was performed following the [DATE] incident. Although the Physician's Progress Notes dated [DATE], [DATE], [DATE], [DATE], and [DATE] indicated Resident #3 was examined by a physician on these dates, the notes contained no documentation to indicate that the physician was notified or aware of Resident #3 being found with a [MEDICATION NAME] needle in his/her arm on [DATE] or related to active substance abuse/use. -Resident #5 was admitted during [DATE] from an emergency department, after being found using illicit drugs at another skilled nursing facility who refused to allow Resident #5 to return. The emergency department record indicated Resident #5's physical examination indicated he/she was an active substance abuse/user. There was no comprehensive assessment of Resident #5's needs related to substance abuse/use or addition. On [DATE], Resident #5 was found unresponsive and required emergent treatment, which included the use of [MEDICATION NAME] (opioid antagonist used to immediately reverse the symptoms of drug overdose); Resident #5 informed the emergency department staff he/she had injected heroine into his/her peripherally inserted central catheter (PICC) prior to becoming unresponsive. Findings include: 1. There was no documentation at the time of survey that addiction services were offered or provided to address Resident #3's history of or current substance abuse. Resident #3 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. The Nurse's Progress Note dated [DATE] for the 11:00 P.M. to 7:00 A.M. shift indicated that at 2:00 A.M., Resident #3 requested pain medication, and was administered 20 milligrams (mg) of [MEDICATION NAME]. The note indicated that Nurse #11 watched Resident #3 put the medication in his/her mouth and swallow a sip of coffee. The note indicated that approximately 20 minutes later, Nurse #11 entered Resident #3's room and observed him/her sitting in front of the bedside table with a [MEDICATION NAME] needle in his/her right antecubital vein (vein at the inner elbow). The note indicated that the [MEDICATION NAME] needle was not of the type stocked by the Facility. The note indicated that Resident #3 said the [MEDICATION NAME] needle contained the [MEDICATION NAME] that the nurse had just administered. The note indicated that Nurse #11 observed additional drug paraphernalia in Resident #3's room, including a spoon with a white powder residue on it, and a lighter. The note indicated that Resident #3 said that it was the first time he/she had ever done that, but that Nurse #11 observed needle marks on Resident #3's arms. The note indicated that the drug paraphernalia was later confiscated by the police department, and that the physician and (former) Director of Nurses were notified. Surveyor #1 and Surveyor #2 interviewed Nurse #11 at 2:33 P.M. on [DATE]. Nurse #11 said that Resident #3 approached her at the medication cart in the hallway and requested his/her pain medication. Nurse #11 said that she administered 4 5 mg tablets of [MEDICATION NAME] to Resident #3 at the medication cart, and watched Resident #3 swallow the pills with a cup of coffee. Nurse #11 said that she asked Resident #3 if he had swallowed the medication, and Resident #3 told her that he/she had and opened his/her mouth and wiggled his/her tongue around to show Nurse #11. Nurse #11 said that shortly after, CNA #1 told her that Resident #3 was hiding behind the bedroom curtain in his/her room. Nurse #11 said that when she entered Resident #3's room, she observed him/her sitting at the bedside table with a [MEDICATION NAME] needle in his/her arm. Nurse #11 said that Resident #3 told her that the substance in the [MEDICATION NAME] needle was the [MEDICATION NAME] that Nurse #11 had just administered to him/her. Nurse #11 said that the [MEDICATION NAME] needle was of the generic variety that anyone could purchase at a drug store, and said that it contained approximately a quarter of an inch of clear liquid. Nurse #11 said that she observed a spoon on the bedside table, which had a yellowish substance on it, which she did not think was the [MEDICATION NAME] she had given Resident #3. Nurse #11 said that when Resident #3 was admitted , she was not notified of his/her substance abuse history. The Physician's Progress Notes dated [DATE], [DATE], [DATE], [DATE], and [DATE] contain no documentation to indicate that the physician was notified or aware of Resident #3 being found with a [MEDICATION NAME] needle in his/her arm on [DATE]. Surveyor #1 interviewed Certified Nurse Aide (CNA) #3 at 1:41 P.M. on [DATE]. CNA #3 said that Resident #3 once told her that he/she could score (obtain drugs) while residing in the Facility. Surveyor #1 and Surveyor #2 interviewed Social Worker #1 at 12:03 P.M. on [DATE]. Social Worker #1 said that she started her employment at the Facility on [DATE]. Social Worker #1 said she was not aware of Resident #3 being found with a [MEDICATION NAME] needle in his/her arm on [DATE] until notified by Surveyor #1 on the date of interview. Surveyor #1 and Surveyor #2 interviewed the Clinical Nurse Evaluator at 12:39 P.M. on [DATE]. The Clinical Nurse Evaluator said she was not aware of Resident #3 being found with a [MEDICATION NAME] needle in his/her arm on [DATE]. 2. There was no documentation at the time of survey that addiction services were offered or provided to address Resident #5's history of or current substance abuse. Resident #5 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. Resident #5's clinical record indicated that Resident #5 was transferred to Hospital #1 from another SNF after questionable use of an illegal substance, possession of drug paraphernalia including a [MEDICATION NAME] needle and observed fresh track marks (injection sites) to Resident #5's left inner elbow. The record indicated that hospital security found additional drug paraphernalia in Resident #5's belongings, including a packet of an unknown powdered substance. Surveyor #1 and Surveyor #2 interviewed the Clinical Nurse Evaluator at 12:39 P.M. on [DATE]. The Clinical Nurse Evaluator said that she reviewed Resident #5's preadmission paperwork prior to him/her being admitted to the Facility, which included information from Hospital #1 from the date of Resident #5's admission to the Facility. The Clinical Nurse Evaluator said that she was aware that Hospital #1's documentation indicated that Resident #5 had been found with drug paraphernalia in his/her possession at his/her prior SNF and at Hospital #1. The Clinical Nurse Evaluator said that she did not inquire as to whether or not Resident #5 was actively using drugs. Surveyor #1 interviewed the Nurse Supervisor at 1:12 P.M. on [DATE]. The Nurse Supervisor said that she recalled Resident #5's family member calling the Facility because she was concerned that Resident #5 would use drugs. The Behavioral Health Consultation and Treatment Plan dated [DATE] indicated that Resident #5 had a history of [REDACTED].#5 preferred to manage his/her psychiatric issues with medication rather than therapy. The Nurse's Progress Note dated [DATE] indicated that Resident #5 was found unconscious and blue at approximately 8:00 P.M., and cardiopulmonary resuscitation (CPR) was initiated. The note indicated that Emergency Medical Services (EMS) responded and administered [MEDICATION NAME] (a medication used to treat narcotic overdose in an emergency situation) with a positive effect. Resident #5's clinical record from Hospital #2 indicated that Resident #5 told EMS personnel that he/she had used heroin, and told hospital staff that he/she had injected heroin into his/her Peripherally Inserted Central Catheter (a form of IV access that can be used for a prolonged period of time; PICC line) at the Facility because he/she was not receiving enough pain medications. The record indicated that Resident #5 wanted treatment for [REDACTED]. 3. There was no documentation at the time of survey that addiction services were offered or provided to address Resident #7's history of or current substance abuse, or that follow up was conducted on Hospital #3's recommendations for sobriety services. Resident #7 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. The Discharge Summary from Hospital #3 dated [DATE] indicated that Resident #7 had been treated with [MEDICATION NAME] (a medication used to treat opiate addiction) for his/her substance abuse, but had relapsed and used IV heroin 3 weeks prior to his/her hospitalization . The summary indicated that Resident #7 had been unable to restart [MEDICATION NAME] because he/she could not afford to fill the prescription, and was planned for outpatient follow up with sobriety program. Resident #7's care plans dated [DATE] indicated that the Facility had not implemented a plan of care to address and provide for the needed care and services for Resident #7's substance abuse and history of self-harm. The History and Physical dated [DATE] indicated that Resident #7 had a history heroin and cocaine use. There was no documentation to indicate that the Physician addressed the recommendations for sobriety services noted on the Discharge Summary from Hospital #3. The physician's orders [REDACTED].#7 may have LOA (Leave of Absence) with a responsible party. There was no documentation to indicate that the Physician ordered Facility staff to follow up with the recommendations for sobriety services noted on the Discharge Summary from Hospital #3. The Social Service Progress Note dated [DATE] indicated that Resident #7 had a history of [REDACTED]. The note indicated that Resident #7 had addiction services to address his/her substance abuse issues prior to his/her admission to the Facility. There was no documentation to indicate that the social worker had followed up, recommended or provided services for Resident #7's history of alcohol, substance abuse and self-harm. 4. There was no documentation at the time of survey that addiction services were offered or provided to address Resident #8's history of or current substance abuse. Resident #8 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. The Midnight Census Report dated [DATE] indicated that Resident #7 and Resident #8 shared at room at the Facility. The Inpatient Consult Note from Hospital #3 dated [DATE] indicated that Resident #8 had been released from prison a few months prior to his/her hospitalization , and had not used IV heroin during his/her incarceration. The note indicated that Resident #8 had relapsed and used heroin in the months since his/her release from prison. The Physician Note dated [DATE] indicated that Resident #8 had a history of [REDACTED]. Resident #8's care plans dated [DATE] indicated that the Facility had not implemented a plan of care to address and provide for the needed care and services for Resident #8's substance abuse. 5. There was no documentation at the time of survey that Resident #9 was evaluated by social services staff at any time during his/her admission to the Facility, or that addiction services were offered or provided to address Resident #9's history of or current substance abuse. Resident #9 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. The History and Physical dated [DATE] indicated that the physician was aware of Resident #9's history of IV drug abuse. The Psychiatric Diagnostic Consultation dated [DATE] indicated that Resident #9 was being seen due to complaints of increased anxiety. The consultation did not include interventions to address Resident #9's substance abuse. 6. There was no documentation at the time of survey that addiction services were offered or provided to address Resident #10's history of or current substance abuse. Resident #10 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. Hospital #3's Psychosomatic Consult Note dated [DATE] indicated that Resident #10 had a history of [REDACTED]. The consult indicated that Resident #10 reported that he/she last used heroin and cocaine in [DATE], and last consumed alcohol on [DATE]. Review of Resident #10's Nurse Progress Notes indicated only one note dated [DATE], which did not indicate Resident #10's alcohol dependence or history of drug use. Resident #10's care plans dated [DATE] indicated that there was no plan of care to address and provide for the needed care and services for Resident #10's alcohol and substance abuse. The Neurologist's Consultation Note dated [DATE] indicated that Resident #10 was recommended for cognitive rehabilitation and an alcohol counselor. Surveyor #2 interviewed Nurse #7 at 11:05 A.M. on [DATE]. Nurse #7 said that she had worked at the Facility for over a year. Nurse #7 confirmed that there was only one nursing progress note written for Resident #10 on [DATE], and no further nursing notes had been written after that date. Nurse #7 confirmed that Resident #10's admission nursing assessments, including: falls risk, elopement risk and pain assessment, had not been completed as of [DATE]. Nurse #7 said that the assessments should have been completed upon Resident #10's admission. Nurse #7 said that the Neurologist's recommendations from [DATE] for Resident #10 to have cognitive rehab and alcohol counselor had not been implemented as of [DATE] because she did not know where to obtain those services for Resident #10. 7. There was no documentation at the time of survey that Resident #11 was evaluated by social services staff at any time during his/her admission to the Facility, or that addiction services were offered or provided to address Resident #11's history of or current substance abuse and expressed request to be enrolled in a [MEDICATION NAME] program. Resident #11 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. The Transfer Summary from Hospital #2 dated [DATE] indicated that Resident #11 had eloped (left without consent or the knowledge of another person) during the initial hospitalization with the intent of obtaining and using opiates. The summary indicated that Resident #11 was given [MEDICATION NAME] (a medication used to treat narcotic drug addiction and/or pain) for opiate withdrawal, and that the social worker met with Resident #11 to discuss outpatient treatment options. The summary indicated that: Treatment and Instructions included rehabilitation for opiate abstinence. The History and Physical dated [DATE] indicated that Resident #11 wanted to get enrolled at a [MEDICATION NAME] clinic. The Physician's Progress Notes dated [DATE], [DATE] and [DATE] indicated that Resident #11 wanted to get enrolled at a [MEDICATION NAME] clinic. The Occupational Therapy Evaluation and Plan of Treatment dated [DATE] indicated that Resident #11's goals included getting sober again and taking care of himself/herself. 8. Surveyor #1 and Surveyor #2 interviewed Social Worker #2 at 9:31 A.M. on [DATE]. Social Worker #2 said that she was hired approximately 6 weeks prior to the date of interview. Social Worker #2 said that social service assessments were not being completed in a timely manner, and she had observed that some were months out of compliance. Social Worker #2 said that the Facility's behavioral health provider did not provide services related to substance abuse issues, that they provided services on behavioral, mental health and dementia issues only. Social Worker #2 said that there were no alcohol or drug rehabilitative services offered at the Facility. Social Worker #2 said that the Facility was contracted with a company that provided addiction treatment services, but that the company did not provide any counseling or addiction services within the Facility. Social Worker #2 said that residents in the addiction treatment program used to go out to the clinic to receive counseling and addiction services, but that was no longer the case. 9. Surveyor #1 and Surveyor #2 interviewed the Director of Social Services at 3:13 P.M. on [DATE]. The Director of Social Services said that if a resident had a history of [REDACTED]. The Director of Social Services said that care plans should be in place for those with a history of substance abuse or self-harm. The Director of Social Services said that the Facility's contracted addiction treatment company did not provide any counseling or addiction services in the Facility.

Based on records reviewed, interviews and observation, for 7 of 8 residents with substance abuse/use issues, (Resident #3, Resident #5, Resident #7, Resident #8, Resident #9, Resident #10 and Resident #11), the facility failed to ensure they had a formalized program or process to ensure they conducted comprehensive medical and interdisciplinary team assessments to determine each resident's immediate needs and the severity of the issue, risks, and strengths; and, identify all appropriate [DIAGNOSES REDACTED]. -The Facility failed to ensure they developed, through their medical director and trained Addiction Medicine/Care Specialist, policies and procedures; staff training; admission and discharge processes, as they relate to the resident with substance abuse/use or addiction, prior to admitting residents with this known need and didn't consistently notify the physician. Resident #3 and Resident #5 were prescribed opioids but the plan of care didn't include an evaluation of risk for the use of opioids for residents with a history of substance abuse. Findings include: 1. Resident #3 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. Resident #3's clinical record indicated that he/she was admitted to the Facility for treatment of [REDACTED]. The Substance Abuse Care Plan, dated [DATE], indicated that Resident #3 had a history of [REDACTED].#3 had a history of [REDACTED].#3 had the potential for complications such as recurrence of substance use. Goals included that Resident #3 was to remain free from acute or post-acute withdrawal symptoms, and would have no alcohol or drugs hidden in his/her room or brought to him/her by visitors. Approaches included to arrange for transportation to support groups, psychological counseling, etc., as ordered by the physician, psych services as needed per physician order, and to assess, record, report to physician signs and symptoms of substance abuse or misuse. There was no reference to substance abuse needs or services. The care plan did not include interventions in regards to how staff were to determine whether Resident #3 had alcohol or drugs hidden in his/her room, or how staff were to prevent visitors from bringing Resident #3 drugs or alcohol. There was no comprehensive medical and interdisciplinary assessment for Resident #3's substance abuse needs, his recent substance use, risk for relapse or the determination of the least restrictive but safe setting for care. The Physician's Progress Notes dated [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] indicated that Resident #3 had a history of [REDACTED]. The Plan of Care for Resident #3 included [MEDICATION NAME] but there was no indication or assessment for the safe use of opioids for a resident with active substance abuse. The Nurse's Progress Note dated [DATE] for the 11:00 P.M. to 7:00 A.M. shift indicated that at 2:00 A.M., Resident #3 requested pain medication, and was administered 20 milligrams (mg) of [MEDICATION NAME]. The note indicated that Nurse #11 watched Resident #3 put the medication in his/her mouth and swallow a sip of coffee. The note indicated that approximately 20 minutes later, Nurse #11 entered Resident #3's room and observed him/her sitting in front of the bedside table with a [MEDICATION NAME] needle in his/her right antecubital vein (vein at the inner elbow). The note indicated that the [MEDICATION NAME] needle was not of the type stocked by the Facility. The note indicated that Resident #3 said the [MEDICATION NAME] needle contained the [MEDICATION NAME] that the nurse had just administered. The note indicated that Nurse #11 observed additional drug paraphernalia in Resident #3's room, including a spoon with a white powder residue on it, and a lighter. The note indicated that Resident #3 said that it was the first time he/she had ever done that, but that Nurse #11 observed needle marks on Resident #3's arms. The note indicated that the drug paraphernalia was later confiscated by the police department, and that the physician and (former) Director of Nurses were notified. Surveyor #1 and Surveyor #2 interviewed Nurse #11 at 2:33 P.M. on [DATE]. Nurse #11 said that Resident #3 approached her at the medication cart in the hallway and requested his/her pain medication. Nurse #11 said that she administered four 5 mg tablets, for a total of 20 mg, of [MEDICATION NAME] to Resident #3 at the medication cart, and watched Resident #3 swallow the pills with a cup of coffee. Nurse #11 said that she asked Resident #3 if he had swallowed the medication, and Resident #3 told her that he/she had and opened his/her mouth and wiggled his/her tongue around to show Nurse #11 that his/her mouth was empty. Nurse #11 said that shortly thereafter, CNA #1 told her that Resident #3 was hiding behind the bedroom curtain in his/her room. Nurse #11 said that when she entered Resident #3's room, she observed him/her sitting at the bedside table with a [MEDICATION NAME] needle in his/her arm. Nurse #11 said that Resident #3 told her that the substance in the [MEDICATION NAME] needle was the [MEDICATION NAME] that Nurse #11 had just administered to him/her. Nurse #11 said that the [MEDICATION NAME] needle was of the generic variety that anyone could purchase at a drug store, and said that it contained approximately a quarter of an inch of clear liquid. Nurse #11 said that she observed a spoon on the bedside table, which had a yellowish substance on it, which she did not think was the [MEDICATION NAME] she had given Resident #3. Nurse #11 said that when Resident #3 was admitted , she was not notified of his/her substance abuse history. The Police Report dated [DATE], indicated that the [MEDICATION NAME] needle was disposed of, and the drug paraphernalia was turned over to the vice squad depository for analysis. The Substance Abuse Care Plan was updated on [DATE] to include twice a day room searches to look for drugs or alcohol, once during the 7:00 A.M. to 3:00 P.M. shift and once during the 3:00 P.M. to 11:00 P.M. shift. The Medication Administration Record [REDACTED]. The MAR for [DATE] did not include documentation to indicate that room searches were completed on 26 out of 62 applicable shifts. The Social Service Progress Note, dated [DATE], indicated that Social Worker #1 was aware that Resident #3 had used an illegal substance while a resident at a prior skilled nursing facility (SNF). The notes dated [DATE], [DATE] and [DATE] did not indicate that the social services plan included interventions to address Resident #3's known history of substance abuse. The Behavioral Health Consultation and Treatment Plan, dated [DATE], indicated that Resident #3 was being seen for an initial evaluation, 27 days after the incident. The Plan did not include interventions to address Resident #3's substance abuse, and did not indicate that the psychiatric service was notified of the incident on [DATE]. 2. There was no documentation to indicate Resident #5 was assessed to determine his/her addiction service needs, including his/her ability to attend substance abuse support groups and an evaluation of Resident #5's substance abuse issues. There was no documentation that a care plan was in place to address Resident #5's history of or current substance abuse. Resident #5 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. Resident #5's clinical record indicated that he/she was transferred to Hospital #1 from another SNF after questionable use of an illegal substance, possession of drug paraphernalia including a [MEDICATION NAME] needle and observed fresh track marks (injection sites indicative of active substance abuse/use) to Resident #5's left inner elbow. The record indicated that hospital security found additional drug paraphernalia in Resident #5's belongings, including a packet of an unknown powdered substance. Surveyor #1 and Surveyor #2 interviewed the Clinical Nurse Evaluator at 12:39 P.M. on [DATE]. The Clinical Nurse Evaluator said that she reviewed Resident #5's preadmission paperwork prior to him/her being admitted to the Facility. The Clinical Nurse Evaluator said that she was aware that Hospital #1's documentation indicated that Resident #5 had been found with drug paraphernalia in his/her possession at his/her prior SNF and at Hospital #1. The Clinical Nurse Evaluator said that she did not inquire as to whether or not Resident #5 was actively using drugs. The History and Physical, dated [DATE], indicated that Resident #5 was admitted to the Facility for treatment of [REDACTED]. There was no documentation to indicate that the medical plan of care included a plan related to Resident #5's substance abuse and/or addiction service needs, risk of relapse or services necessary to attain or maintain sobriety. The Physician's Telephone Order, dated [DATE], indicated an order for [REDACTED]. The Social History and Initial Assessment, and the Social Service Progress Note, dated [DATE] did not indicate the reason for Resident #5's recent admission to Hospital #1, or for his/her transfer from the previous SNF to Hospital #1. The Social History and Initial Assessment indicated that Resident #5 said that he/she had a history of [REDACTED]. The Surveyor interviewed Social Worker #1 at 12:03 P.M. on [DATE]. Social Worker #1 said that she received a copy of the preadmission paperwork distributed by the Clinical Nurse Evaluator prior to any resident's admission to the Facility. The Psychiatric Diagnostic Consultation form indicated that Resident #5 was not evaluated by psychiatry until [DATE]. The form indicated that Resident #5 had a history of [REDACTED].#5's drug use at his/her prior SNF, identify services needed related to Resident #5's substance abuse issues, or identify interventions to supervise Resident #5. The Behavioral Health Consultation and Treatment Plan, dated [DATE], indicated that Resident #5 had a history of [REDACTED].#5 preferred to manage his/her psychiatric issues with medication rather than therapy, but there was no plan or intervention related to substance abuse/use. The Nurse's Progress Note dated [DATE] indicated that Resident #5 was found unconscious and blue (an abnormal assessment finding indicative of inadequate oxygenation) at approximately 8:00 P.M., and cardiopulmonary resuscitation (CPR) was initiated. The note indicated that Emergency Medical Services (EMS) responded and administered [MEDICATION NAME] (a medication used to treat narcotic overdose in an emergency situation) with a positive effect. The Police Report, dated [DATE], indicated that Resident #5 was unresponsive prior to the administration of 2 doses of [MEDICATION NAME] by the Fire Department and EMS, and then was transported to Hospital #2. Resident #5's clinical record from Hospital #2 indicated that Resident #5 stated to EMS personnel that he/she had used heroin, and told hospital staff that he/she had injected heroin into his/her PICC line at the Facility because he/she was not receiving enough pain medications. The record indicated that Resident #5 wanted treatment for [REDACTED]. 3. Resident #7 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. The Discharge Summary from Hospital #3, dated [DATE], indicated that Resident #7 had been treated with [MEDICATION NAME] (a medication used to treat opioid addiction) for his/her substance abuse, but had relapsed and used IV heroin 3 weeks prior to his/her hospitalization . The summary indicated that Resident #7 had been unable to restart [MEDICATION NAME] because he/she could not afford to fill the prescription, and was planned for outpatient follow up with sobriety program. Resident #7's care plans, dated [DATE], indicated that there was no plan of care to address and provide for the needed care and services for Resident #7's substance abuse and history of self-harm. Surveyor #1 and Surveyor #2 interviewed Social Worker #2 at 9:31 A.M. on [DATE]. Social Worker #2 said that there was no care plan in place to address Resident #7's history of self-harm. The physician's orders [REDACTED].#7 was prescribed IV antibiotics, [MEDICATION NAME] 40 milligrams (mg) twice a day, and [MEDICATION NAME] 20 mg every 4 hours as needed for severe pain. There was no documentation to indicate a medical assessment had been conducted related to how the use of narcotic/opioid pain medications might impact Resident #7's ability to maintain sobriety while at the Facility. The History and Physical, dated [DATE], indicated that Resident #7 had L2-L3 infectious osteo[DIAGNOSES REDACTED] (inflammation of bones in the lower back caused by infection), back pain and a history of heroin and cocaine use. There was no indication the physician documented or addressed Resident #7's history of self-harm. 4. There was no documentation that Resident #8's medical plan of care included a plan on how to monitor, treat, evaluate, or supervise Resident #8's addiction needs or sobriety. Resident #8 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. The Midnight Census Report, dated [DATE], indicated that Resident #7 and Resident #8 shared at room at the Facility. The Inpatient Consult Note from Hospital #3, dated [DATE], indicated that Resident #8 had been released from prison a few months prior to his/her hospitalization , and had not used IV heroin during his/her incarceration. The note indicated that Resident #8 had relapsed and used heroin in the months since his/her release from prison. The Physician Note, dated [DATE], indicated that Resident #8 had a history of [REDACTED]. Resident #8's care plans, dated [DATE], indicated that there was no plan of care to address and provide for the needed care and services for Resident #8's substance abuse history and there was no assessment for the risk for relapse or services needed to attain or maintain the sobriety. 5. There was no documentation that a comprehensive assessment was conducted or that a care plan was in place to address Resident #9's substance abuse. Resident #9 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. The History and Physical, dated [DATE], indicated that the physician was aware of Resident #9's history of IV drug abuse. Resident #9's care plans indicated that there was no plan of care to address and provide for the needed care and services for Resident #9's substance abuse history, or a comprehensive medical and interdisciplinary team assessment to include evaluation of risks associated with Resident #9's substance abuse/use, risk of relapse, or to determine services necessary to attain or maintain sobriety. The Psychiatric Diagnostic Consultation dated [DATE] indicated that Resident #9 was being seen due to complaints of increased anxiety. The consultation did not include interventions to address Resident #9's substance abuse. The physician's orders [REDACTED].#9 could go on a leave of absence (LOA) with a responsible person. Surveyor #1 interviewed Nurse #8 at 4:09 P.M. on [DATE]. Nurse #8 said that during report at change of shift, she was told that Resident #9 had been sent to the hospital after being found outside, but did not know the reason for the transfer. The Nursing Home to Hospital Transfer Form, and Physician's Telephone Order, dated [DATE], indicated that Resident #9 was being transferred for evaluation of possible recreational drug use while at the Facility. Resident #9's Emergency Department Record, dated [DATE], from Hospital #3 indicated that Resident #9 was sent to Hospital #3 from the Facility after a nurse found him/her in the bathroom with heroin and [MEDICATION NAME] needles. The record indicated that while in the emergency department, Resident #9 admitted to snorting heroin in the Facility. The record indicated that the Facility was contacted about discharge, and the Facility said that Resident #5 could return to the Facility. There was no indication the Facility determined the least restrictive but safest setting related to Resident #9's active heroin use prior to allowing Resident #9 to return to the Facility. The Nurse's Progress Note, dated [DATE], at 11:00 P.M. indicated that Resident #9 arrived back at the Facility, and left the Facility against medical advice approximately 5 hours later. The Facility's Accident/Incident Report and Investigation, dated [DATE], was provided to Surveyor #1 on [DATE]. The report indicated that the Nursing Supervisor was approached by an Emergency Medical Technician (EMT), who reported seeing Resident #9 exchanging money for an unknown item in the parking lot of the Facility. The report indicated that the Nursing Supervisor found Resident #9 in his/her bathroom, with a bag containing 3 [MEDICATION NAME] needles and a baggie with a powdery substance in it. The report indicated that Resident #9 told the Nursing Supervisor that the baggie contained heroin, and that someone from outside of the Facility had brought it to him/her. 6. For Resident #10, there was no documentation that an assessment was conducted or that a care plan was in place to address Resident #10's history of or current substance abuse, or that the Facility followed up with or implemented the Neurologist's recommendations for cognitive rehabilitation and an alcohol counselor for Resident #10. Resident #10 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. Hospital #3's Psychosomatic Consult Note, dated [DATE], indicated that Resident #10 had a history of [REDACTED]. The consult indicated that Resident #10 reported that he/she last used heroin and cocaine in [DATE], and last consumed alcohol on [DATE]. There was no indication a comprehensive medical or interdisciplinary team evaluation was completed related to Resident #10's active substance abuse/use, risks associated with Resident #10's substance abuse/use; risk for relapse; or determined the services necessary for Resident #10 to attain or maintain sobriety. Review of Resident #10's Nurse Progress Notes indicated that, as of [DATE], Resident #10 had only one nursing progress note dated [DATE] in his/her clinical record. Resident #10's care plans indicated that the Facility did not have a plan of care in place to address and provide for the needed care and services for Resident #10's alcohol and substance abuse. The Neurologist's Consultation Note, dated [DATE], indicated that Resident #10 was recommended for cognitive rehabilitation and an alcohol counselor. Surveyor #2 interviewed Nurse #7 at 11:05 A.M. on [DATE]. Nurse #7 said that she had worked at the Facility for over a year. Nurse #7 said there was only one nursing progress note written for Resident #10 on [DATE], and no further nursing notes had been written after that date. Nurse #7 confirmed that Resident #10's admission nursing assessments, including: falls risk, elopement risk and pain assessment, had not been completed as of [DATE]. Nurse #7 said that the assessments should have been completed upon Resident #10's admission. Nurse #7 said that the Neurologist's recommendations from [DATE] for Resident #10 to have cognitive rehabilitation and an alcohol counselor had not been implemented as of [DATE] because she did not know where to obtain those services for Resident #10. 7. There was no documentation that an assessment was conducted or that a care plan was implemented to address Resident #11's history of or current substance abuse, history of self-harm, and expressed request to be enrolled in a [MEDICATION NAME] program. Resident #11 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. The urine toxicology report from Hospital #2, dated [DATE], indicated that Resident #11 had tested presumptively positive for [MEDICATION NAME] & opioids. The Transfer Summary from Hospital #2, dated [DATE], indicated that Resident #11 had eloped during the initial hospitalization with the intent of obtaining and using opiates. The summary indicated that Resident #11 was given [MEDICATION NAME] (a medication used to treat narcotic drug addiction and/or pain) for opiate withdrawal, and that the Hospital Social Worker met with Resident #11 to discuss outpatient treatment options. The summary indicated that: Treatment and Instructions included rehabilitation for opiate abstinence. Although Resident #11 was identified to need rehabilitation for opiate abstinence, the Facility admitted Resident #11 without being able to provide this level of care or service. The Patient Care Referral Facility and Home Care form, dated [DATE], indicated that Resident #11 was an active heroin user. The History and Physical, dated [DATE], indicated that Resident #11 was admitted to the Facility for treatment of [REDACTED]. The note also indicated that Resident #11 wanted to get enrolled at a [MEDICATION NAME] clinic. The physician's orders [REDACTED].#11 could go on a LOA with a responsible person, and indicated an order for [REDACTED].#11's ability to attain or maintain sobriety after being prescribed an opioid. The Physician's Progress Notes, dated [DATE], [DATE] and [DATE], indicated that Resident #11 wanted to get enrolled at a [MEDICATION NAME] clinic. The Occupational Therapy Evaluation and Plan of Treatment, dated [DATE], indicated that Resident #11's goals included becoming sober again and taking care of himself/herself. The Nurse's Progress Note, dated [DATE] during the 7:00 A.M. to 3:00 P.M. shift, indicated that Resident #11 was exhibiting some exit seeking behaviors and asked to go out for an hour. There was no indication Resident #11 was evaluated for a [MEDICATION NAME] program, and no indication that any outpatient therapy drug program was initiated. There was no documentation at the time of survey that Resident #11 was evaluated by social services staff at any time during his/her admission to the Facility. 8. Surveyor #1 and Surveyor #2 interviewed Social Worker #2 at 9:31 A.M. on [DATE]. Social Worker #2 said that she was hired approximately 6 weeks prior to the date of interview. Social Worker #2 said that she did not complete care plans for residents as she was not trained on how to complete a care plan. Social Worker #2 said that social service assessments were not being completed in a timely manner, and she had observed that some assessments were months out of compliance. Social Worker #2 said that the Facility's behavioral health provider did not provide services related to substance abuse issues, that they provided services on behavioral, mental health and dementia issues only. Social Worker #2 said that she did not know how the provision of substance abuse services within the Facility would work, that she was not familiar with how the process would work in a facility versus the community. Social Worker #2 said that there were no alcohol or drug rehabilitative services offered at the Facility. Social Worker #2 said that the Facility contracted with an outpatient addiction treatment center but the contracted outpatient addiction treatment center did not provide any counseling or addiction services within the Facility. Social Worker #2 said that residents in the addiction treatment program used to go to that center, and would receive counseling and addiction services there. Social Worker #2 said that those residents were also drug tested weekly at the addiction treatment center, but were not drug tested at the Facility. Social Worker #2 said that there was no review of a resident's history prior to being placed with a roommate. Social Worker #2 said that residents with dementia were not placed in rooms with residents with substance abuse issues. When notified that Non-sampled Resident #1, who had a [DIAGNOSES REDACTED].#3's roommate, Social Worker #2 said that she was unaware of that. 9. Surveyor #1 and Surveyor #2 interviewed the Director of Social Services at 3:13 P.M. on [DATE]. The Director of Social Services said that if a resident had a history of [REDACTED]. The Director of Social Services said that care plans should be in place for those with a history of substance abuse or self-harm. The Director of Social Services said that the addiction treatment center contracted with the Facility did not provide any counseling or addiction services within the Facility.

Based on records reviewed and interviews, for 6 of 8 sampled residents with substance abuse issues (Resident #3, Resident #5, Resident #7, Resident #8, Resident #10 and Resident #11), the facility failed to ensure that although they actively admitted residents with active substance abuse/use or addition needs, they failed to ensure that emergency medication such as Narcan (a medication used to treat narcotic overdose in an emergency situation) was available and that staff were trained and competent in its use, in the event of a resident experienced symptoms indicative of possible opioid overdose. On 3/18/16, Resident #5, who was an active substance user, was found unconscious and blue (abnormal assessment finding indicative of decreased oxygenation), and cardiopulmonary resuscitation (CPR) was initiated, but Resident #5 was not provided Narcan until Emergency Medical Services (EMS) responded and administered Narcan, which had a positive effect in reversing Resident #5's life-threatening symptoms. Findings include: 1. The contents list of the Facility's emergency medications kit, received on 04/29/16, indicated that the kit did not include Narcan. 2. Surveyor #1 and Surveyor #2 interviewed the Assistant Director of Nursing (ADON) at 10:23 A.M. on 05/03/16, and throughout the survey days on 05/03/16 and 05/04/16. The ADON said that the Facility implemented a house-wide standing physician order [REDACTED]. The ADON said that she was unable to locate the signed standing house order for Narcan that was started in December 2015, but that the pharmacy had the order. The ADON and said the former Director of Nursing had handwritten every Narcan order for [REDACTED]. As of 05/04/16, the ADON had not been able to provide Surveyor #1 or Surveyor #2 with the Narcan orders from December 2015 from the pharmacy, as requested. Surveyor #1 interviewed the Nurse Supervisor at 1:29 P.M. on 04/29/16. The Nurse Supervisor said that the Facility's standing house order for Narcan was not implemented until shortly after Resident #5's overdose in March 2016. Surveyor #2 interviewed Nurse #7 oat 11:05 A.M. on 05/04/16. Nurse #7 said that she had worked at the Facility for over a year. Surveyor #2 confirmed with Nurse #7 that Resident #10, who was admitted in April 2016, had a history of [REDACTED].#2 asked Nurse #7 why Resident #10 did not have orders for Narcan. Nurse #7 said that she was informed on 05/03/16 that Narcan orders were supposed to be standard orders for all residents as of December 2015. Nurse #7 said that she was was working on implementing those orders for all of the residents on her unit, including Resident #10. Surveyor #1 and Surveyor #2 interviewed the Medical Director at 12:50 P.M. on 05/04/16. The Medical Director said that she had been the Medical Director at the Facility for approximately two and a half years. The Medical Director said that she was not aware the Facility had implemented standing house orders for Narcan for all residents in December 2015. The Medical Director said that she received a call 2 or 3 days prior to the date of interview to initiate standing house orders for Narcan. The Medical Director said that she gave verbal authorization for the implementation of the standing house order for Narcan, but said that she did not know if the order was intended for every resident in the Facility. The Medical Director said that she did not know how the order for Narcan was written out (dose, administration instructions), because she had not been in the Facility to see the order in person and had not discussed the order with the Administrator or Director of Nurses (DON). The Medical Director said that she planned to review the order and discuss it with the Administrator and DON on 05/06/16. 3. Resident #3 was admitted to the Facility in January 2016 with [DIAGNOSES REDACTED]. Resident #3's clinical record indicated that he/she was admitted to the Facility for treatment of [REDACTED]. The physician's orders [REDACTED].#3 was admitted with orders for medications which included oxycodone (an opioid pain medication with a high risk for addiction and dependence) twice a day. The orders also indicated that, effective 02/05/16, Resident #3 had orders for varying doses of oxycodone as needed (PRN) every 4 hours based on Resident #3's reported severity of pain. The Nurse's Progress Note dated 02/23/16 for the 11:00 P.M. to 7:00 A.M. shift indicated that the nurse administered the maximum ordered dose of PRN oxycodone to Resident #3 due to complaints of pain. The note indicated that approximately 20 minutes later, the nurse observed Resident #3 with a hypodermic needle, not of the type stocked by the Facility, in his/her arm. The note indicated that Resident #3 said the hypodermic needle contained the oxycodone that the nurse had just administered. The note indicated that the nurse observed additional drug paraphernalia in Resident #3's room, which was later confiscated by the police department. The note indicated that Resident #3 denied ever injecting himself/herself at the Facility prior to that date, but that the nurse observed needle marks on Resident #3's arms. The note indicated that the physician was notified that Resident #3 was found with a hypodermic needle in his/her arm and would be in that day to see Resident #3. The physician's orders [REDACTED].>4. Resident #5 was admitted to the Facility in March 2016 with [DIAGNOSES REDACTED]. Resident #5's clinical record indicated that Resident #5 was transferred to Hospital #1 from another SNF after questionable use of an illegal substance, possession of drug paraphernalia including a hypodermic needle and observed fresh track marks (injection sites) to Resident #5's left inner elbow. The record indicated that hospital security found additional drug paraphernalia in Resident #5's belongings, including a packet of an unknown powdered substance. The History and Physical dated 03/07/16 indicated that Resident #5 was admitted to the Facility for treatment of [REDACTED]. The physician's orders [REDACTED]. The Nurse's Progress Note dated 03/18/16 indicated that Resident #5 was found unconscious and blue at approximately 8:00 P.M., and cardiopulmonary resuscitation (CPR) was initiated. The note indicated that Emergency Medical Services (EMS) responded and administered Narcan with a positive effect. The Police Report dated 03/18/16 indicated that Resident #5 was unresponsive prior to the administration of 2 doses of Narcan by the Fire Department and EMS, and then was transported to Hospital #2. There was no documentation at the time of survey that an order for [REDACTED]. 5. Resident #7 was admitted to the Facility in April 2016 with [DIAGNOSES REDACTED]. The Discharge Summary from Hospital #3 dated 04/20/16 indicated that Resident #7 had been treated with Suboxone (a medication used to treat opiate addiction) for his/her substance abuse, but had relapsed and used IV heroin 3 weeks prior to his/her hospitalization . The Hospital Discharge Summary indicated that Resident #7 had been unable to restart Suboxone because he/she could not afford to fill the prescription, and was planned for outpatient follow up with sobriety program. The History and Physical dated 04/2016 indicated that Resident #7 was admitted to the Facility for treatment of [REDACTED]. The physician's orders [REDACTED].#7 was admitted with orders for medications which included oxycodone twice a day and every 4 hours PRN. There was no documentation at the time of survey that an order for [REDACTED]. 6. Resident #8 was admitted to the Facility in April 2016 with [DIAGNOSES REDACTED]. The Midnight Census Report dated 05/04/16 indicated that Resident #7 and Resident #8 shared at room at the Facility. The Inpatient Consult Note from Hospital #3 dated 04/05/16 indicated that Resident #8 had had relapsed and used heroin in the few months prior to his/her admission to Hospital #3. There was no documentation at the time of survey that an order for [REDACTED]. 7. Resident #10 was admitted to the Facility in April 2016 with [DIAGNOSES REDACTED]. Hospital #3's Psychosomatic Consult Note dated 04/14/16 indicated that Resident #10 had a history of [REDACTED]. The consult indicated that Resident #10 reported that he/she last used heroin and cocaine in March 2016, and last consumed alcohol on 04/07/16. There was no documentation at the time of survey that an order for [REDACTED]. 8. Resident #11 was admitted to the Facility in March 2016 with [DIAGNOSES REDACTED]. The Transfer Summary from Hospital #2 dated 03/18/16 indicated that Resident #1 had eloped (left without consent or the knowledge of another person) during the initial hospitalization with the intent of obtaining and using opiates. The summary indicated that Resident #11 was given Methadone (a medication used to treat narcotic drug addiction and/or pain) for opiate withdrawal. The History and Physical dated 03/19/16 indicated that Resident #11 was admitted to the Facility for treatment of [REDACTED]. The physician's orders [REDACTED].>There was no documentation at the time of survey that an order for [REDACTED].

Based on records reviewed and interviews, the facility failed to ensure that the Medical Director was responsible for the implementation of resident care policies and coordination of care for residents with substance abuse issues in the facility, or notified of incidents involving the health and safety of the residents. - The Facility failed to ensure that the Medical Director was consulted to assist in the development of admission and discharge policies; assessments; and, supervision required for residents with substance abuse/use or addiction, prior to the Facility admitted residents with a known need. -The Facility failed to ensure the Medical Director was fully informed that a visitor in the Facility overdosed on what was thought to be illicit substances, requiring emergent administrator of [MEDICATION NAME] to reverse the life-threatening symptoms. -The Facility failed to ensure the Medical Director's oversight of physician services as they pertained to residents with substance abuse/use or addiction. Specifically, Resident #3 and Resident #7 were prescribed opioid medication without a comprehensive medical evaluation of risks related to use of this medication and failed to ensure that the physicians determined how the use of this medication would impact each resident's ability to attain or maintain sobriety. Findings include: 1. Surveyor #1 and Surveyor #2 interviewed the Medical Director at 12:50 P.M. on 05/04/16. The Medical Director said that she was not made aware of any residents or visitors using illegal substances or overdosing in the Facility. The Medical Director denied being aware that Resident #3 was found on 02/23/16 with a [MEDICATION NAME] needle in his/her arm and with various drug paraphernalia. The Medical Director also denied being aware of Resident #5 using heroin in the Facility on 03/18/16 and requiring the administration of [MEDICATION NAME] by emergency personnel. The Medical Director denied being aware of staff reports that within the 6 months prior to the date of interview, at least one family member had overdosed in the Facility and required the administration of [MEDICATION NAME] by emergency personnel. 2. The Medical Director said that she had been the Medical Director at the Facility for approximately two and a half years, and said that she was the medical director for the long term care units, not for the short term unit. The Medical Director said that she attended quarterly quality assessment and assurance meetings at the Facility. The Medical Director said that she did not pay attention when substance abuse related issues were discussed. The Medical Director said that she was aware that there were residents with substance abuse issues in the Facility. The Medical Director said that she did not really pay attention to those residents because she did not provide physician's services for them. The Medical Director said that the residents with substance abuse issues were admitted to the short term unit, and so were assigned to other physicians. The Medical Director said that the Facility mainly took substance abuse residents for their underlying medical issues, not to address the substance abuse. During the interview, the Medical Director repeatedly said that she did not deal with substance abuse residents at the Facility. Surveyor #2 interviewed the Administrator at 1:04 P.M. on 05/04/16. The Administrator said the Medical Director was responsible for all of the units at the Facility Resident #3 was admitted to the Facility in January 2016 with [DIAGNOSES REDACTED]. Resident #3's clinical record indicated that the Medical Director was his/her attending physician at the Facility. The record included two Physician's Progress Notes dated 03/10/16 and 03/17/16 signed by the Medical Director, which documented Resident #3's history of drug and [MEDICAL CONDITION]. Resident #6 was admitted to the Facility in November 2015 with [DIAGNOSES REDACTED]. Resident #6's clinical record indicated that the Medical Director was his/her attending physician at the Facility. The record included Physician's Progress Notes dated 11/19/15, 12/17/15, 01/21/16 and 03/31/16 signed by the Medical Director, which documented Resident #6's history of opioid dependence. Resident #10 was admitted to the Facility in April 2016 with [DIAGNOSES REDACTED]. Resident #10's clinical record indicated that the Medical Director was his/her attending physician at the Facility. The record included an admission note dated 04/16/16 signed by the Medical Director, which documented Resident #10's history of [MEDICAL CONDITION], but did not document his/her history of psychoactive substance abuse. 3. The Medical Director said that she was aware of the services provided by the company contracted with the Facility to provide addiction treatment services to some of it's residents, as she worked with the company elsewhere. The Medical Director said that she was not aware that the Facility had a contract with them. The Business Associate and Service Agreement between the addiction treatment services company and the Facility indicated that it was signed by a representative of the Facility on 11/04/15. 3. Surveyor #1 and Surveyor #2 interviewed the Assistant Director of Nursing (ADON) at 10:23 A.M. on 05/03/16. The ADON said that she confirmed with the pharmacy that the Facility's standing house order for [MEDICATION NAME] was effective starting on 12/01/15. The ADON said that meant that every resident admitted to the Facility had an order for [REDACTED]. The Medical Director said that she was not aware the Facility had implemented standing house orders for [MEDICATION NAME] for all residents in December 2015. The Medical Director said that she received a call 2 or 3 days prior to the date of interview to initiate standing house orders for [MEDICATION NAME]. The Medical Director said that she gave verbal authorization for the implementation of the standing house order for [MEDICATION NAME], but said that she did not know if the order was intended for every resident in the Facility. The Medical Director said that she did not know how the order for [MEDICATION NAME] was written out (dose, administration instructions), because she had not been in the Facility to see the order in person and had not discussed the order with the Administrator or Director of Nurses (DON). The Medical Director said that she planned to review the order and discuss it with the Administrator and DON on 05/06/16. See F 209 and F 319

Based on records reviewed and interviews, the Facility failed to identify and address quality of care concerns for residents with substance abuse issues or the potential for self-harm; and, failed to identify and address the lack of training of staff regarding the care and treatment of [REDACTED]. - On [DATE], Nurse #11 observed Resident #3 with a [MEDICATION NAME] needle in his/her right antecubital vein (vein at the inner elbow) attempting to self-inject an unknown substance, needle marks on Resident #3's arms, and additional drug paraphernalia in Resident #3's room. - On [DATE], Resident #5 was found unresponsive as a result of an apparent overdose, and told hospital staff that he/she had injected heroin at the Facility. - On [DATE], the Nurse Supervisor observed Resident #9 in the bathroom at the Facility with heroin and [MEDICATION NAME] needles, and Resident #9 admitted to hospital staff that he/she snorted heroin in the Facility. - On [DATE], Resident #10 had recommendations in place for cognitive rehabilitation and an alcohol counselor, which were not implemented. - On [DATE], Resident #12 was found with a plastic bag over his/her head in an apparent suicide attempt, after being admitted to the Facility following treatment due to a suicide attempt. - There was no indication that in response to these incidents the Facility performed a quality assessment related to the incidents of resident substance abuse or self-harm, failed to initiate plans of action, and failed to identify quality deficiencies. The Facility continued to admit residents with substance abuse issues or addiction needs without having any formal programs, staff education, or policies and procedures to ensure that the care needs of residents with substance abuse issues could be safely met at the Facility. The Facility failed, through its quality assurance program and review, to identify whether continued admission of residents with substance use/abuse or addiction care needs placed these residents, other residents, and/or staff at risk. Findings include: 1. Records reviewed for 9 of 11 sampled residents with substance abuse issues (Resident #3, Resident #5, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12 and Resident #14) indicated that there were no comprehensive medical and interdisciplinary assessments to address the resident's substance abuse needs, recent substance use, risk for relapse or the determination of the least restrictive but safe setting for care, and/or potential for self-harm. A. Resident #3's clinical record indicated that he/she was admitted to the Facility with [DIAGNOSES REDACTED]. The Substance Abuse Care Plan did not indicate that Resident #3 had a history of [REDACTED]. The Nurse's Progress Note, dated [DATE] for the 11:00 P.M. to 7:00 A.M. shift, indicated that at approximately 2:20 A.M., Nurse #11 observed Resident #3 with a [MEDICATION NAME] needle in his/her right antecubital vein (vein at the inner elbow) attempting to self-inject an unknown substance. The note indicated that Nurse #11 observed needle marks on Resident #3's arms and additional drug paraphernalia in Resident #3's room. B. Resident #5's clinical record indicated that he/she was admitted to the Facility with [DIAGNOSES REDACTED]. The record indicated that he/she had questionable use of an illegal substance, the possession of drug paraphernalia, and indicators of drug use while at a prior skilled nursing facility. The record indicated that, on the date of transfer to the Facility, hospital security found additional drug paraphernalia in Resident #5's belongings. Resident #5's care plans indicated that there was no plan of care to address and provide for the needed care and services for Resident #5's substance abuse history. The Nurse's Progress Note dated [DATE] indicated that Resident #5 was found unconscious and blue (an abnormal assessment finding indicative of inadequate oxygenation) at approximately 8:00 P.M., and cardiopulmonary resuscitation (CPR) was initiated. The note indicated that Emergency Medical Services (EMS) responded and administered [MEDICATION NAME] (a medication used to treat narcotic overdose in an emergency situation) with a positive effect. Resident #5's clinical record from Hospital #2 indicated that Resident #5 told hospital staff that he/she had injected heroin at the Facility, and that he/she wanted treatment for [REDACTED]. C. Resident #7 was admitted to the Facility with [DIAGNOSES REDACTED]. The Discharge Summary from Hospital #3, dated [DATE], indicated that Resident #7 had been treated with [MEDICATION NAME] (a medication used to treat opiate addiction) for his/her substance abuse, but had relapsed and used IV heroin 3 weeks prior to his/her hospitalization . Resident #7's care plans indicated that there was no plan of care to address and provide for the needed care and services for Resident #7's substance abuse and history of self-harm. D. Resident #8 was admitted to the Facility with [DIAGNOSES REDACTED]. The Inpatient Consult Note from Hospital #3, dated [DATE], indicated that Resident #8 had relapsed and used heroin in the months since his/her release from prison. Resident #8's care plans indicated that there was no plan of care to address and provide for the needed care and services for Resident #8's substance abuse history. E. Resident #9 was admitted to the Facility with [DIAGNOSES REDACTED]. Resident #9's care plans indicated that there was no plan of care to address and provide for the needed care and services for Resident #9's substance abuse history. Resident #9's Emergency Department Record dated [DATE] from Hospital #3 indicated that a nurse found Resident #9 in the bathroom at the Facility with heroin and [MEDICATION NAME] needles. The record indicated that Resident #9 admitted to snorting heroin in the Facility. F. Resident #10 was admitted to the Facility with [DIAGNOSES REDACTED]. Hospital #3's Psychosomatic Consult Note, dated [DATE], indicated that Resident #10 had a history of [REDACTED]. The consult indicated that Resident #10 reported that he/she last used heroin and cocaine in [DATE], and last consumed alcohol on [DATE]. Resident #10's care plans indicated that there was no plan of care in place to address and provide for the needed care and services for Resident #10's alcohol and substance abuse. G. Resident #11 was admitted to the Facility with [DIAGNOSES REDACTED]. The Transfer Summary from Hospital #2, dated [DATE], indicated that Resident #11 had eloped (left without consent or the knowledge of another person) during the initial hospitalization with the intent of obtaining and using opiates. The summary indicated that Resident #11 was given medication for opiate withdrawal, and that the social worker met with Resident #11 to discuss outpatient treatment options. The summary indicated that: Treatment and Instructions included rehabilitation for opiate abstinence. The Patient Care Referral Facility and Home Care form, dated [DATE], indicated that Resident #11 was an active heroin user. Resident #11's clinical record indicated documentation on [DATE], [DATE], [DATE], [DATE] and [DATE], indicated that Resident #11 wanted to become sober again and/or get enrolled at a [MEDICATION NAME] (a medication used to treat narcotic drug addiction and/or pain) clinic. Resident #11's care plans indicated that there was no plan of care in place to address and provide for the needed care and services for Resident #11's substance abuse, history of self-harm, or expressed request to be enrolled in a [MEDICATION NAME] program. H. Resident #12's clinical record indicated that he/she was admitted to the Facility with [DIAGNOSES REDACTED]. The record indicated that he/she was admitted to the Facility after being treated following a suicide attempt. The Mood Care Plan dated [DATE] indicated that the goals included for Resident #12 to have less thoughts of suicidal ideation. The care plan did not include measurable quantifiers, or resident-specific interventions to address Resident #12's recent suicide attempt or how to prevent potential future attempts. The Facility's Internal Investigation indicated that on [DATE], the Facility received a call from the police dispatcher. The investigation indicated that Resident #12 had called 911 and reported that he/she had a plastic bag over his/her head. The investigation indicated that staff entered Resident #12's room, found him/her with a plastic bag over his/her head and removed the bag. The investigation indicated that Resident #12 was transferred to Hospital #3 for evaluation. I. Resident #14 was admitted to the Facility with [DIAGNOSES REDACTED]. Resident #14's care plans indicated that there was no plan of care in place to address and provide for the needed care and services for Resident #14's alcohol and substance abuse. Surveyor #1 and Surveyor #2 interviewed the Clinical Nurse Evaluator at 12:39 P.M. in [DATE]. The Clinical Nurse Evaluator said that approximately 40% to 60% of new referrals for admission to the Facility were for residents with substance abuse issues. The Facility's Orientation Materials, Annual Nursing and Certified Nurse Aide (CNA) Competency Training materials, and Monthly Mandatory Inservice Calendar 2016 did not indicate any materials or scheduled trainings for Facility staff regarding the care of residents with substance abuse issues. Surveyor #1 and Surveyor #2 interviewed the Staff Development Coordinator (educator; SDC) at 10:16 A.M. on [DATE]. The SDC said that she had not seen any orientation materials regarding staff education for the care of residents with substance abuse issues, and did not provide any educational training regarding substance abuse related issues. Surveyor #1 and Surveyor #2 interviewed the Assistant Director of Nurses (ADON) at 10:24 A.M. on [DATE] and throughout the dates of survey. The ADON said that substance abuse training was not included in the Facility's Annual Nursing or CNA Competency Trainings. The ADON said that the Facility had not conducted any staff educational training regarding substance abuse, but that a Facility-contracted outside addiction treatment center had. The ADON provided the Surveyors with continuing education attendance records dated [DATE] and [DATE], with a total of 19 attendees' signatures, which were not signed by the Instructor. The ADON said the signatures did not represent all licensed staff at the Facility, and did not include any CNAs. The ADON said there had not been any other educational training at the Facility regarding the care of residents with substance abuse issues. Surveyor #1 and Surveyor #2 interviewed the Medical Director at 12:50 P.M. on [DATE]. The Medical Director said she was not aware of any educational training conducted by the Facility for staff regarding the care of residents with substance abuse issues. The Facility's Medical CQI meetings monthly attendance sheets indicated that CQI meetings were conducted on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. The Facility's CQI attendance/topic sheets indicated the Medical Director was in attendance at the quarterly meetings on [DATE] and [DATE]. The attendance sheets did not include the documentation of topics discussed at the meetings on [DATE] and [DATE]. The attendance/topic sheets did not indicate that there was a discussion of any substance abuse related issues at the meetings held on [DATE], [DATE], [DATE] and [DATE]. Surveyor #1 and Surveyor #2 interviewed the Administrator at 3:40 P.M. on [DATE]. The Administrator said that he attended the monthly CQI meeting, and said that the CQI attendance sheets included the topics discussed at the meetings on [DATE], [DATE], [DATE] and [DATE]. The Administrator said that he could not find any information about the topics discussed at the CQI meetings on [DATE] and [DATE]. The Administrator said the Facility did not have minutes for the CQI meetings held on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. The Medical Director said that she had been the Facility's Medical Director for approximately two and a half years, and attended the Facility's quarterly Medical CQI meetings. The Medical Director said she would not have paid attention to any discussions of substance abuse issues at the CQI meetings because she did not provide services to residents at the Facility with substance abuse issues. The Medical Director said that she was aware the Facility had residents with substance abuse issues.

Based on records reviewed and interviews, for 11 of 11 sampled residents with substance abuse issues (Resident #3, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13 and Resident #14), the facility failed to ensure that licensed staff were trained and provided the necessary competencies to meet the needs of residents with substance abuse issues in order to attain or maintain their safety and sobriety. Findings include: Surveyor #1 and Surveyor #2 interviewed the Clinical Nurse Evaluator at 12:39 P.M. on [DATE]. The Clinical Nurse Evaluator said that approximately 40% to 60% of new referrals for admission to the Facility were for residents with substance abuse issues. 1. The Facility's Orientation Materials did not include any information related to staff education regarding the care of residents with substance abuse and related issues. Surveyor #1 and Surveyor #2 interviewed the Staff Development Coordinator (educator; SDC) at 10:16 A.M. on [DATE]. The SDC said that she had been employed at the Facility for two weeks. The SDC said that she was not provided with any educational training on substance abuse during her orientation, which was conducted by the Assistant Director of Nursing (ADON). The SDC said she had conducted orientation for 3 new staff members within a week prior to the date of interview, including a licensed weekend nurse supervisor, and had not provided any training regarding residents with substance abuse issues. The SDC said that she had not seen any orientation materials regarding the education of staff on residents with substance abuse issues. Surveyor #1 and Surveyor #2 interviewed Social Worker #2 at 9:31 A.M. on [DATE]. Social Worker #2 said that she had been employed at the Facility for approximately 6 weeks. Social Worker #2 said that she had not received any training on substance abuse issues at orientation. 2. The Facility's Annual Nursing Competency Training materials did not include any education regarding the care of residents with substance abuse and related issues. Surveyor #1 and Surveyor #2 interviewed the ADON at 10:24 A.M. on [DATE] and throughout the survey. The ADON said that educational training on [MEDICATION NAME] (a medication used to treat narcotic overdose in an emergency situation), [MEDICATION NAME] (a medication used to treat narcotic drug addiction and/or pain) and substance abuse was not included in the Facility's Annual Nursing Competency Training. 3. The Facility's Monthly Mandatory Inservice Calendar 2016 did not indicate that there were any scheduled inservices to provide staff with education regarding substance abuse and related issues. The ADON said that she was the Facility's SDC from [DATE] through mid-[DATE]. The ADON said that the Facility had admitted residents who were known to be active substance abusers. The ADON said that the Facility had not conducted any staff educational training regarding substance abuse, but that a Facility-contracted outside addiction treatment center had. The ADON provided the Surveyors with a continuing education attendance record entitled: [MEDICATION NAME]/[MEDICATION NAME], dated for [DATE] with 15 signatures of attendees. The ADON said that the signatures indicated 15 staff members (14 licensed nurses and one speech language pathologist) had been educated on the administration of [MEDICATION NAME] and [MEDICATION NAME], but not substance abuse issues. The record indicated that it was signed by the ADON as the Staff Development Coordinator, but not signed by the Instructor. The ADON provided the Surveyors with another continuing education attendance record entitled: (addiction treatment center) Patients, dated for [DATE] with 4 signatures of attendees. The ADON said that the signatures indicated 4 licensed staff members had been educated on the treatment center's [MEDICATION NAME] program. The record was not signed by the Instructor or by the Staff Development Coordinator. The ADON said there had not been any other educational training on [MEDICATION NAME] or substance abuse at the Facility, and said that the signatures did not represent all licensed staff at the Facility. The SDC said that she did not provide any educational training on [MEDICATION NAME] or substance abuse issues. 4. The Clinical Nurse Evaluator said that she knew training had been done regarding the Facility's [MEDICATION NAME] protocol, and thought that the Facility's behavioral health provider had provided some training, but said that she did not know the contents of the trainings. Surveyor #1 interviewed Nurse #8 at 4:09 P.M. on [DATE]. Nurse #8 said that she had not been provided with any educational training on substance abuse at the Facility. Nurse #8 said that the nurses at the Facility learn from each other,or words to that effect. Surveyor #1 and Surveyor #2 interviewed Nurse #11 at 2:33 P.M. on [DATE]. Nurse #11 said that she had been employed at the Facility since [DATE], and had never received training from the Facility regarding substance abuse issues. Surveyor #1 and Surveyor #2 interviewed Social Worker #1 at 12:03 P.M. on [DATE]. Social Worker #1 said that the Facility had admitted residents with substance abuse. Social Worker #1 said that she was not aware of the Facility providing any staff education regarding substance abuse issues, and had not been involved in any substance abuse educational training. Social Worker #2 said that the Facility had a contract with an outside addiction treatment center, but was not aware of any training they might have provided regarding substance abuse issues. Surveyor #1 and Surveyor #2 interviewed the Director of Social Services at 3:13 P.M. on [DATE]. The Director of Social Services said she had been employed at the Facility for approximately one month and had not received any educational training on substance abuse. The Director of Social Services said she did not know if the Facility-contracted behavioral health center offered any substance abuse education. Surveyor #1 and Surveyor #2 interviewed the Medical Director at 12:50 P.M. on [DATE]. The Medical Director said that she was not aware of any educational training conducted at the Facility on substance abuse issues. The Medical Director said that she did not provide any guidance or education on substance abuse. - Resident #3 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. The Nurse's Progress Note, dated [DATE] for the 11:00 P.M. to 7:00 A.M. shift, indicated that at approximately 2:20 A.M., Nurse #11 entered Resident #3's room and observed him/her sitting in front of the bedside table with a [MEDICATION NAME] needle in his/her right antecubital vein (vein at the inner elbow) attempting to self-inject an unknown substance. The note indicated that Nurse #11 observed additional drug paraphernalia in Resident #3's room, and needle marks on Resident #3's arms. - Resident #5's clinical record indicated that he/she was transferred to Hospital #1 from another skilled nursing facility after questionable use of an illegal substance, possession of drug paraphernalia and observed fresh track marks (injection sites). The record indicated that hospital security found additional drug paraphernalia in Resident #5's belongings. The Nurse's Progress Note, dated [DATE], indicated that Resident #5 was found unconscious and blue (an abnormal assessment finding indicative of inadequate oxygenation) at approximately 8:00 P.M., and cardiopulmonary resuscitation (CPR) was initiated. The note indicated that Emergency Medical Services (EMS) responded and administered [MEDICATION NAME] (a medication used to treat narcotic overdose in an emergency situation) with a positive effect. The Police Report, dated [DATE], indicated that Resident #5 was unresponsive prior to the administration of 2 doses of [MEDICATION NAME] by the Fire Department and EMS, and was then transported to Hospital #2. Resident #5's clinical record from Hospital #2 indicated that Resident #5 stated to EMS personnel that he/she had used heroin, and told hospital staff that he/she had injected heroin at the Facility. - Resident #9's Emergency Department Record, dated [DATE], from Hospital #3 indicated that a nurse found Resident #9 in the bathroom at the Facility with heroin and [MEDICATION NAME] needles. The record indicated that Resident #9 admitted to snorting heroin in the Facility.

Based on records reviewed, observations and interviews, for 5 of 14 sampled residents (Resident #3, Resident #5, Resident #9, Resident #12 and Resident #13), the facility failed to provide the necessary supervision to prevent substance abuse, a suicide attempt, and/or an elopement from the Facility. Findings include: 1. Resident #3 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. The Substance Abuse Care Plan, dated [DATE], indicated that Resident #3 had a history of [REDACTED].#3 had a history of [REDACTED].#3 had the potential for complications such as recurrence of substance use, and that goals included that Resident #3 would have no alcohol or drugs hidden in his/her room or brought to him/her by visitors. The Care Plan did not include interventions in regards to how staff were to determine whether Resident #3 had alcohol or drugs hidden in his/her room, or how staff were to prevent visitors from bringing Resident #3 drugs or alcohol. The Nurse's Progress Note, dated [DATE] for the 11:00 P.M. to 7:00 A.M. shift, indicated that at approximately 2:20 A.M., Nurse #11 observed Resident #3 with a hypodermic needle in his/her right antecubital vein (vein at the inner elbow) attempting to self-inject an unknown substance. The note indicated that Resident #3 said that it was the first time he/she had ever done that, but that Nurse #11 observed needle marks on Resident #3's arms and additional drug paraphernalia in Resident #3's room. Surveyor #1 and Surveyor #2 interviewed Nurse #11 at 2:33 P.M. on [DATE]. Nurse #11 said that she had observed Resident #3 with a syringe in his/her arm on [DATE], attempting to self-inject a substance. Nurse #11 said that she had not been informed on admission that Resident #3 was an active substance user. 2. Resident #5 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. Resident #5's clinical record indicated that he/she was transferred to Hospital #1 from another SNF after questionable use of an illegal substance, possession of drug paraphernalia including a hypodermic needle and observed fresh track marks (injection sites) to Resident #5's left inner elbow. The record indicated that hospital security found additional drug paraphernalia in Resident #5's belongings, including a packet of an unknown powdered substance. Surveyor #1 and Surveyor #2 interviewed the Clinical Nurse Evaluator at 12:39 P.M. on [DATE]. The Clinical Nurse Evaluator said that Resident #5's preadmission paperwork contained information from Hospital #1, which included documentation that Resident #5 had been found with drug paraphernalia in his/her possession at his/her prior SNF and at Hospital #1. There was no documentation at the time of survey that interventions to supervise or monitor Resident #5 for potential relapse of substance use were in place. The Nurse's Progress Note, dated [DATE], indicated that Resident #5 was found unconscious and blue (an abnormal assessment finding indicative of inadequate oxygenation) at approximately 8:00 P.M., and cardiopulmonary resuscitation (CPR) was initiated. The note indicated that Emergency Medical Services (EMS) responded and administered Narcan (a medication used to treat narcotic overdose in an emergency situation) with a positive effect. Resident #5's clinical record from Hospital #2 indicated that Resident #5 told hospital staff that he/she had injected heroin at the Facility, and that he/she wanted treatment for [REDACTED]. 3. Resident #9 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. There was no documentation at the time of survey that interventions to supervise or monitor Resident #9 for potential relapse of substance use were in place. Resident #9's Emergency Department Record, dated [DATE], from Hospital #3 indicated that Resident #9 was sent to Hospital #3 after a nurse found him/her in the bathroom at the Facility with heroin and hypodermic needles. The record indicated that while in the emergency department, Resident #9 admitted to snorting heroin in the Facility. The Facility's Accident/Incident Report and Investigation, dated [DATE], indicated that the Nursing Supervisor was approached by an Emergency Medical Technician (EMT), who reported seeing Resident #9 exchanging money for an unknown item in the parking lot of the Facility. The report indicated that the Nursing Supervisor found Resident #9 in his/her bathroom with a bag containing hypodermic needles and a baggie with a powdery substance in it, which Resident #9 identified as heroin. The report indicated that Resident #9 reported that someone from outside of the Facility brought him/her the heroin. 4. Resident #11 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. The Transfer Summary from Hospital #2, dated [DATE], indicated that Resident #11 had eloped during the initial hospitalization with the intent of obtaining and using opiates. The Nurse's Progress Note, dated [DATE] during the 7:00 A.M. to 3:00 P.M. shift, indicated that Resident #11 was exhibiting some exit seeking behaviors. There was no documentation at the time of survey that an elopement assessment was completed at the time of Resident #11's admission. 5. Resident #12 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. Resident #12's clinical record indicated that he/she was admitted to the Facility from an acute care hospital, where he/she was treated after a suicide attempt. The physician's orders [REDACTED].#12 every shift for sign or symptoms of suicidal ideation (thoughts of harming oneself). There was no documentation at the time of survey that Resident #12 was monitored every shift for signs or symptoms of suicidal ideation. The Mood Care Plan, dated [DATE], indicated that the goals included for Resident #12 to have less thoughts of suicidal ideation. The care plan did not include measureable quantifiers, or resident-specific interventions to address Resident #12's recent suicide attempt or potential future attempts. The Facility's Internal Investigation indicated that on [DATE], the Facility received a call from the police dispatcher. The investigation indicated that Resident #12 had called 911 and reported that he/she had a plastic bag over his/her head. The investigation indicated that staff entered Resident #12's room, found him/her with a plastic bag over his/her head and removed the bag. The investigation indicated that Resident #12 was transferred to Hospital #3 for evaluation. Surveyor #1 and Surveyor #2 interviewed Nurse #13 at 1:29 P.M. on [DATE]. Nurse #13 said that she received a telephone call from the police dispatcher, who said that Resident #12 called and said he/she had a plastic bag over his/her head and wanted to kill himself/herself. Nurse #13 said that Certified Nurse Aide (CNA) #8 went down to Resident #12's room, pulled the bag off of his/her head, and stayed with him/her until emergency services could transport him/her to the hospital. Nurse #13 said that Resident #12 had not expressed any suicidal ideation to her, but said that she knew Resident #12 had been admitted to the Facility after attempting suicide. Nurse #13 said that staff would monitor Resident #12 by asking Resident #12 if he/she had thoughts of harming himself/herself whenever staff saw him/her. 6. Resident #13 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. to communicate via written and/or spoken language). There was no documentation at the time of survey that an Elopement Risk Screen was completed at the time of Resident #13's admission, in accordance with the Facility's Elopement Policy and Procedure. Surveyor #1 and Surveyor #2 interviewed CNA #10 at 2:51 P.M. on [DATE]. CNA #10 said that on [DATE], Resident #13's roommate came to the nurses' station and reported that he/she had not seen Resident #13 in a while. Surveyor #1 and Surveyor #2 interviewed CNA #11 at 1:02 P.M. on [DATE]. CNA #11 said that a nurse asked her to go get Resident #13. CNA #11 said that she looked everywhere for Resident #13 and was unable to locate him/her. The Facility's Accident/Incident Report and Investigation form dated [DATE] indicated that Resident #13 was last seen in his/her room by Nurse #8 at approximately 5:30 P.M. The form indicated that Nurse #8 told Resident #13 to wait in his/her room for a scheduled dose of medication, but that Resident #13 could not be found at 6:00 P.M. The form indicated that Resident #13 was located, some unknown time later, at a family member's residence (approximately 3.5 miles from the Facility). The form indicated that Resident #13 said that he/she walked to the residence. The form did not indicate how Resident #13 was able to exit the Facility. Observations throughout the dates of survey, and review of the Facility's Floor Plan, indicated that Resident #13's room was located on a secured unit, which required a keypad code to deactivate the alarms at each exit door. Signs posted next to the keypads indicated that staff were not to provide the alarm codes to residents or visitors. Surveyor #1 and Surveyor #3 interviewed CNA #5 at 2:42 P.M. on [DATE]. CNA #5 said that staff were responsible for entering the keypad alarm codes whenever someone wanted to go through an alarmed door, regardless of who the person was.

Based on records reviewed and interviews, for 9 out of 14 sampled residents (Resident #3, Resident #5, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12 and Resident #14) with known substance abuse issues, the facility failed to develop care plans to address the residents' substance abuse issues and potential need for addiction treatment services, and/or the residents' potential for self-harm. Findings include: Surveyor #1 and Surveyor #2 interviewed Social Worker #2 at 9:31 A.M. on [DATE]. Social Worker #2 said that [DATE] was her first day of employment at the Facility. Social Worker #2 said that as of the date of interview, she had not been trained on how to create or implement care plans. Surveyor #1 and Surveyor #2 interviewed the Director of Social Services at 3:13 P.M. on [DATE]. The Director of Social Services said that any resident with substance abuse issues or a history of self-harm should have a care plan in place. A. Resident #3 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. The Substance Abuse Care Plan, dated [DATE], indicated that Resident #3 had a history of [REDACTED].#3 had a history of [REDACTED].#3 had the potential for complications such as recurrence of substance use, and that the goals included that Resident #3 would have no alcohol or drugs hidden in his/her room or brought to him/her by visitors. The Care Plan approaches included to assess, record, report to physician signs and symptoms of substance abuse or misuse. The Nurse's Progress Note, dated [DATE] for the 11:00 P.M. to 7:00 A.M. shift, indicated that at approximately 2:20 A.M., Nurse #11 observed Resident #3 with a [MEDICATION NAME] needle in his/her right antecubital vein (vein at the inner elbow) attempting to self-inject an unknown substance. The note indicated that Resident #3 said that it was the first time he/she had ever done that, but that Nurse #11 observed needle marks on Resident #3's arms and additional drug paraphernalia in Resident #3's room. The Substance Abuse Care Plan was updated on [DATE] to include twice a day room searches on the 7:00 A.M. to 3:00 P.M. and 3:00 to 11:00 P.M. shifts. The care plan did not indicate who should conduct the room searches, or what to look for. The Social Service Progress Note, dated [DATE], indicated that Social Worker #1 was aware that Resident #3 had used an illegal substance while a resident at a prior skilled nursing facility (SNF). The Social Service Progress Notes, dated [DATE] and [DATE], did not indicate that the social services plan included interventions to address Resident #3's known history of substance abuse, or that any assessment was conducted related to Resident #3's IV drug use. There was no documentation at the time of survey that Resident #3's care plan included interventions on how to prevent Resident #3 from having alcohol or drugs hidden in his/her room or brought to him/her by visitors, or to address the potential of Resident #3 retaining pain medications and later attempting to inject them. B. Resident #5 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. Resident #5's clinical record indicated that he/she was transferred to Hospital #1 from another SNF after questionable use of an illegal substance, possession of drug paraphernalia and observed fresh track marks (injection sites). The record indicated that hospital security found additional drug paraphernalia in Resident #5's belongings. Resident #5's care plans indicated that there was no plan of care to address and provide for the needed care and services for Resident #5's substance abuse history. The Social History and Initial Assessment, dated [DATE], indicated that Resident #5 said that he/she had a history of [REDACTED]. The Psychiatric Diagnostic Consultation, dated [DATE], indicated that Resident #5 had a history of [REDACTED].#5's potential drug use at his/her prior SNF, identify services needed related to Resident #5's substance abuse issues, or identify interventions to supervise or monitor Resident #5. The Behavioral Health Consultation and Treatment Plan, dated [DATE], indicated that Resident #5 had a history of [REDACTED]. The Nurse's Progress Note, dated [DATE], indicated that Resident #5 was found unconscious and blue (an abnormal assessment finding indicative of inadequate oxygenation) at approximately 8:00 P.M., and cardiopulmonary resuscitation (CPR) was initiated. The note indicated that Emergency Medical Services (EMS) responded and administered [MEDICATION NAME] (a medication used to treat narcotic overdose in an emergency situation) with a positive effect. Resident #5's clinical record from Hospital #2 indicated that Resident #5 told hospital staff that he/she had injected heroin at the Facility, and that he/she wanted treatment for [REDACTED]. C. Resident #7 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. The Discharge Summary from Hospital #3 dated [DATE] indicated that Resident #7 had been treated with [MEDICATION NAME] (a medication used to treat opiate addiction) for his/her substance abuse, but had relapsed and used IV heroin 3 weeks prior to his/her hospitalization . The summary indicated that Resident #7 had been unable to restart [MEDICATION NAME] because he/she could not afford to fill the prescription, and was planned for outpatient follow up with a sobriety program. Resident #7's care plans indicated that there was no plan of care to address and provide for the needed care and services for Resident #7's substance abuse and history of self-harm. Social Worker #2 said that there was no care plan in place to address Resident #7's history of substance abuse or self-harm. D. Resident #8 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. The Inpatient Consult Note from Hospital #3, dated [DATE], indicated that Resident #8 had relapsed and used heroin in the months since his/her release from prison. Resident #8's care plans indicated that there was no plan of care to address and provide for the needed care and services for Resident #8's substance abuse history. E. Resident #9 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. The Psychiatric Diagnostic Consultation, dated [DATE], did not include interventions to address Resident #9's substance abuse. Resident #9's care plans indicated that there was no plan of care to address and provide for the needed care and services for Resident #9's substance abuse history. Resident #9's Emergency Department Record, dated [DATE], from Hospital #3 indicated that a nurse found Resident #9 in the bathroom at the Facility with heroin and [MEDICATION NAME] needles. The record indicated that while in the emergency department, Resident #9 admitted to snorting heroin in the Facility. F. Resident #10 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. - Hospital #3's Psychosomatic Consult Note, dated [DATE], indicated that Resident #10 had a history of [REDACTED]. The consult indicated that Resident #10 reported that he/she last used heroin and cocaine in [DATE], and last consumed alcohol on [DATE]. The Neurologist's Consultation Note, dated [DATE], indicated that Resident #10 was recommended for cognitive rehabilitation and an alcohol counselor. Surveyor #2 interviewed Nurse #7 at 11:05 A.M. on [DATE]. Nurse #7 said that she had worked at the Facility for over a year. Nurse #7 said that the Neurologist's recommendations from [DATE] for Resident #10 to have cognitive rehab and alcohol counselor had not been implemented because she did not know where to obtain those services for Resident #10. - The Facility's Admission Checklist indicated that admission paperwork must be completed 24 hours from the time of admission. Resident #10's clinical record indicated that the following assessments were not completed: Admission Checklist, Fall Risk Admission Checklist, Fall Risk Evaluation, Pain Evaluation, Oral Exam, Side Rail Assessment Form, Weekly Skin Audit, Occasional/Former Smoker Evaluation, Smoking Safety Screen, Abnormal Involuntary Movement Scale, and the Dehydration Evaluation. Nurse #7 said that Resident #10's admission nursing assessments had not been completed as of [DATE]. Resident #10's care plans indicated that the Facility did not have a plan of care in place to address and provide for the needed care and services for Resident #10's alcohol and substance abuse. G. Resident #11 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. The Transfer Summary from Hospital #2, dated [DATE], indicated that Resident #11 had eloped (left without consent or the knowledge of another person) during the initial hospitalization with the intent of obtaining and using opiates. The summary indicated that Resident #11 was given [MEDICATION NAME] (a medication used to treat narcotic drug addiction and/or pain) for opiate withdrawal, and that the social worker met with Resident #11 to discuss outpatient treatment options. The summary indicated that: Treatment and Instructions included rehabilitation for opiate abstinence. The Patient Care Referral Facility and Home Care form, dated [DATE], indicated that Resident #11 was an active heroin user. The History and Physical dated [DATE], and the Physician's Progress Notes dated [DATE], [DATE] and [DATE], indicated that Resident #11 wanted to get enrolled at a [MEDICATION NAME] clinic. The Occupational Therapy Evaluation and Plan of Treatment, dated [DATE], indicated that Resident #11's goals included getting sober again and taking care of himself/herself. Resident #11's care plans indicated that the Facility did not have a plan of care in place to address and provide for the needed care and services for Resident #11's substance abuse, history of self-harm, or expressed request to be enrolled in a [MEDICATION NAME] program. H. Resident #12 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. Resident #12's clinical record indicated that he/she was admitted to the Facility from an acute care hospital, where he/she was treated following a suicide attempt. The Mood Care Plan, dated [DATE], indicated that the goals included for Resident #12 to have less thoughts of suicidal ideation. The care plan did not include measureable quantifiers, or resident-specific interventions to address Resident #12's recent suicide attempt or how to prevent potential future attempts. The Facility's Internal Investigation indicated that on [DATE], the Facility received a call from the police dispatcher. The investigation indicated that Resident #12 had called 911 and reported that he/she had a plastic bag over his/her head. The investigation indicated that staff entered Resident #12's room, found him/her with a plastic bag over his/her head and removed the bag. The investigation indicated that Resident #12 was transferred to Hospital #3 for evaluation. Surveyor #1 and Surveyor #2 interviewed Nurse #13 at 1:29 P.M. on [DATE]. Nurse #13 said that she received a telephone call from the police dispatcher, who said that Resident #12 called and said he/she had a plastic bag over his/her head and wanted to kill himself/herself. Nurse #13 said that CNA #8 went to Resident #12's room, pulled the bag off of his/her head, and stayed with Resident #12 until emergency services could transport him/her to the hospital. I. Resident #14 was admitted to the Facility in [DATE] with [DIAGNOSES REDACTED]. There was no documentation at the time of survey that an assessment was conducted regarding Resident #14's substance abuse issues, or that a plan of care was developed to address and provide for the needed care and services for Resident #14's alcohol and substance abuse.

Based on record review and staff interview, the facility failed to maintain/restore as much normal bladder function as possible for 1 (#6) of 15 sampled residents with urinary incontinence, in a total sample of 24. Findings include: For Resident #6, the facility failed to assess bladder function and implement appropriate interventions to restore or maintain as much normal bladder function as possible when the resident had a decline in bladder continence. Resident #6 was admitted to the facility in 2/2014 with [DIAGNOSES REDACTED]. Review of the facility's Continence Management Policy with a revision date of 2/1/10, indicated the following; -The Urinary Incontinence Assessment will be completed if the resident is incontinent upon admission or re-admission with a change in status. Continence status will be reviewed with a change in continence. -The purpose is to provide appropriate treatment and services to minimize urinary tract infections and restore as much normal elimination function as possible. Further review of the Policy indicated the process as the following; -If the resident is incontinent, complete Urinary Incontinence Assessment, part A. -Address transient causes before initiating the Three Day Continence Diary. -Develop plan of care based on information from the assessments and Three Day Continence Diary. -Review the assessment and complete the Program Evaluation section at the next care plan or Weekly at Risk meeting. -Monitor resident for changes and implement revisions to the plan of care as needed. Review of the Admission Resident-Data Collection dated 2/26/14 and completed by nursing, indicated the resident was continent of bladder. Review of the Three Day Continence Dairy dated 2/26/14 (completed 3/1/14) and Urinary Incontinence assessment dated [DATE], indicated the resident was continent of bladder. Review of the 3/4/14 Admission Minimum Data Set (MDS) and 5/27/14 Quarterly MDS Assessments, indicated the resident had moderate cognitive impairment, was independent for toilet use and was always continent of bladder. Review of the May 2014 Resident Daily Flowsheet indicated the resident was always continent of bladder. Review of the Interdisciplinary Team Meeting Form dated 6/10/14, indicated the resident was continent of bladder. Review of the June 2014 Resident Daily Flowsheet indicated the resident was continent of bladder for the following shifts/days; -11:00 P.M.-7:00 A.M. shift: 6/1/14 through 6/24/14, -7:00 A.M.-3:00 P.M. shift: 6/1/14 through 6/9/14, 6/11/14 through 6/18/14, 6/21/14, 6/24/14, 6/26/14 and 6/27/14, and -3:00 P.M.-11:00 P.M. shift: 6/1/14 through 6/18/14 and on 6/21/14, 6/24/14, 6/26/14 and 6/27/14. Review of the Licensed Nursing Summary dated 6/25/14, indicated the resident was incontinent of bladder. Review of a Three Day Continence Dairy dated 6/25/14 through 6/29/14, indicated 22 of 51 documented episodes showed urinary incontinence. Review of the nurse's notes dated 7/2/14, indicated the resident was hospitalized for [REDACTED]. A nurse's note dated 7/7/14, indicated the resident was readmitted to the facility Review of the 7/2014 Resident Daily Flow Sheets, indicated the resident was incontinent of bladder for the following shifts/days: -11:00 P.M.-7:00 A.M. shift: all days except 7/3/14, 7/5/14, 7/6/14 and 7/12/14, -7:00 A.M.-3:00 P.M. shift: all days except 7/3/14 through 7/7/14 and 7/30/14, and -3:00 P.M.-11:00 P.M. shift: all days except 7/2/14, 7/3/14, 7/5/14 and 7/6/14. Review of Three Day Continence Diary dated 7/8/14 through 7/12/14, indicated 11 of 33 documented episodes showed urinary incontinence. Review of the Licensed Nursing Summary dated 7/26/14, indicated the resident was incontinent of bladder Review of the 8/12/14 Quarterly MDS Assessment indicated the resident was cognitively intact, an extensive assist for toileting and was always incontinent of bladder. Review of the 8/2014 Resident Daily Flow Sheets, indicated the resident was incontinent of bladder for all days except for 3 days (8/1, 8/13 and 8/28) on the 7:00 A.M.-3:00 P.M. and 1 day (8/1) on the 3:00 P.M.-11:00 P.M. shift. Review of a nurse's note dated 8/21/14 indicated the resident had an antibiotic ordered to treat his/her urinary tract infection. Review of the Licensed Nursing Summary dated 8/26/14, indicated the resident was incontinent of bladder. Review of the 9/2014 Resident Daily Flowsheet (9/1 through 9/17) indicated the resident was always incontinent of bladder for all shifts. Review of the Interdisciplinary Team Meeting Form dated 9/2/14 indicated the resident was incontinent of bladder. During an interview on 9/18/14 at 9:45 A.M., Unit Manager #1 (UM) said the resident now required 2 assist for toileting and was incontinent. He said the resident has had a recent, steady overall decline in his/her condition. During an interview on 9/18/14 at 10:15 A.M., the MDS Coordinator said that the resident should have had a complete bladder and bowel assessment after being readmitted in July when the incontinence was identified and when the 8/12/14 Quarterly MDS Assessment was done. During an interview on 9/18/14 at 1:30 P.M., the Director of Nursing said the resident should have had a complete bladder assessment after his/her incontinence was identified. She said that after the Three Day Continence Dairy was completed in June and July, further assessment and interventions should have been implemented per the facility's policy to help restore his/her bladder continence.

Based on interviews and record review, for 1 of 5 sampled residents (Resident #5), the facility failed to ensure that the nursing staff followed the manufacturer's recommendations and the Facility's protocol for mechanical lift transfers. On 7/24/13 Certified Nurse Aide (CNA) #13 transferred Resident #5 without another staff member present for the entire process and did not keep the adjustable base in its widest position during transfer, per the manufacturer's recommendations and the Facility protocol. The mechanical lift tipped and staff lowered Resident #5 to the floor. Nurse #4 notified the physician of Resident #5's fall and he ordered an x-ray for the following morning. The Radiology Report, dated 7/25/13, indicated that Resident #5 suffered a fractured femur. Findings include: The Face Sheet indicated that the Facility admitted Resident #5 in September 2008. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 6/4/13, indicated that Resident #5 was alert and oriented and dependent for transfers. The Certified Nurse Aide (CNA) Kardex and Plan of Care regarding falls, dated 6/5/13, included: 2 assist with the mechanical lift for transfers. The mechanical lift User Manual indicated that the manufacturer recommended 2 staff assist for all lift preparation and transfers. The User Manual indicated that before lifting the patient, the adjustable lift base must be opened to its maximum open position for optimal stability and safety. The Surveyor interviewed the Staff Development Coordinator (SDC) on 9/4/13 at 7:55 A.M. The SDC said the CNAs completed an annual mechanical lift competency that included to set the lift base at its widest position to assure the highest level of stability. The SDC said during the competency, she emphasized that 2 staff must be present when the mechanical lift was used for transfers. The Clinical Competency Evaluation for mechanical lifts, dated 4/16/13, indicated that CNA #13 met the critical elements of the competency. The Nurse's Note, dated 7/24/13 at 11:00 P.M., and written by Nurse #4, indicated that at 10:30 P.M., the CNA reported they (they not identified) were using the mechanical lift when the mechanical lift tipped and they lowered Resident #5 to the floor. The Nurse's Note indicated that Resident #5 was alert and oriented and complained of left knee pain. The Nurse's Note indicated that Nurse #4 notified the physician of Resident #5's fall and he ordered an x-ray for the following morning. The Radiology Report, dated 7/25/13, indicated that Resident #5 suffered a fractured femur. The Surveyor interviewed Nurse #4 on 9/4/13 at 2:55 P.M. Nurse #4 said her nurse's note referred to CNA #13 and CNA #15. Nurse #4 said CNA #13 reported that she and CNA #15 attempted to transfer Resident #5 to bed via the mechanical lift and had to lower Resident #5 to the floor. Nurse #4 said CNA #15 told her CNA #13 had asked him for assistance and when he arrived at Resident #5's door, CNA #13 was raising Resident #5 out of the wheelchair. Nurse #4 said CNA #15 reported he was in Resident #5's doorway when the mechanical lift tipped. Nurse #4 said after Resident #5's fall, she pulled the mechanical lift from service for the Maintenance Director to examine. The Surveyor interviewed CNA #13 on 9/4/13 at 1:00 P.M. CNA #13 said that on the evening of 7/24/13, she asked CNA #15 to assist with Resident #5's transfer to bed. CNA #13 said she hooked the lift pad up to the mechanical lift and opened the base of the mechanical lift to the maximum open position. CNA #13 said she did not raise Resident #5 out of the wheelchair until CNA #15 arrived at the door of Resident #5's room. CNA #13 said CNA #15 moved Resident #5's wheelchair out of the way after Resident #5 was raised. CNA #13 said space to maneuver the mechanical lift was tight so she closed the base of the lift half-way. CNA #13 said the casters of the lift tended to stick and on that night a caster stuck. CNA #13 said when the caster stuck she attempted to move the mechanical lift and it began to tip. CNA #13 said she and CNA #15 attempted to prevent the mechanical lift from tipping over and could not CNA #13 said she thought she had spoken to nurses about the casters of the mechanical lift sticking. The Surveyor interviewed CNA #15 on 9/4/13 at 3:10 P.M. CNA #15 said when CNA #13 asked him for assistance with transferring Resident #5, CNA #15 said he finished with a resident's care then proceeded to Resident #5's room. CNA #15 said as he arrived in the doorway he observed that CNA #13 had raised Resident #5 up out of and away from the wheelchair and was moving the lift toward the bed. CNA #15 said he observed the mechanical lift starting to tip. CNA #15 said he ran into the room and attempted to help stabilize the mechanical lift, could not, and lowered Resident #5 to the floor. CNA #15 said he did not notice the position of the mechanical lift base. CNA #15 said occasionally the caster on the mechanical lift stuck and would correct with 2 staff present to maneuver the lift back and forth. The Surveyor interviewed Resident #5 on 9/4/13 at 11:15 A.M. Resident #5 said CNA #13 attempted to transfer him/her via the mechanical lift without assistance. Resident #5 said CNA #13 hooked the pad to the mechanical lift, raised him/her out of the wheelchair with the lift, and started to move the mechanical lift away from the wheelchair. Resident #5 said he/she did not observe the position of the mechanical lift base. Resident #5 said he/she was facing the window (with his/her back to the door). Resident #5 said during this time there was no other staff in the room. Resident #5 said suddenly the mechanical lift began rocking then tipped to the left. Resident #5 said there was no sudden change or jolt in the lift's movement just prior to the fall. The Surveyor interviewed Nurse #3, a day shift nurse, on 9/4/13 at 12: 50 P.M. and Nurse #4, an evening shift nurse, on 9/4/13 at 2:55 P.M. Nurse #3 and Nurse #4 said no one had reported to them any concerns with the mechanical lift on the Long Term Care Unit. The Surveyor interviewed the Director of Nurses (DON) on 9/4/13 at 8:30 A.M. The DON said the investigation determined CNA #13 attempted to transfer Resident #5 without assistance. The DON said when she interviewed CNA #13, she did not report any problems with the mechanical lift's function. The DON said the only issue with the mechanical lift was that the caster occasionally stuck and easily unstuck with movement. At the time of the survey, the mechanical lift remained out of service in the maintenance department. The Surveyor reviewed copies of the Maintenance Log for June and July 2013. The Log indicated that staff had not documented any complaints regarding the mechanical lift function on Resident #5's Unit prior to Resident #5's fall. The Surveyor interviewed the Maintenance Director on 9/4/13 at 8:10 A.M. The Maintenance Director said he had not received any verbal complaints from staff regarding the mechanical lift on Resident #5's unit. The Maintenance Director said he examined the mechanical lift the day after Resident #5's fall and initially found no problems with its function. The Maintenance Director said when he attempted to return the lift to the Long Term Care Unit the right rear caster stuck. The Maintenance Director said it corrected with movement however, he kept the lift out of service and ordered new casters.

Based on observation, record review and interview, the facility failed to provide the necessary care and services to ensure effective pain control for 1 resident (#4) in a total sample of 24. The findings included: Resident #4 had [DIAGNOSES REDACTED]. Observation of the Resident on 4/14/11 at 9:15 A.M. revealed the Resident seated in her room eating breakfast. The Surveyor asked about daily life at the facility and the Resident responded about an inability to sleep at night. The Resident went on to say that the left ankle pain she had was an ongoing issue which caused prolonged discomfort and lack of sleep. On 4/14/11 at 10:30 A.M., the Surveyor observed the treatment to the Resident's left ankle venous ulcer. The dressing was being changed by two nurses. The Surveyor observed the resident grimacing, but non-vocal during cleansing with normal saline application. The Resident was asked by the Surveyor if she was experiencing pain and the response was "yes it hurts." The Surveyor then inquired of the Resident's nurse about medicating the resident prior to the dressing change. The nurse responded that she was a per diem and not familiar with the Resident. The Surveyor then inquired of the nurse manager about pain management prior to the dressing change. The nurse manager responded that the resident had a standing order for Tylenol 500 milligrams, by mouth three times per day at 9:00 A.M., 1:00 P.M. and 9:00 P.M.. On 4/19/11 at 9:30 A.M., the Resident was observed eating breakfast. The Surveyor asked the Resident how her weekend was. The response was "terrible because I didn't sleep well." The Surveyor further inquired why the Resident did not sleep well and the Resident responded that her ankle was "throbbing." The Surveyor then asked if the staff had provided pain medication or elevated the left foot and the Resident responded "sometimes." The Minimum Data Set (MDS) review for 4/14/11 and 4/19/11 revealed the most recent quarterly MDS was completed 1/26/11. The MDS indicated that the resident was cognitively impaired and required extensive assistance with bathing and dressing. The MDS Pain Assesssment Interview scored the resident with a pain intensity level of 6 out of 10 and pain frequency 3, meaning occasionally. Review of the current care plan for pain management included the following approaches: monitor and record complaints of pain, monitor and report alternative medications with physician, reposition in bed for comfort, elevate left ankle, pressure reducing mattress on bed, heel protectors while in bed, administer physician ordered pain medication of Tylenol 500 milligrams (mg) by mouth three times per day. Review of the daily log/ record book revealed an entry dated 4/8/2011 stating that the Resident's daughter (health care proxy) notified the facility that the Resident was in pain and therefore having difficulty sleeping. The daughter wanted the physician contacted for pain medication adjustment. The physician was notified and [MEDICATION NAME] 50 milligrams with two extra strength tylenol three times per day, as needed was ordered on [DATE] 3-11pm shift. Review of the weekly wound consultant notes/recommendations from 11/01/2010 to 4/18/2011 included the following recommendations: elevate left foot to relieve [MEDICAL CONDITION], supportive TED stockings, pressure reduction to foot when in chair and specific wound treatments/dressing changes which occurred everyday. On four separate dates (3/21/11, 3/28/11, 4/4/11 and 4/11/11) the wound care physician documented: "give [MEDICATION NAME] 30 minutes prior to wound dressing." On three of these four referenced dates (3/28, 4/4 and 4/11) the wound consultant documented that the resident was grimacing or crying with the pain associated with the ankle venous ulcer. Review of the 3/2011 and 4/2011 medication administration records revealed the recommendation for [MEDICATION NAME] 30 minutes prior to dressing change was not implemented until 4/19/11. In addition, the pain assessment grid on the 4/2011 MAR indicated [REDACTED]. However, observation and Surveyor inquiry of the Resident on 4/14 at 9:15 A.M. and 4/19 at 9:30 A.M. revealed that the Resident complained of pain and inability to sleep through the night due to left ankle pain. On 4/14/11, the facility documented that [MEDICATION NAME] was administered in the P.M. (no exact time indicated on MAR), despite complaints of pain in the morning on two separate dates. On 4/17/11 during the 7:00 A.M. shift, nursing documented on the pain assessment grid that the Resident was experiencing pain (Y), however no [MEDICATION NAME] was administered according to the MAR for all three shifts. In addition, when [MEDICATION NAME] was provided for breakthrough pain, on 14 of 19 administrations, nursing failed to document the effect of the medication on the "reason and result" section of the April 2011 MAR, and failed to modify necessary interventions to anticipate, prevent or manage the Resident's pain. On 4/19/11 at 10:20 A.M. and 3:30 P.M., the Director of Nursing was informed of concerns with the facility's management of Resident #4's pain on the BurnCoat Unit. The facility failed to recognize pain promptly, monitor/ modify interventions for pain breakthrough and failed to implement physician's recommendations to provide [MEDICATION NAME] prior to anticipated pain (eg., dressing changes).